If Radial Access Helps Increase Patient Safety, Why Aren’t More Doctors Using It?
During TCT 2009 this past fall in Washington D.C. I had the chance to listen to Shigeru Saito, M.D., FACC, ShonanKamakura General Hospital, Sapporo, Japan, explain reasons why he feels transradial artery access for interventional procedures is better than the U.S. standard of femoral access. Dr. Shigeru is among the biggest advocates in the world for transradial access, and is a self-described transradial intervention (TRI) evangelist. Living up to that title, he travels the globe each year to spread the word about the benefits of TRI and train physicians. Last year alone he visited 35 countries.
The first TRI was attempted in 1992. Dr. Shigeru said he started using the procedure in 2004 and since has become its biggest proponent. He advocates radial access as a way to help cut door-to-balloon times, because he says once doctors get familiar with TRI they can perform procedures faster than femoral access. He also said from his experience there is a high instance of complications using femoral access — primarily bleeding and incision site infection.
These same safety issues were highlighted in a recent meta-analysis of data on patients who underwent interventional procedures using either the femoral or radial access techniques. The study was published online in November in the American Heart Journal. The study found radial access significantly decreases risk of major bleeding compared to femoral access. Data also showed a trend toward fewer deaths and ischemic events using radial access.
Sanjit S. Jolly, M.D., of McMaster University in Hamilton, Canada and fellow researchers searched MEDLINE, EMBASE and CENTRAL from 1980 to April 2008 and conference abstracts from 2005 to April 2008 to identify randomized trials comparing radial vs. femoral access and examined cases for major bleeding, death, myocardial infarction and procedural times. They found 21 randomized trials with more than 5,400 patients. Their analysis showed radial access offered a significant reduction in major bleeding events and led to better outcomes compared to femoral access. Radial access also led to shorter hospital stays, the researchers found.
While these numbers seem promising, TRI accounts for a small number of the overall procedures conducted worldwide. In the U.S. the technique is rarely used and there is a lot of debate among American doctors about it. Dr. Shigeru classified the debate whether to use TRI as a fight between young and old interventionalists.
One of the arguments against using the access method has been hand ischemia induced by the procedure. There is also a steep learning curve to master the radial access technique, which is not taught at most U.S. medical schools.
Another reason why TRI has not been well received in the U.S. may be based on patient preferences. They generally don’t want scars on their wrists, which are much more visible than the groin. Second, it was pointed out in the TCT session patients need to be more heavily sedated because they tend to fight clinicians who are attempting to puncture their wrists.
We would be interested in hearing back from cardiologists who have attempted radial access and discontinued its use, and from those who adopted it as their preferred access method. My e-mail is firstname.lastname@example.org.