Cath Lab Digest

Yes, every single floor in this hospital has been trained on the transradial procedure and how to use the TR Band, including how to take it off. They have also been trained to handle potential complications.

How are things different at the University of Miami from your previous position?

There was only one doctor at my previous position who was performing transradial procedures. At University of Miami, we actually have a number of doctors who are now performing transradial procedures. They know they can rely on Dr. Cohen during a case, if his assistance is needed. He’s our resident expert.

What have been the benefits to the cath lab that you’ve seen from transradial access?

It means less time for patients to be in the hospital. They don’t have to be lying flat for 4-5 hours. Also, we are using a lot less equipment. For example, using transradial access, we can perform a basic diagnostic procedure with a single catheter, as compared to three catheters when going through the femoral artery. It’s a cost savings for the department.

Kym Manni is Associate Vice President of the cardiovascular service line at the University of Miami Hospital.

How many cath labs are in the University of Miami cardiovascular service line?

We currently have five cath labs and 24 staff members. We are constantly recruiting and currently have 10 openings. We can’t build this program fast enough. We have a multi-disciplinary staff of physicians that use the cath lab: vascular surgeons, open-heart surgeons, interventional radiologists, cardiologists and electrophysiologists. There are at least 60 physicians with privileges in the cath lab.

What are your thoughts about transradial access?

Radial access has been around for a number of years. Most physicians were typically trained to perform the femoral approach, so in my past experience, transradial would only be used if we couldn’t get femoral access. The University of Miami is the first lab I’ve worked in with a physician whose preference is to do procedures transradially. For all of us who have been in the business for a number of years, access has always been through the groin, so by default, that was the habit. Rethinking and implementing a new access strategy is challenging. Yet, once mastered, it offers many benefits, including additional patient safety factors, immediate patient ambulation post procedure and the potential for early patient discharge from the hospital. Regarding patient ambulation, this contrasts against a patient having to lay flat for four hours or more post procedure with a transfemoral approach. In our institution, we treat a number of patients from the Florida Keys, which is a four-hour drive from Miami. By using a transradial versus a transfemoral approach, we are able to treat and discharge patients much quicker, often enabling them to make the long trip home before dark.

What have you seen happen from a financial perspective?

Financially, there is a significant cost reduction for radial access versus femoral access, both in terms of equipment used and length of stay, which benefits from quicker ambulation post procedure.

Interestingly, Dr. Cohen’s overall cost per procedure is roughly $2,000 less than his counterparts using transfemoral access. Physician cost per procedure is something that we’ve only recently started to keep track of; the university has only owned this hospital for a little more than a year. These things are now being tracked and are shared with physicians through our cath lab committee.

We still use the same number of staff per procedure. Ultimately, I think the biggest benefit is patients being discharged sooner. They can ambulate much quicker, and we don’t have all the groin complications with closure devices or groin bleeds, so from the patient safety standpoint, that is where we see the biggest benefit. Patients can have a post-procedure bleed with femoral access. They can require care for a pseudoaneurysm. We have not seen any complications with our transradial program.

Dr. Mauricio Cohen can be contacted at mgcohen@med.miami.edu

Joey Collazo, RCIS, can be contacted at jcollazo2@med.miami.edu

Kym Manni, RCIS, PhD, can be contacted at kmanni@med.miami.edu

__________________________

Summarized Policy for Transradial Access at University of Miami Hospital Cardiac Catheterization Hospital

• The use of transradial arterial approach in the cardiac catheterization laboratory is at the discretion of the attending interventional cardiologist.

• All catheterization laboratory personnel will be familiarized with this approach through in-service education and review of the unit procedure manual.

• The advantages of the transradial versus transfemoral approach include, but are not limited, to: immediate patient ambulation, dual blood supply to the hand associated with a decrease in vascular complications, easily compressed vessel, less risk for nerve injury and patient preference.

• Radial access should be strongly considered in patients who are morbidly obese or have significant coagulation disorders, or with severe peripheral vascular disease without femoral access.

• The contraindications of the transradial approach are abnormal modified Allen’s test, patients who require intra-aortic balloon pump (IABP) counterpulsation, known upper extremity vascular disease, patients on hemodialysis with arterio-venous (AV) fistulas in the upper extremities, and pre-existence of internal mammary grafts contralateral to the site of entry.

Supplies and Drugs Needed for Transradial Approach

 Oversized Plexiglass arm board

 “Brachial” sterile drape