I am pleased to be joined this month by Dr. Richard Heuser. Dr. Heuser and his lab have been a pioneers in the endovascular space. They are early adopters of technology that brings better outcomes for patients and makes the job of a successful clinical outcome all the more achievable. Dr. Heuser and his team have been longtime radial-first operators, and with the advent of devices that can now reach the legs from the wrist, he is once again breaking new ground to demonstrate not only the clinical efficacy but the overall utility, cost savings, and staff involvement that make these cases possible — and possibly more desirable — than the traditional femoral approach. He is joined by Gavin Lennan, RT(R), Cath Lab Manager at St. Luke’s Medical Center in Phoenix, Arizona.
— Gary Clifton, Vice President, Terumo Business Edge
Can you describe the impact of radial access in your lab, how staff is involved, and its cost effectiveness?
Richard Heuser, MD: We do involve the staff with the sheathless guides to our radial approach for peripheral cases. In our lab I prefer to use the Terumo R2P Destination Slender. Particularly when we are looking at length, utility of other technology, etc., it is really a team effort, more so than in many of the other procedures we do in the laboratory. We perform approximately 1500 cases per year, and in my practice, it consists of about 400 procedures, 50% of which are peripheral. In the overall lab, I would say 40% are peripheral procedures.
We have been a radial-first lab for the last 10 years, and even before sheathless guides were available, I would traditionally do my peripheral cases from the radial approach in order to ascertain the best access for treating whatever peripheral disease was present in our patient. If a patient with critical limb ischemia has a total occlusion of the distal superficial femoral artery or distal popliteal vessels, an antegrade stick with possible pedal approach allows us to be more successful. We do a lot of pedal access, but primarily in critical limb patients, many times we go with an antegrade stick. The advantage of a sheathless guide from the patient’s standpoint is manyfold. I no longer have to say to the patient, “We are probably going to have to stick your groin” after a roadmap from the radial approach, for example.
Just this week, I saw a patient of mine, a very hardworking nurse with bilateral leg claudication who could not take any more than 1 day off. She was one of our early patients to be treated very effectively with the use of a sheathless guide after we found a bifurcation iliac stenosis. She is still happy and cannot say enough positive things about this approach. Many of our patients have been treated in outside facilities from the groin approach and have always been happy when we are able to treat via radial access. I just saw a patient who I have been treating for the last 25 years who was unfortunately admitted to a hospital in another city with unstable angina. They went in from the right groin, she had a retroperitoneal bleed, and came back to have her left anterior descending coronary artery treated here in Phoenix. Unfortunately, she still has severe right groin pain and so was happy to hear we will be able to do this procedure from the right wrist.
This scenario is not at all uncommon. In Phoenix we not only get “snowbirds”, but also have a lot of patients who have moved here from up north, specifically, the midwest. An example is a practicing physician with known coronary disease who moved to Phoenix for an employment opportunity and saw via Google that we were the place to go for a radial procedure. Unfortunately, we have had to do several interventions since he moved here, but he is happy he hooked up with a radial-first physician.
The 3 cases shared in our article (page 14) are fairly illustrative of how radial procedures are cost effective. In terms of the carotid procedure, about one-third of our patients need to be in the hospital more than 24 hours, because of continued hypotension and because of the concern that it may be due to a vascular issue. Imaging of the groin as well as computed tomography (CT) scans have to be performed in a percentage of these patients. In the peripheral cases where an infusion would have been necessary, these hospitalizations could go for 3-4 days, and require expensive tPA infusions, transfusions, and evaluation for vascular complications. In both of the complex femoral cases, this issue was delineated in these patients, who would have otherwise been in the hospital for 3-4 days. In our experience, we usually keep them only for 3-4 hours, and 90% of our peripheral procedures, including patients with critical limb ischemia, go home the same day. We have been successfully performing outpatient chronic total occlusion percutaneous coronary intervention (PCI), but over the last 10 years, have almost uniformly discharged all PCIs the same day because of the radial approach. Same-day discharge with the radial approach continues for 80 to 90% of our treated patients.
We believe the staff interaction with the radial procedure is very satisfying for them, since it is easy to manage these patients and complications are so rare. The patients are happy and whether the procedure is done in the traditional radial access or via the distal radial artery, we have worked together with staff on different techniques to improve success as well as patient satisfaction.
Very early on, our facility did market the fact that we were a radial-first lab, and we have used our radial-first status regularly for marketing purposes, particularly in papers we write, and are accessed by many patients through their online Google searches.
As an interventional cardiologist involved with this specialty since 1979, I have found radial access to be very satisfying. My initial training at Johns Hopkins was with the Sones approach, which I feel very comfortable with. The improvement in catheters has been very satisfying. We have tried to utilize other shuttle-type catheters to do peripheral and carotid procedures, but found their use results in too much friction in the brachial area, resulting in spasm and a painful procedure. It is nice that manufacturers have taken it upon themselves to improve this technology, resulting in greater patient satisfaction.
For facilities and physicians that are reluctant to adopt radial access, I would say that if you continue to do radial procedures selectively, you will not get the full benefit of radial access for patients, physicians, or staff. Once your staff and physicians are used to treating ST-elevation myocardial infarctions from the radial approach, bleeding complications, which are a real phenomenon in these patients, will be a thing of the past, and the whole team will be behind you as a healthcare provider.
Gavin Lennan, RT(R), Cath Lab Manager: The cost of going radial compared to the groin can vary. If it is a basic diagnostic cath, the cost for equipment used in our lab is under $139. The cost for equipment used for the groin access is $312. That is the biggest difference we see financially, because when you go to do an intervention, the cost can vary due to many factors, including:
1) Catheter selection — does the guide give enough support from the radial position? Different catheters may have to be used.
2) If you decide to go to a 7 French system, you may have to go via the groin anyway or can use sheathless guides that have a bigger inner diameter. For a basic intervention, the cost I am using includes a guide, wire, indeflator, and stent. Radial is $1,105 compared to groin, which is $1,323.
From a clinical standpoint, there are many benefits to going radial:
1) Patient comfort, because they are allowed to sit up after the procedure.
2) The risk of complications is reduced from those that can occur when going with the groin approach, i.e.: hematoma, arteriovenous fistula, pseudoaneurysms, retroperitoneal bleeds, and possible infection. With those complications, there could be risk compartment syndrome, cold leg, or possibly the need for surgery. When it comes to radial, you have to worry about spasm and hematoma.
3) The shorter recovery time of radial at 1.5-3 hours compared to 4-12 hours (usually 6-8 hours, on average) with the groin.
More from Dr. Heuser in this issue:
Richard Heuser, MD, can be contacted at email@example.com.
Gavin Lennan, RT(R), Cath Lab Manager, can be contacted at firstname.lastname@example.org.