Disclosure: Dr. Minisi reports no conflicts of interest regarding the content herein.
Dr. Anthony J. Minisi can be contacted at email@example.com.
I am the proverbial “Old Dog”. I am 61 years old. I completed cardiology fellowship at the Medical College of Virginia (now Virginia Commonwealth University) in the mid-1980s, when the required training was two years of clinical rotations. I had the good fortune to train under two legendary senior faculty members who are considered masters of invasive/interventional cardiology. Based on this training, I have spent my professional career performing cardiac cath procedures from the femoral approach with very good results. I consider myself to be excellent at what I do. For the rare case in which the femoral approach was not an option, I would access the left brachial artery and muddle uncomfortably through the procedure. Despite years of experience, I am still unable to pan from the left side of the cath table.
I readily acknowledge that my initial reaction to innovation is skepticism. As a result, my response to early reports of performing catheterization through the right radial artery was dismissive. As a senior operator, I figured that no one could reasonably expect that I would make such a radical change at this point of my career.
However, the impetus to adopt this new technique has been as unrelenting as a riptide. Cries of “retool or retire” have at times seemed to be aimed directly at me. Former fellows who I had painstakingly trained in the cath lab were now telling me about their experiences with adopting the radial approach in practice. Not last and not least, we have all observed that our patients referred for cath are getting bigger and bigger.
So for these and other reasons, I have taken the plunge. I now consider myself to be a radial-first operator. I started by attending a one-day symposium devoted to catheterization and intervention from the radial approach. Following this, my progress was both hampered and facilitated by working in a cath lab with active fellowship programs. Our cardiology fellows were less than thrilled about me becoming the primary operator during my learning curve. As a long-time program director, I am sensitive to these training issues, but I figured that before I could teach others how to do radial catheterization, I had to prove to myself that I could do it. Conversely, it was a win-win situation between me and our advanced interventional fellows — I taught them how to do interventions and they guided me through my radial learning curve.
During this process, I have evolved a technique that represents a synthesis of several tips and tricks that I have witnessed or created along the way. For other operators who are considering making this transition, I would suggest the following methods to “keep it simple”:
- Be heavy with the sedatives. The importance of administering vasodilators and sedatives to minimize arm discomfort and arterial spasm was heavily emphasized during the training course that I attended. I have found this to be sage advice. In the absence of contraindications, I use conscious sedation for all cath lab procedures. For femoral procedures, my goal is to “take the edge off”. For radial cases, I aim for light snoring.
- Access. During my days as a resident and fellow, I struggled with placing radial arterial lines. I had no problem hitting the artery, but threading the cannula was problematic. This is one reason why I was reluctant to embrace the radial approach. For the radial novice, I would recommend the “through and through” approach using a 22-gauge catheter. This allows you to slowly withdraw the cannula and have your wire ready to pass as soon as you get blood return. I have found this to be a very forgiving technique and have been pleasantly surprised at the ease of obtaining radial access.
- Traverse the arm with the “Baby J” guide wire. Our cath lab staff refers to it as the “Baby J” wire, but the Rosen (Cook Medical) is a prototype. These wires have a small enough J curve to atraumatically traverse the radial artery. However, if there is trouble at the elbow, you will get instant tactile feedback, and can then image the vessel to see what you are dealing with. I place the Wholey (Medtronic) and Glide wires (Terumo) in the “Eighth Wonder of the World” category as far as cath lab equipment goes. However, these wires will find their way into accessory radial arteries and you may not realize that this has occurred until the catheter becomes frozen in place. This will not happen with the “Baby J” wire.
- Secure the sheath. I do this with a Tegaderm, but any adhesive bandage will do. This facilitates catheter exchanges, particularly if you are performing the procedure from the left radial artery and having to reach across the table.
- Universal catheters. The sleeper sofa is frequently criticized for being a bad sofa and a bad bed. I think the same thing applies to the universal catheters — all of them. In my experience, they are substandard left coronary catheters and substandard right coronary catheters. It is a beautiful thing when they work, but for the novice radial operator, I think that the simplest approach is to stick with the Judkins catheters that we have used for our entire careers. The disadvantage of this approach is the need for a catheter exchange. When using the right radial artery, I would recommend performing this with an exchange length guide wire to avoid losing your position in the ascending aorta. I should note that these comments apply to diagnostic cases only. For interventions, particularly right coronary interventions from the right radial artery, I would recommend guiding catheters that supply more backup support.
- Hemodynamics. I am a hemodynamics extremist. I think patient safety is improved by knowing filling pressures at the start of the procedure. For patients who do not require right heart catheterization, I will initially pass the right Judkins catheter. This catheter is helpful in traversing the knuckle that is commonly encountered in the innominate artery. Using the guide wire to cross the aortic valve, this catheter can be placed into the left ventricle for measurement of end diastolic pressure. What happens to this catheter on pullback has been a big surprise to me. Not uncommonly, the catheter will stay in the left cusp and allow preliminary nonselective visualization of the left main coronary artery. In several cases, additional manipulation of this catheter has allowed for good quality selective angiography of the left coronary. In these cases, the right Judkins catheter essentially becomes a universal catheter.
- Respect the left main. I was trained to approach catheter engagement of the left main coronary artery as if I was carrying a bomb that could explode in my hands at any second if I was not careful. From the right radial approach, we frequently have to engage the left main using a guide wire without even monitoring catheter pressure. As a hemodynamic extremist as well as an old dog training young pups, this remains a matter of concern for me. There are times when the catheters get into unworkable positions and must be straightened out by advancing the guide wire. However, I have seen even fourth-year interventional fellows start to advance the guide wire when the catheter is in the left cusp and could even be in the left main, for all we know. I calmly advise them that this is not a “best practice”.
- There is no substitute for experience. As mid- to late-career operators, we have the benefit of caseload. As I tell our trainees, the more cases I do, the better my luck gets. It is not always simple to engage coronary arteries from the femoral approach. Over the years, we have become adept at getting catheters to places they may not want to go. These skills readily transfer to the radial approach. The catheter manipulations are different with the radial approach, but for the experienced operator, this is a short learning curve.
Now that I have made this transition, I must confess that I really like it. It is so much better for the patients. For our elective radial percutaneous coronary intervention (PCI) cases, we are having a difficult time understanding why they need to stay overnight. It has also been good for me. It has invigorated me and renewed my enthusiasm. For other experienced femoral operators who are considering this transition, I would encourage you to proceed. If difficulties are encountered early on, just cross over to the femoral approach. Despite what the more ardent radial proponents would say, crossing over is not the end of the world. However, I think you will find that the majority of cases go well and that your skill set is ideally suited for this transition. As your experience grows, you can decide if you want to tackle more challenging radial and/or aortic anatomy. After all, every experienced femoral operator has had to traverse the iliac artery loop.
Acknowledgements: I wish to thank Kathy Boyd David for her review of the essay and Kevin F. Sumption, MD, for his assistance with photography.