Cath Lab Digest

The most important thing has been the consistent reports of the positive benefits for patients undergoing transradial procedures. Interventional tools are getting smaller, and virtually all of the procedures interventionalists perform can now be done transradially. Previously the need for smaller catheters was a limitation to the technique; the radial artery is obviously smaller than the femoral artery. But now there really are no technical disadvantages when you go to transradial access.

Another important development is that the honeymoon period for femoral closure devices is now over. Physicians have realized that there are still significant groin complications if you use a closure device after an interventional procedure. In fact, there are new groin complications, such as infections, that we didn't see before the use of closure devices.

There has also been increasing interest from university-based physicians. The physicians who teach interventions were previously not comfortable with transradial access being incorporated into the program at their hospital. This was a significant impediment to its adoption in the U.S., since there was no training in fellowship. Yet now we're seeing more university-based interventionalists using this technique.

Europeans have been proactive in doing outpatient stenting procedures. Even though at present it is not reimbursed in the United States, I think it will be just a short period of time before outpatient stenting procedures are performed here. Right now, U.S. hospitals are not paid by insurance companies if procedures are done as an outpatient. I would expect that within the next 12-18 months this will change. Several studies have now been published demonstrating that it is safe to send selected patients home the same day after stenting.

The lack of payment by insurance companies has been one obstacle to outpatient stenting in the United States.

Yes, I think that in general, American physicians tend to be a little more conservative than Europeans. We have legal aspects to worry about, the result of which is that American physicians are much more cautious. Really, it's just been in the last several years that enough studies have been published to prove that outpatient stenting is indeed safe.

What have been some of the obstacles to mainstream adoption of the transradial procedure?

You really can’t say mainstream, because it’s really only an issue in the United States. Worldwide, transradial access has been adopted in huge numbers. In the Far East, for example, probably 30-35% of all interventions are done transradially, and in France, over 50% of all interventions are done transradially. The mainstream has accepted transradial access; it’s the U.S. which has been very slow in adopting it. This is because of the factors we talked about: the hope of femoral closure devices and that most physicians these days are not trained in arm techniques. The standard of training in the United States is the femoral technique. There’s also not been a lot of support from national professional organizations. Plus, there is still an awful lot of what I would call low-volume operators in the United States physicians who do less than a 100 interventions per year. I think in these situations, physicians are very reluctant to take on a new technique, particularly when they haven’t had any training.

We had a 5-hour transradial session with edited live cases at TCT this year and really had an excellent attendance. This reflects the increasing interest in the technique in the U.S.

How does the transradial learning curve compare to that of learning femoral access?

Of course, there is a learning curve for both. With the transradial approach, it’s a little steeper, because many physicians are not comfortable with doing procedures from the arm. The radial artery is a smaller vessel, and technically it’s a little more challenging. The positive aspect is that the patients overwhelmingly prefer to have procedures done from the arm as opposed to the leg. In centers where they do transradial, I think that patient and nurse enthusiasm perpetuates the technique.

Can you discuss a few of the recent meetings focused solely on transradial access?

Our hospital (Wake Heart Center, Raleigh, North Carolina) hosted a transradial course in April 2006. Over two days, approximately 20 live cases illustrating a variety of technical challenges were interspersed with lectures from several international experts. We also have daily courses for individual physicians throughout the year.

The TRIP 2006 (TransRadial Interventional Program) meeting at Mercy Hospital in Scranton, Pennsylvania took place this past July. It was a meeting in which the transradial approach was discussed in detail, and live cases were done. A solid faculty was present, a lot of ground was covered, and it was quite comprehensive for a one-day meeting.

The 14 years of TRI Annual Live Demonstration Course was held in Amsterdam on October 13-14. The OLVG interventional group, headed by Dr. Kiemeneij, performed the first coronary angioplasty via the radial artery in 1992, and continues to be leading advocates of the technique. This course always discusses the latest developments with the technique.

How did the transradial access simulator come about?