Can you share your history with left radial access?
For the last several years, prior to having the StandTall device (TZ Medical), my radial access rate for all cases was at 80%, with 20% of my cases being done with femoral access. The overwhelming majority of femoral access cases involved patients who had bypass grafts. In the past, I had utilized left radial access intermittently, but it was not routine for all patients with bypass grafts because of the risk of back injury that can result from leaning over the patient. Back injuries are a major concern in interventional cardiology, as such injuries can prematurely end careers in the cath lab. As a result, I have always tried to be mindful of that potential and avoided, when possible, having to lean over to the far side of the table.
Has use of the StandTall sheath extender helped with the ergonomics of a left radial approach?
Yes. I was a little skeptical at first. The StandTall is basically a short accessory tube that attaches to the hub of the access sheath and I wondered initially how much it would really reduce the need for an operator to lean across the table. I found the combination of the StandTall and a left arm positioner, the Cobra Board (TZ Medical), worked well to bring the left radial access site over to the right side of the table, thereby eliminating the need to lean over the patient. As I noted above, I had historically been using radial access in only 80% of cases. In the past year, with the use of the StandTall device, I committed to attempting all of my cases radially and to use the left radial approach for any bypass cases. For the calendar year of 2019, 95% of my cases were done radially. The only cases I haven’t done radially are those where the radial artery was used for prior bypass and or those in which radial artery access was unsuccessful. The StandTall has allowed me to adopt a left radial first approach for bypass cases, because I can use a left radial access without having to lean over the table.
Do you see any benefit to patients in being able to increase the frequency of left radial access?
Yes, I can speak to our cath lab as a whole. We have pushed all of our operators in the past year to adopt a radial-first approach. I am not the only operator in our cath lab who now is routinely using left radial access for bypasses. We have several operators in our lab who have radial access rates well above 90% and that has been a change in the last year that occurred, in some part, because of the availability of the StandTall and the Cobra arm board. As a result of the radial push over the last year, we have seen an increase in radial access rates as a whole for our entire lab and along with that, we have seen a reduction in our access site bleeding complications. I do think the StandTall has made it more comfortable for operators to use left radial access in bypass cases.
What about setup?
The staff have no problem with setting up the StandTall, which is quite user friendly. The operator will typically walk around to the left side of the table to get left radial access. The StandTall device is then connected to the sheath and the left arm is positioned across the patient’s chest. The staff will slide in the Cobra board behind the upper arm to support the arm in the desired location. Then the operator goes to the patient’s right side and performs the catheterization from the standard side of the table.
Do you notice any increased catheter resistance with the use of the StandTall?
No, I have not noticed any additional resistance when torqueing catheters. When you initially advance your J-tipped wire through the StandTall and subsequently advance a catheter over the wire, you often feel the transition point between the StandTall to the sheath. But after the catheter is in the ascending aorta, I don’t notice a significant impact of the StandTall device on catheter manipulation. Use of the StandTall device has not impacted my selection of catheters for any given cases.
What about radiation exposure?
There is a general concern that if you are going left radial and leaning over the patient, that the operator may be exposed to more radiation. Whether use of the StandTall device might reduce physician radiation exposure by preventing the operator from leaning over the patient has not been studied.
Any final thoughts?
The StandTall device and Cobra board have enabled me to do more left radial access without having to lean over. I am hopeful this approach will reduce the risk of back injury while allowing my patients to avoid the risks associated with femoral access.
Disclosure: Dr. Madder has received research support from and serves on the advisory board of Corindus Vascular Robotics.
The authors can be contacted via Dr. Ryan Madder at firstname.lastname@example.org.