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Alternate Route
— Comparing Radial and Femoral Access The femoral artery is the proven, traditional route for most interventional procedures. But access to a more superficial artery in the arm offers advantages over the thigh, advocates say. When performing percutaneous diagnostic and therapeutic coronary procedures, such as angiograms and balloon angioplasty, interventional radiologists and cardiologists have typically used the femoral artery as their entry site. It’s an expedient selection: Located in the thigh near the groin area, the femoral artery offers a large-bore vessel through which cannula insertion and catheter manipulation can usually be easily managed. However, clinicians have increasingly looked to the right radial artery as a more appropriate entry site. “For a long time, the femoral artery has been the gold standard, but over the past 12 years, more and more clinicians are using the [radial] artery as their access point, however only gradually,” says David Hilton, MD, interventional cardiologist at Royal Jubilee Hospital in Victoria, British Columbia, Canada. One reason for this ongoing but slow-moving shift is that the radial artery provides potentially safer access. Bundled within the wrist anatomy, the radial artery has a superficial location while the femoral artery is embedded deep within the leg. As such, transradial access poses less risk of vascular complications, and hemostasis is more easily accomplished. Other documented advantages include less pain for patients, reduced postprocedural discomfort, quicker mobility following treatment, and shortened hospital stays. Still, some clinicians are reluctant to embrace this alternative. The trouble is, while percutaneous procedures essentially remain the same whatever the arterial route, the transradial approach can be more challenging and, as such, involves a substantial learning curve. Smaller
Equipment The transradial approach became viable with the miniaturization of devices, such as sheaths, guidewires, catheters, and stents. “In the early years, the equipment we used, either for diagnostic or interventional procedures, was too large to use safely or effectively in the radial artery. But as the technology evolved and devices became smaller, the radial artery is used more often,” says Hilton. “Ten years ago, we would never have dreamed of doing some kind of intervention through the radial artery,” says Barry S. George, MD, an interventional cardiologist who now accomplishes transradial access for many percutaneous procedures at Riverside Methodist Hospital in Columbus, Ohio. “We just didn’t have the right tools. The existing ones were too big and bulky.” Transradial
Advantages Hilton’s comments indicate just one of several advantages to using the radial artery: Risks of complications involving bleeding or bruising are considerably lessened. Hemostasis is typically easily accomplished by simple compression of the artery, such as with a pressure bandage over the puncture site to stop the bleeding. Hemostatic considerations for the femoral approach can be more complicated. For example, physicians have to precisely fine-tune the anticoagulation/hemostasis balance. Moreover, bleeding complications can still be difficult to prevent, even if a physician takes proper hemostatic precautions. The transradial approach has often been described as more patient-friendly. It can be completed in less time than a transfemoral procedure, is less painful, and involves less postprocedural discomfort. Another advantage for the radial approach is that patients have been known to get up and walk around within a few hours after leaving the catheterization suite. With the transfemoral approach, patients require a significantly longer period of bed rest, which helps prevent any disruption to their puncture site. Typically, they’re required to lie flat for at least six to eight hours. For some patients, an overnight stay with bed rest is required. Such prolonged time lying on their backs can pose problems for some patients, particularly those who have left ventricular dysfunction, lung disease, or back and hip pain. Also, the extended bed rest doesn’t guarantee that a patient won’t experience puncture-site complications, such as a hematoma or pseudoaneurysm, or require additional treatment, such as a blood transfusion or surgical arterial repair. As far as hospital stay, transradial patients can often go home on the same day they have their treatment. Transfemoral patients typically stay in the hospital overnight and sometimes remain hospitalized for as long as three days. Such advantages benefit healthcare facilities, and staff as well, by reducing costs, increasing patient turnover, and demanding less intensive nursing care. Some observers believe that interventional procedures performed with transradial access could one day be done as outpatient procedures. Disadvantages
of Transradial Access “Currently, it’s perceived that the learning curve entails performing 80 to 100 cases before someone would truly feel comfortable working with the much smaller radial artery,” Hilton says. He adds that some physicians who have been performing femoral access procedures for a long time may not be enthusiastic about going back and learning a new and complex technique. “I think it would be a lot easier for the younger physicians who are still in the learning phase of their careers,” Hilton says. “If they get the education during their training years, they will more easily adapt to it and will want to do it. It’s sort of like learning to play the piano. It’s much easier to do when you’re younger.” Looking ahead, transradial approach use will likely increase, and Hilton thinks younger physicians may find that learning the technique will provide a boost to their careers. “Because it has been demonstrated that patients can be ambulated much more quickly and that it costs hospitals less money, the younger doctors who have the radial technique in their bag of tools make for more attractive hires,” Hilton says. Patient
Suitability “At my hospital, we’ve transformed to doing about 80% to 85% radial,” Hilton adds. “It’s sort of like having a great starting pitcher and a great relief pitcher,” says George of the value of knowing both techniques. “Today, I think more and more of the high-volume operators will possess both skills and, at the same time, recognize the benefits and limitations.” Generally, suitable candidates are patients with good pulsating radial arteries and adequate blood flow through the arteries and in their hands. Transradial access is especially suitable for obese patients. For them, the femoral approach can entail risks because the femoral artery is entrenched so deeply in the leg. Cannulation can be extremely difficult, if not impossible; compression is harder to manage; and it can be hard to perceive any bleeding. Those problems aren’t present with the radial artery, which George says is the most superficial and compressible blood vessel that can easily be found. “In my own practice, I often use radial entry for certain diagnostic studies, particularly in patients who are morbidly obese. In such cases, it is extraordinarily safer,” George says. “There’s less likelihood of complications such as hematomas. In fact, hematomas are very unusual with the radial approach. Also, a patient can’t die from a hematoma in the radial artery, but they could from a hematoma in the groin.” He also points out that, for patients with peripheral vascular disease, the transradial technique is safer and more effective. “Sometimes, you can’t even move up from the groin area and into the heart or into the carotids to perform a procedure such as a diagnostic angiography because of obstructive vascular disease,” George says. One case where the transfemoral route should be used is for those which require larger catheters. Increasing
Usage However, increased usage seems inevitable as younger physicians trained in the technique move into the medical workforce. Also, physicians like Hilton travel throughout North America introducing others to the benefits of radial artery access. He is a member of the Radial Force Group, an organization that champions radial artery access. The international group is comprised of transradial specialists who have combined their expertise to increase application of the technique in interventional practice. They promote their cause through information dissemination and by offering educational programs. Though he advocates using the transradial approach, Hilton believes it won’t completely replace the transfemoral approach. “I’m committed to using the radial approach whenever possible, but there are some cases where it is not feasible for technical reasons,” he says. “For instance, a patient may have had bypass surgery, and their radial artery had to be extricated for graft material. Also, some patients have radial arteries that are just too small for even 5- and 6-French-size equipment. It would cause them too much pain.” He also indicates that some patients need to undergo complicated heart procedures, and treating physicians would require a large-bore guide to be able to use equipment necessary to a successful outcome. “If a physician is doing a left main angioplasty on a big patient, they may want to do two stents simultaneously, and they couldn’t use a 6- or 7-French guide,” he explains. “So, I don’t believe the radial will ever completely supplant the femoral. For some patients, femoral artery access is the best and safest option. But while radial is not for everyone, it’s becoming appropriate for more patients each year.” — Dan Harvey is a freelance writer based in Wilmington, Del. He is a frequent contributor to Radiology Today.
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