Conversations in Cardiology: Should You Still Prepare the Femoral Site for Radial Cases?

Compiled by Morton J. Kern from contributions by Robert Applegate, Wake Forest University, Winston-Salem, North Carolina; Malcolm Bell, Mayo Clinic, Rochester, Minnesota; Samuel M. Butman, Heart & Vascular Center of Northern Arizona, Cottonwood, Arizona; David J. Cohen, Saint Luke’s Mid America Heart Institute, Kansas City, Missouri; Mauricio G. Cohen, University of Miami, Miami, Florida; John McB Hodgson, Cincinnati, Ohio; Kirk Garratt, Lenox Hill Hospital, New York City, New York; David Kandzari, Piedmont Hospital, Atlanta, Georgia; Aaron Kaplan, Dartmouth, New Hampshire;  Prashant Kaul, University of North Carolina at Chapel Hill, North Carolina; Ajay Kirtane, Columbia University/New York-Presbyterian Hospital, New York City, New York; Michael Krucoff, Wake Forest University, North Carolina; August Pichard, Washington Heart Center, Washington, D.C.; Ramon Quesda, Miami, Florida; Fred Resnick, Boston, Massachusetts; Peter Ver Lee, Eastern Maine Medical Center, Bangor, Maine; Mladen I. Vidovich, Chicago, Illinois; Chris White, Ochsner Clinic, New Orleans, Louisiana.

Compiled by Morton J. Kern from contributions by Robert Applegate, Wake Forest University, Winston-Salem, North Carolina; Malcolm Bell, Mayo Clinic, Rochester, Minnesota; Samuel M. Butman, Heart & Vascular Center of Northern Arizona, Cottonwood, Arizona; David J. Cohen, Saint Luke’s Mid America Heart Institute, Kansas City, Missouri; Mauricio G. Cohen, University of Miami, Miami, Florida; John McB Hodgson, Cincinnati, Ohio; Kirk Garratt, Lenox Hill Hospital, New York City, New York; David Kandzari, Piedmont Hospital, Atlanta, Georgia; Aaron Kaplan, Dartmouth, New Hampshire;  Prashant Kaul, University of North Carolina at Chapel Hill, North Carolina; Ajay Kirtane, Columbia University/New York-Presbyterian Hospital, New York City, New York; Michael Krucoff, Wake Forest University, North Carolina; August Pichard, Washington Heart Center, Washington, D.C.; Ramon Quesda, Miami, Florida; Fred Resnick, Boston, Massachusetts; Peter Ver Lee, Eastern Maine Medical Center, Bangor, Maine; Mladen I. Vidovich, Chicago, Illinois; Chris White, Ochsner Clinic, New Orleans, Louisiana.

Disclosure: Dr. Kern reports he is a consultant and speaker for St. Jude Medical and Volcano Therapeutics, and a consultant for Boston Scientific, Opsens, ACIST Medical, and Merit Medical.

This conversation in cardiology centers on moving beyond radial first, challenging conventional wisdom with regard to the need to prepare the femoral access at the beginning of every radial case. As an offshoot of the discussion, if one does need to change access, can we make the left radial access easier and perhaps the best default second access site? 

As with all our previous conversations in cardiology, I want to thank my expert cath lab colleagues for sharing their thoughts and approaches to what may be on first look, simple problems. Their answers and discussion points often have had a profound impact on our approach to many common cardiology and cath lab problems.

The question: prep the groin?

Gus Pichard, Washington Heart Center, asks, “Mort, who among the radialists has stopped shaving the groin? I have for the last year and had to cross over once in a year. Some nurses have concerns about this. I know many of the world experts never shave the groin to start with.” 

Mort Kern, Long Beach, Calif.: The short answer for the VA Long Beach and UCI labs is yes, we still prep the groin. We are not under pressure to go fast, so we can still take the time to have a femoral access should we need to bail out in the uncommon case. 

Kirk Garratt, New York City, New York: I really HATE delays in the lab — even short ones. So, for that 1 in 40 or 50 cases that have some radial limitation (that usually becomes apparent after a long effort to get access, e.g. a radial loop, or a tortuous, unforgiving subclavian/innominate section), I want the groin ready. Ergo, everybody gets a groin prep at the start of the case. I have to admit the better move would be to reorganize for a left radial approach, but the ergonomics of doing left-sided cases in our labs is so unpleasant that I don’t usually take that approach, especially when frustrated [Note from MK: See left radial access tips below].

David Kandzari, Atlanta, Georgia: I no longer prep groins unless it is a small frame woman, bypass grafts, or an elderly patient. That said, we have just started using a new drape that exposes the wrist and groins, and so if you’re really superstitious (as I can be), it’s a useful drape. I have more and more patients requesting radial and expecting radial, and so when the groins are prepped systematically, there’s a lot of apprehension among the patients — even despite our educated staff telling them “just in case.” 

I questioned whether this issue of prepping the groins is an “American” thing. I was at a meeting with about 80 international physicians from Central and Latin America; essentially, all are predominantly radial operators. I asked the audience if they also prep the groins, and the answer was a fairly unanimous “no” for elective, non-shock/AMI [acute myocardial infarction] cases.

Aaron Kaplan, Dartmouth, New Hampshire: My protocol is to always prep and evaluate the groins. It’s good to know your options even if rarely used.

David Cohen, Kansas City, Missouri: Yes [we prep] — mostly because I find that’s the best way to avoid needing to access the femoral artery in the first case (i.e. we’re very superstitious, too).

John McB Hodgson, Cincinnati, Ohio: We prep too, but just the right groin. I will go to the ulnar or left side if the right radial fails.1 The only time I use the groin is for graft cases. 

Mauricio G. Cohen, Miami, Florida: If we can’t get radial access using palpation, we use ultrasound. We rarely miss access using ultrasound imaging. However, when we encounter a non-negotiable loop or have difficulties with subclavian tortuosity, we transition to the other arm. However, prepping the left arm takes longer than going through a groin that is already prepped. Most of my colleagues will transition to the groin. We don’t do graft cases through the groin; we use left radial access systematically.

Mladen I. Vidovich, Chicago, Illinois: We prep the groin. One of our nurses (Lulu) also designed a combo femoral/radial drape (the “Lulu” drape, Cardinal Health, Figure 1) that makes the prep/draping super easy. 

Prashant Kaul, Chapel Hill, North Carolina: I routinely asked to prep the right groin. However, given the almost negligible femoral bail out rate (with our preference for contralateral radial PRN [pro re nata, as needed]), the staff made a conscious decision to stop prepping the groin, but had not told me. It only came up when I happen to notice one day. At that point, it had been several months without prepping the groin. Now I don’t insist on prepping the groin unless we have a STEMI [ST-elevation myocardial infarction] or other unstable case that may require emergent IABP [intra-aortic balloon pump]. However, I always palpate both femoral pulses prior to each case so I know my options. 

Ramon Quesda, Miami, Florida: Yes, we prep the groins, mostly to keep consistency and protocol, since we do all cases radial, STEMI included. For electives and probably the majority of other cases, it is not necessary.

Robert Applegate, Wake Forest University, North Carolina: I asked the staff to stop prepping groins early on to inspire confidence that we would either get right or left radial access, and to stop patients asking why we were prepping their leg if we were going through the wrist. When I last checked, my crossover was <5%, so I don’t prep the left wrist unless it is clear we are not making headway from the right radial. 

Malcolm Bell, Mayo Clinic, Rochester, Minnesota: I do not prep except in emergency cases (access for IABP/Impella [Abiomed] or the rare failed access). My default if right radial fails is to go to the other radial. Some are now advocating use of ulnar for options.1 Patients appreciate the fact that their modesty is preserved and when crossover rates are less than 5%, it seems a waste of effort. I fully appreciated this for the first time when one of our cath lab personnel presented with a NSTEMI [non-STEMI] and with a smile, told us that they had prepped their own groins at home before leaving for the emergency department. 

Sam Butman, Cottonwood, Arizona: Yep. Groins prepped for all. For left radial cases in an older person or those with grafts, we would not prep the right wrist, as we would not use it.

Peter Ver Lee, Eastern Maine Medical Center, Bangor, Maine: [The prep] depends on the case. STEMI, yes [we do groin prep]. All others, no. We shave the groins, but do not wash, put a lead drape over the patient from knees to umbilicus and a regular sterile femoral drape without exposing the femoral holes. In the rare case we need to switch to femoral approach, we remove the lead shield, wash the groin, and expose the femoral area. It only takes a minute. We do CABG [coronary artery bypass graft] cases from left radial. We put in a 25cm sheath, leave about 10-12cm sticking out of the wrist and position the patient’s arm over the left groin. For complex cases including CTOs [chronic total occlusions], we use femoral. If we can’t find the radial artery on ultrasound (US), we try ulnar with US, or go to the opposite side. We do most STEMIs with radial unless the patient is in shock, intubated, etc. I really believe that interventional cardiologists need to get comfortable using US to find arteries. It doesn’t take long to get familiar with it, and it significantly shortens your procedure time. If your cath lab has a SonoSite, you’ve paid for it, use it.

Ajay Kirtane, Columbia University, New York City, New York: Our protocol is to prep both groins for all cases. However, based upon this conversation and especially considering the patients’ perspective, we are going to revisit the issue internally by looking at how frequently groin prep could be anticipated to be needed for urgent/emergent access for support, temporary pacing wire, etc. 

Fred Resnick, Boston, Massachusetts: Our default protocol is to prep right groin in all cases and cover with sterile towel and then with lead drape placed under the sterile top drape, in order to reduce scatter. If groin access is needed, the tech carefully removes the lead drape, and we move to femoral access. 

Malcolm Bell, Rochester, Minnesota: It’s been very interesting to read all these different perspectives and practice. Here’s my last 2 cents worth — and with due respect — rather than superstition, old habits, and impatience determining our practice, perhaps looking at it from the patient perspective should take a higher priority? [Note from MK: Agree wholeheartedly. See CLD Dec 2009 Clinical Editor’s Corner, “Changing Behavior and Culture in the Cath Lab: Addressing Motivations and the ODNT (Old Dog/New Trick) Syndrome.”]

Gus Pichard, Washington Heart Center, Washington, D.C.: It was good to read how you all do it. I stopped prepping the groin about 10 months ago. The patients love it. It definitely increases patient satisfaction. The techs also prefer it. It makes the set up much more expeditious and simple. I do ask that the groin be prepped in if the patient may need circulatory assistance. In the exceptional case where crossover to femoral is needed, we do careful, good groin prep and switch over. Our drape comes with the two openings for femoral access. The entire drape is lifted for good sterile prep, then dropped down. For the left radial, I do it like Sunil1 [ulnar] and usually (not always) prefer it for patients with LIMA [left internal mammary artery graft].

Is there a way to make left radial approach easier? 

Chris White, New Orleans, asked, “We do not have a reasonable solution to convert to a left radial approach without a lot of work and delay. Can anyone share ‘best practices’ to make left radial access easier?”

Malcolm R. Bell, Mayo Clinic, Rochester, Minnesota: We do the same thing as Sunil1 [ulnar], but some operators who do left as a default prefer to stay on the left side, but I get terrible left-right confusion when I am in that position and our rooms are not set up for that.

Mitchell W. Krucoff, Wake Forest University, Winston-Salem, North Carolina: There is a neat trick to add (with courtesies to Dr. Sunil Rao): bringing the left hand to the left groin, grab the drapes around the wrist and clip with a hemostat. Beyond just supporting the elbow from below, this keeps the hand rotated, stable and comfortable for the patient. In addition, most of our other faculty swing the left arm over and work from the right. I find that approach problematic, especially with obese patients. I feel I have better catheter control working from the left side. It does require an additional individual to pan. 

Peter Ver Lee, Maine Medical Center, Bangor, Maine: I stay on the patient’s ride side and swing the arm over so the wrist is over the left groin. You have to support it with something under the arm and hand. I also put in a long 25cm Glidesheath (Terumo Corporation) and leave about 6 inches sticking out. This gives you a little more reach. I pin the little suture hole in the Glidesheath to the underlying drape. 

Robert Applegate, North Carolina: I don’t prospectively prep the left side unless we plan to start there for a LIMA case, but we will prep it once I know the right radial approach won’t work. There’s not much time lost doing that. I actually work from the left side. I tried the wrist pull over (to the midline), but was really frustrated with the positioning. The left arm is prepped straight out from the body on a swivel arm board. I have one of the fellows pan from the right side and a tech assists me on the left. I actually turn my back to the patient so I can manipulate the catheters as I would from the right side. The monitors are pulled out as far as they can go on the left, and angled so I can see them as well as the person panning. It is a little awkward to start with, but is really not a problem once you have done a few. In the hybrid room, it is really no problem, since we have multiple monitors that we can position directly in front of us on the left side. Once we go to PCI [percutaneous coronary intervention], we turn over our scrub bucket and build a platform so it is on a level with the patient’s arm. With rapid exchange equipment, it’s not a big deal. 

Bottom line

While I did not include every comment from all my expert colleagues, there appears to be a split decision on the continued need for groin preps, especially for experienced labs. Those labs with a long track record of radial success, do not prep groins and use the left radial as bail out. For labs with less experience or those who are creatures of habit, groin prep is the norm. Overall, I don’t believe the issue is of great clinical significance, but more of an operational nuisance. For STEMI patients, most labs always prep the groin for the emergency or prophylactic use of left ventricular support or pacemakers. 

As for approach to left radial, most operators stay on the right side of the table, and use some method to bring the left arm to the center line and secure it for the procedure. One can go to the left side of the table and work backward, but this is uncomfortable, difficult, and produces visual dyslexia. 

As with all our conversations, I hope this discussion was helpful in support of changing habits and learning new approaches to better patient experiences and safety. n

References

  1. Rao SV, Kedev S. Approaching the post-femoral era for coronary angiography and intervention. JACC Cardiovasc Interv. 2015 Mar 17. pii: S1936-8798(15)00158-2. doi: 10.1016/j.jcin.2014.12.231. [Epub ahead of print]. 

Further reading from Cath Lab Digest regarding use of the ulnar artery

Singh V, Cohen MG. Crossover from radial to ipsilateral ulnar access: an additional strategy in the armamentarium of the “radialist”. Cath Lab Digest. 2015 Apr; 23(4). Available online at http://www.cathlabdigest.com/article/Crossover-Radial-Ipsilateral-Ulnar-Access-Additional-Strategy-Armamentarium-%E2%80%9CRadialist%E2%80%9D. Accessed April 17, 2015.