By William H Crowder
The transition from a transfemoral to a transradial practice can be a daunting challenge for an interventional cardiologist. This is especially true for those cardiologists who have been practising for years and have had great success with the femoral approach. The truth, however, is that radial artery catheterisation is here to stay and will ultimately become the standard of care for coronary diagnostic imaging and intervention.
Currently in the USA, there are very few centres that have more than 50% radial penetration. Surveys of individual cardiologists indicate that physician comfort, along with lack of knowledge and training, are some of the main barriers to wider adoption. While most acknowledge the safety of the radial approach, others still question the notion that the radial artery approach significantly reduces complications related to access. Nonetheless, as the radial technique evolves along with appropriate use of the various haemostasis bands, these safety data will be further solidified.
Another benefit of the radial approach is the improved turnaround times associated with the procedure. Less bed rest post-procedure can be a great help to already strained hospital resources. At St Dominic’s, we opened a “radial lounge” for recovering heart catheterisation patients. This is an area where the patient can sit in a comfortable chair and enjoy a meal/coffee, read, or watch TV while recovering from their catheterisation procedure. This frees up recovery beds for patients undergoing more invasive procedures and increases overall hospital productivity.
The decision to start a radial programme should be a team approach. I cannot emphasise enough how important it is to have the support of the cath lab staff, hospital, manager and physician partners to start this endeavour. As part of a large group practice that covers two tertiary referral centres, the core team of interventionists within the group decided that implementing the radial approach would be an important part of our future practice. Once the decision was made, we immediately put together a plan that included input from lab staff, nurses, and our industry partners.
The next step is scheduling cases. The first few radial days should be low volume. We started with a series of three patients and blocked the whole morning for these cases. Time is needed to get familiar with the access process, sheath placement, and the various catheters that are available for radial. While some start with the traditional Judkins catheters, I recommend starting with one of the radial-specific catheters and getting used to the idea that one catheter can engage both arteries.
The first cases are going to be frustrating, and they will take longer. Do not let these frustrations cause setbacks. Persistence pays off. I instructed the cath lab staff to set up all of my left heart catheterisations as radial unless otherwise specified. This forced me to use radial. It did take about 50 cases to start to gain some of the confidence I felt with the femoral approach. After 100 cases, I preferred the radial approach, as the procedure saved time, and most importantly, improved patient outcomes.
With our team approach and with support from our hospitals, we now perform the vast majority of our heart catheterisation via the radial approach. Today, more than 90% of my catheterisations are radial. There are still some physicians who favour femoral, but their resolve is weakening as they recognise the success and patient satisfaction we have achieved with the radial approach. Radial is here to stay. Don’t let it pass you by.
William H Crowder, Cath Lab director, St Dominic’s Hospital, Jackson, USA