Spearheading Transradial Access in Las Vegas

Cath Lab Digest talks with Dr. Branavan Umakanthan, Las Vegas, Nevada, about learning transradial access during his fellowship and driving its use in the Las Vegas area.
Cath Lab Digest talks with Dr. Branavan Umakanthan, Las Vegas, Nevada, about learning transradial access during his fellowship and driving its use in the Las Vegas area.
Can you tell us about your current practice and community? I moved to the Las Vegas area nearly a year and a half ago, after finishing my interventional fellowship in Pittsburgh, Pennsylvania. Currently, I am practicing as an interventional cardiologist, performing coronary and peripheral vascular interventions, as well as structural heart procedures. The Las Vegas area sees a very broad spectrum of cardiovascular disease and is one of the more challenging areas to practice cardiology, due to its rather large transient population, traveling from many parts of the world. Needless to say, coronary and peripheral arterial disease is rampant in my practice community. About one year ago, I launched a transradial angiography program at some of the local Las Vegas hospitals, and I have been very happy with its great success. How are you currently applying transradial access in your practice? At present, I’m doing at least 80% of my diagnostic and interventional cases through the transradial approach. My use of this approach began with my cardiology fellowship rotations at the VA hospital in Loma Linda, California. We were caring for heavier patients who had a lot of peripheral arterial disease, and that’s why I made the shift towards transradial access in my fellowship. In Las Vegas, I encounter much of the same type of patient population, and this was the driving force behind my initiation of local transradial programs. We’ve done everything from simple ballooning and stenting to intravascular ultrasound, embolic protection and vein grafts, rotoblator cases, and even acute MI interventions through the radial approach. All have been very successful. Tell us more about the radial approach in acute myocardial infarction (MI) cases. The biggest issue is the learning curve, which directly correlates with total procedure time. In the first several cases through the radial approach, there’s definitely more time required. The operator is learning how to gain access and engage the coronary arteries. As I became more proficient with transradial access, I progressed to more complex cases, including MIs. Typically, many operators prefer starting with larger sheath sizes when treating MIs, usually going with a 7 or 8F. This can potentially be a limiting factor for transradial access in selected patients. However, with the technology available today, I think that more than 90% of coronary interventions, even acute MI and simple bifurcation interventions can be performed transradially through a 6F sheath. Do you believe you are the sole operator offering transradial access in the Las Vegas area? There are a few physicians in the Las Vegas valley that might do occasional cases transradially due to a lack of other forms of access. However, I am the only operator performing routine cases through the transradial approach. How did you start your transradial program at local Las Vegas hospitals? The most important thing was education, in particular for the cath lab staff and the nursing staff in the post-cath recovery unit. I am fortunate to work with progressive cath lab staff members at most of my hospitals. They like to try newer procedures and techniques, so they were very anxious to learn, experience, and adopt the transradial technique. The team’s attitude and support were key factors in our success. As soon as we had a few cases under our belt, they immediately noticed the benefits to the transradial procedure, such as the essential lack of bleeding complications and the degree of patient comfort the procedure offers. Can you describe your initial learning experience with transradial access? During my cardiology fellowship rotations at the VA hospital in Loma Linda, California, one of my attending cardiologists was Dr. Gary P. Foster. He came from a busy private practice setting in Oregon, where he performed a good number of radial cases. When he came to the VA hospital, he brought the concept of transradial angiography to our fellowship program. Most of the physicians at our facility were used to performing their cases femorally. If they felt the need to go through the arm, they would use the brachial approach. Many of them were trained in the era of the Sones cut down, so they were very comfortable with the brachial technique. Initially, the transradial technique was taken with a grain of salt by staff and physicians. I wouldn’t say there was resistance, but definitely there was that sense of “there’s going to be a learning curve.” Over the course of several months, as we started doing more and more cases with the radial approach, that feeling was quickly put to rest. First, we realized that the cases were completed with relative ease. Then, more importantly, we saw that the patients liked it and there were essentially zero complications from the transradial approach. At that point, transradial adoption grew and spread quickly. Can you elaborate more on the learning curve required for transradial success? There are two key thresholds in the learning curve, confidence and competence. I felt confident immediately following my training. I understood what I needed to consider and what I needed to do. To become competent, I began with diagnostic procedures on easy-to-treat patients. This helped me keep my focus and helped to quickly build the confidence of my cath lab team. Through time, I progressed in terms of the patients I treated and case complexity. This stepwise approach helped my entire staff and I become increasingly more competent. As with any new technique or procedure, there is a learning curve required for personal comfort and proficiency. We don’t hesitate to put in our learning time, regardless of how often we may use the technique or perform the procedure. Yet, for some reason, this has not been the case with transradial access in the U.S. Moving from confidence to competence is absolutely possible. There is no set timeframe or magic number of cases to achieve competence, but approached correctly, it will come. How do brachial access and radial access differ? The brachial artery is considered an end artery, much like the femoral artery. The brachial artery is up in the middle portion of the arm. When performing a brachial angiogram, one must puncture the brachial artery before it bifurcates into both the radial and ulnar arteries. It’s referred to as an end artery because in the event thrombosis does occur in the brachial artery, it could potentially be limb-threatening, as the patient may lose blood flow to the entire upper extremity from the elbow down. The radial artery, however, is not an end artery, because the hand has a dual blood supply from both the radial and ulnar arteries. Since the radial artery is not an end artery, even in the worst-case scenario with the radial approach, i.e. thrombosis of the radial artery, the patient is not at risk of losing their upper extremity. The brachial artery also lies very close to the median nerve, a major nerve structure that goes through the elbow. If there is inflammation of that area, it leads to median nerve compression, which can cause a lot of discomfort to the patient. The radial artery is free of any neurovascular structures or any major nerves. So, for those two reasons, I think it is a much safer approach than the brachial approach. With regards to bleeding complications, heavier individuals at risk for pseudoaneurysm or hematoma formation from the femoral artery approach are at almost identical risk for pseudoaneurysm or hematoma formation with the brachial artery approach. Conversely, with the radial artery, the risk is negligible. What is your experience with bleeding complications? To this day, I have not received any calls due to bleeding complications on my radial cases. Not one. This is a significant benefit and results in greater staff and patient satisfaction. Patients love the fact that they are able to literally get up off the table and move around without having to worry about bleeding. Have you had any issues with spasm or difficulty gaining access? Theoretically, the reported incidence of spasm is somewhere between 5-7%. I have not had any problems with spasm thus far. Occasionally, we will run across some anomalous anatomy in the radial artery, which makes it a little more challenging to get up into the subclavian artery, but we’ve been able to overcome this with careful technique. When anatomy is tortuous, we have been able to navigate up into the subclavian artery more than 90% of the time with use of a Terumo Glidewire. There was one case where I actually had to resort to two .014” coronary wires to work through a radial loop and straighten it out, and then I was able to safely take my catheters up into the subclavian artery. I believe the technology available to us today is an important factor in our not seeing spasm as much anymore. The hydrophilic coating on the Terumo Glide Sheath dramatically helps to reduce the incidence of spasm. It’s much easier to insert into the vessel, and when the sheath is taken out, the hydrophilic coating facilitates very easy removal without running the risk of arterial eversion. The new Glide Sheath also is able to be inserted into the radial artery directly over a 0.018” wire, allowing the operator to directly feed the sheath into the radial artery over the micropuncture wire. This eliminates a potential extra step of sheath exchanging when gaining access. The key to preventing spasm is to minimize sheath exchanges, and where possible, catheter exchanges. By minimizing the number of exchanges we are able to reduce the incidence of spasm. Along that same line, Terumo has manufactured a whole line of diagnostic radial catheters. These catheters allow for easy cannulation of the left coronary artery, the right coronary artery and also to go into the left ventricle, so one can perform a left ventriculogram all with one catheter. This also helps to reduce the incidence of spasm dramatically. How are your patients responding to the use of the transradial approach? They are quickly becoming aware of transradial access through word of mouth. My patients probably have been my biggest advocates. They talk to other people in the general public and educate them about this “new” approach to angiography, even though this really isn’t new. Through patient word of mouth, I’ve gotten referrals and patients coming to see me specifically for radial procedures. Patients have actually gone and talked to their physicians about the transradial approach. I have gotten referrals from local cardiologists and those in neighboring states for radial angiograms. I believe that this has been driven by patients spreading the word in local communities. What are your plans for the future? A few hospitals are already up and running with a very successful transradial program. There are several other hospitals in the Las Vegas valley that have indicated interest in starting radial programs as well. I’d like to see if I can expand the transradial program to various other hospitals in the community. Ideally, my goal is to expand its use in all Las Vegas hospitals. In the very near future, I will be starting transradial training programs for local physicians and physicians from other states who are interested in learning the technique and bringing it to their facilities. In structuring my training program, I want to make sure that it is a hands-on program, rather than merely an observational one. I’m convinced that this is the only way physicians can learn the technique of puncturing the radial artery and manipulating the catheters. Any final thoughts? I owe a great deal to my general cardiology fellowship experience at the VA hospital in Loma Linda, California. My training there sparked my interest in transradial angiography and was a valuable part of my life. It was Dr. Gary Foster and myself who were responsible for starting a transradial program at the VA hospital in Loma Linda. Dr. Foster remains very active and passionate about keeping the program going. I was lucky to experience a lot of the challenges of starting a transradial program during my fellowship, such as training cath lab staff and nurses, and obtaining appropriate equipment and medication cocktails for the procedure. Based on that experience, I have now become familiar and comfortable with starting radial programs wherever I practice. Along with transradial work, I also hope to increase the awareness of the variety of endovascular treatment options available for peripheral vascular disease in the Las Vegas area. Many people here are still not aware of the medical and endovascular treatment options for peripheral arterial disease, and are frequently subjected to early amputation. In conjunction with many of the progressive interventional cardiologists in the area, I hope to educate the public and medical community about the whole host of endovascular treatments available for peripheral arterial disease. Dr. Umakanthan can be contacted at