When was the last time you came across a simple and straightforward change in clinical technique that typically results in better clinical outcomes, fewer complications, higher patient satisfaction, and lower cost per procedure? While that has occasionally happened in the cardiovascular field, the increasing trend for substitution of the transradial (through the wrist) for the transfemoral (through the groin) approach for PCI, seems to be a real "win-win" for everyone involved.
Traditionally, guidewires and catheters for PCI are inserted through the femoral artery. Bleeding or vascular complications occur about 2% of the time. Patients are recovered lying flat and immobile for 4-6 hours to prevent bleeding, which has also been helped by the advent of vascular closure devices. The patient is more comfortable, dangerous bleeds are reduced, but vascular complications still exist. Enter the transradial approach in the late 1980's. Outside of the U.S., about 40-50% of all PCI's are done transradially. In the U.S., that number currently is in the low single digits and only a small percentage of U.S. interventional cardiologists have been trained to use this approach.
The advantages of the transradial over transfemoral approach are significant and include:
- The initial needle puncture is simple and straightforward
- Not impacted by a patient with peripheral vascular disease, obesity or female gender
- No need to recover the patient lying flat and immobile; patients are recovered sitting up and can leave the cath lab almost immediately post-procedure; this allows (theoretically) the patient to forgo spending an overnight stay in the hospital
- Because no vascular closure device is required, a significant cost is eliminated
- Less bleeding and other complications, significantly decreasing the risk of mortality
- If present, bleeding or other complications are readily identified and easy to address
- Overall case cost is decreased by obviating the use of vascular closure devices
- It is safer, more convenient, and more comfortable for the patient
There are several reasons the approach has not been used more frequently, including:
- Lack of trained cardiologists
- Lack of financial incentives due to the existing reimbursement structure
- Lack of a marketing campaign by device manufacturers (who have concentrated their efforts outside the U.S.)
- Lack of patient demand because the approach has not been widely publicized
- An impression that the learning curve is too steep and learning inertia on the part of busy interventional cardiologists
- Lack of recognition and inclusion in practice guidelines or recommended practices by professional societies
As with any procedure, there are certain contraindications and potential complications. Additionally, physicians need to be trained in the procedure by those with solid experience. Like all new procedures, there is a learning curve. Despite these factors, the transradial approach is gaining momentum, fostered by recent study results and an increasing recognition by influential physicians that this approach has real benefit. CV services management staff should fully evaluate this approach, seek out physician champions and put together an implementation plan to successfully integrate this technology into their program. This can be a perfect hospital and physician performance improvement project or targeted metric as part of a physician/hospital alignment effort. It's not very often that a modest clinical change can simultaneously improve clinical outcomes, reduce complication rates, increase patient satisfaction, and lower procedure costs and be a "win-win" for all involved!
For further information, CFA suggests you review the article, Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention: A Report from the National Cardiovascular Data Registry, published in the November 2009 Journal of the American College of Cardiology - Cardiac Interventions.