In the fashion world, some of what is a “hot, new” fashion is, in reality, a fashion comeback; this is also true in medicine. Many times, a new method or treatment is not really new and has been tried years earlier. Today’s youngsters recently saw bell-bottom jeans as the latest exciting, “new” craze. Their grandparents felt the same way about these jeans, but in the 1960’s and 70’s. Radial access is no exception. It tried in the mid-1990’s, but did not gain the popularity it enjoys today.
Nowadays, the young interventional cardiologist and the progressive catheterization lab consider it “hip” to provide transradial cardiac catheterization.
In the 1960’s, Dr. Mason Sones pioneered left cardiac catheterization using brachial artery access via cut down and using a bulky 8 French (Fr), semi-rigid, woven Dacron Sones catheter. For the next ten years, a new generation of invasive cardiologists (intervention did not yet exist) was trained throughout the United States and the world on doing cardiac catheterization via the brachial artery cut down. Surprisingly, the procedure became simple, easy to master, and quick. A whole generation of cardiologists now in their 70’s and 80’s, were proficient at doing brachial artery cut down in a matter of 10 minutes and finishing a cardiac catheterization only 10 to 15 minutes longer than their younger counterpart using the Judkins technique via femoral access.
In the 1970’s, Judkins (a pioneer radiologist) popularized percutaneous femoral artery access for cardiac catheterization using the Seldinger technique (and later, the Cook needle) and the Judkins catheters. By the late 1980’s, training programs in the U.S. were no longer teaching the brachial artery cut down access and the 8 Fr woven Dacron Sones catheter was obsolete. A new generation of lower-profile, polyurethane/polyethylene 6 Fr and 7 Fr Judkins catheters became the standard catheters, and femoral artery percutaneous access was the standard approach; however, in situations where the femoral artery was not accessible, the radial, brachial or axillary artery percutaneous approach were all reasonable options. In the 1990’s, there was renewed interest in radial artery access because the catheters were becoming smaller (5 and 6 Fr) and could easily accommodate smaller arteries. Some catheterization labs felt it was a niche to be able to offer coronary intervention in a through-the-arm approach (radial or brachial), and offer the patient the ability to walk right after the procedure and go home the same day. At the time, it did not gain popularity and went by the wayside within a year or two. Reasons for the lack of interest in the transradial approach in the 1990’s were multi-factorial. One can only speculate and offer potential explanations.
During that time, medical liability and litigation was on the rise, and cardiologists were uneasy about a non-conventional approach and potential litigation. The insurance climate and payers were in favor of an overnight hospital stay following cardiac intervention. At that time, doing outpatient coronary intervention via the radial artery approach was frowned upon by the insurance payer, the hospital chief financial officer and the cardiologist office manager. It did not make any sense to shorten the hospital stay when everyone, except for the patient, was against it. The cardiologist had to jump through hoops to make sure the early discharge would not result in a vascular complication that the patient would be experiencing hours after the procedure, then home alone!
In the 1990’s, there were no customized or special tools for radial artery hemostasis.
The radiation exposure to the cardiologist was higher using radial access than the femoral approach. The x-ray cameras were less efficient (many non-digital) and provided poorer image quality than with the femoral approach. The cardiologist had to lean over to do the procedure via radial artery and had to experiment with various catheters.
Today, any added radiation exposure on the cardiologist is less of an issue, because of equipment improvement and increased efficiency. The table is more conducive to a transradial approach and the cardiologist can stand up or sit down while doing the procedure. The catheters are smaller and more flexible. Image quality is superior to what it was a decade ago because of advanced technology, digitization and computer enhancement.
The vascular access complication rate also plays a major role. Brachial access is less popular today because it is less forgiving in the rare case of vascular occlusion. The hand is totally dependent on the brachial artery blood supply at the elbow, but has dual blood supply by the wrist. Untoward occlusion of the radial artery may result in some hand and finger ischemia, but this would be a much more serious hand ischemia should the occlusion take place at the level of the brachial artery. In fact, in most cases, the loss of radial pulse after the procedure may go unnoticed. In addition, obtaining hemostasis over the radial artery is much easier than obtaining hemostasis over the brachial artery.
At the present time, the ability to ultrasound the radial artery prior to access adds to the safety. The proper selection of radial versus femoral access by cardiologists makes the procedure quite safe. The customized devices to apply pressure on the puncture site are user-friendly, well tolerated by the patient and provide safe post-procedure radial artery hemostasis.
It is still a great advantage to be able to do cardiac catheterization/ intervention and allow the patient to walk immediately afterwards. The patient can go home and resume normal life the same day.
Today, the transradial approach is applauded by the insurance payers, by the hospital chief financial officer and by the cardiologist office manager. The medical liability is less of a concern as the procedure has become standard of care, and the medical malpractice climate has implemented some degree of reform in the past decade.
The long-term safety and efficacy of radial artery approach remains to be seen. It is unknown what the complication profile would be like when this procedure is adapted on a large scale, becomes the preferred choice for access, and is used routinely in every lab. It is also unknown if this access is suitable for repeat and numerous procedures, just like the ability to do repeat procedures via femoral artery access. The radial artery is much smaller than the femoral artery and may not be suitable access in small people, especially females with a small-caliber radial artery. It is too small to accommodate a closure device. It may not be suitable for a vein graft or left internal mammary artery (LIMA) visualization. It does not offer the ability to insert an intra-aortic balloon pump (IABP) in case of emergency. It does not have the proximity of a large femoral vein, in case there is a need for right heart catheterization or temporary pacing. Despite all these drawbacks, it is a very attractive choice that will always be favored over the femoral artery approach, both by the patients because of convenience and by the medical community because of the cost savings.
The future of transradial cardiac catheterization remains to be seen. It may be another fashion craze fading over time, or it maybe here to stay, becoming the dominant access site. In the coming years, if the femoral artery approach becomes obsolete, it would be reminiscent of our colleagues, those older-generation cardiologists who were doing brachial artery cut downs a mere two or three decades ago.
Dr. Bitar has been an interventional cardiologist since 1989. He can be contacted at email@example.com