Techniques

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Transradial PCI

A review of transradial percutaneous coronary intervention.

With the first Percutaneous Coronary Intervention (PCI) performed in the 1970s, transfemoral access (through the groin) became the default strategy for treating patients.  However femoral access requires a larger entry site, which has been associated with increased risk of potentially life-threatening complications including:

  • Blood loss and hemorrhage
  • Retroperitoneal hematoma
  • Pseudoaneurysm
  • Arteriovenous fistula
  • Neuropathy

In the hands of experienced operators in high-volume transradial catheterization centers (i.e. hospitals primarily utilizing vascular access through the wrist), transradial intervention (TRI) offers decreased access-site complications and improved patient comfort.

The Rise of TRI

By the early 1990s, many of the procedural complications noted above presented significant risk to patients, particularly those at high risk for bleeding complications, such those with Acute Coronary Syndrome (ACS) with or without ST-Elevation Myocardial Infarction (STEMI), the obese, elderly, females and left ventricular dysfunction patients. This prompted Ferdinand Kiemeneij, MD, PhD, to seek an alternative method of PCI and perform the first transradial coronary stenting procedure, forever changing the landscape of interventional cardiology.

TRI has been slow to catch in some parts of the world until recently because many cath labs prefer to perform same-sitting interventional procedures and must be ready for complication. The femoral artery allows passage of large caliber guiding catheters and adjunctive devices such as balloon pumps to allow virtually any type of percutaneous interventional procedure.

Performing PCI via the radial artery is technically more challenging and time consuming during the initial phases of learning, which has also contributed to slower adoption of TRI, especially in the US.

Recent technical advances in the miniaturization of diagnostic catheters to 4F and 5F catheters, along with very low profile stent technologies such as SLENDER IDS, now address many of these concerns.

With data from large, randomized, controlled clinical trials now consistently demonstrating that TRI, compared with transfemoral intervention, provides important patient safety benefits, including reduced:

  • Bleeding complications and blood transfusions1, 3-5
  • Death, myocardial infarction and stroke6
  • Contrast administration7

Its adoption is spreading much more rapidly. TRI has been recommended as the default strategy for PCI in Europe9. In fact, cath labs there performing TRI have established outpatient clinics where patients are treated and discharged the same day following a short observation period in a comfortable lounge.

Today TRI accounts for 68% of procedures worldwide. In the US, TRI has grown from less than 5% of PCI in 2007 to approximately 30% today10, representing the fastest growing segment in coronary stenting.

Clinical Benefits of TRI

In recent years, data from many landmark studies including MORTAL, RIVAL, HORIZONS-AMI, RIFLE-STEACS and others have established the considerable clinical benefits of TRI when compared with the transfemoral approach.

These include significantly fewer vascular complications and a reduction of access site bleeding complications by approximately 58% as compared to those resulting from femoral access.

Bleeding after PCI is associated with mortality. In the hands of experienced transradial intervention (TRI) operators, large, randomized studies have shown that compared with the transfemoral approach, TRI reduces

  • Bleeding complications and blood transfusions
  • Morbidity and mortality
  • Contrast administration

These clinical benefits are even more pronounced in acute myocardial infarction (AMI) patients.

Patient Benefits of TRI

Because no major nerves or veins are in the anatomic vicinity of the radial artery pulse over the radial styloid, the likelihood of neuropathies or arteriovenous fistulas is extremely small. Beyond anatomy alone, TRI goes a long way to enhancing patient experience:

  • Significantly minimized risk of nerve damage, which is more common with the femoral approach due to proximity of the femoral artery to the femoral nerve
  • Quicker ambulation. No need for the patient to lie flat for four-to-six hours, as generally is required with patients accessed by the femoral approach
  • Reduced length of stay: Same-day discharge is an option, because most patients are mobile almost immediately after the procedure
  • Reduced use of adjunctive products (e.g., contrast media) and exposure to radiation for the patient and healthcare team

Post-procedural Quality of Life (QOL) assessments have also been conducted during clinical studies and with patients most often complaining of:

  • Body pain stemming from the arterial access site
  • Back and/or hip pain
  • Overall peri and post-procedural discomfort
  • Difficulty walking
  • Ability to use the bathroom
  • Impaired social function
  • Depressed mental health

ALL of the above were significantly reduced with patients undergoing TRI as opposed to intervention via transfemoral approach.

And for those experiencing PCI via both methods, TRI was preferred by 90% of patients while transfemoral was preferred by only 2% (8% of patients expressed ambivalence). Given the discharge guidelines patients are typically presented prior to leaving the hospital, these results are not surprising.

Cost Benefits of TRI

A 2013 study of more than 7,000 patients undergoing PCI at five U.S. medical centers found:

  • US hospitals can experience nearly $50 million in cost savings annually by performing PCI via transradial versus transfemoral approach
  • Cost savings can exceed $800 per PCI procedure compared with transfemoral, driven by reduced post-procedural patient length of stay and reductions in bleeding complications
  • A single return trip to the hospital more than doubles the cost of care for Medicare patients undergoing PCI and receiving a DES, increasing costs from approximately $15,000 for an episode of care to $31,000 with a single readmission

Since 2009 the Centers for Medicare and Medicaid Services (CMS) are publicly reporting hospital readmission rates to increase the transparency of hospital care, with the goal of helping consumers choose a care venue while providing hospitals with a benchmark in their quality improvement efforts.

CMS went further in 2012, launching the Hospital Readmissions Reduction Program (HRRP), in which hospitals with high rates of readmissions for acute myocardial infarction, heart failure, and pneumonia are penalized with a 3% reduction in Medicare payments.  Today it is estimated 78% of hospitals are assessed some level of penalty by CMS. And, HRRP is expected to expand in the coming years to include penalties for PCI readmissions.

In multiple large, randomized clinical studies, TRI has consistently demonstrated reduced bleeding complications compared with the transfemoral approach1-4, including in high-risk patients presenting with AMI.  Utilizing TRI alone may reduce bleeding complications and subsequent readmissions associated with PCI by 10%.

TRI Resources

Angioplasty.org – This website covers a broad range of information for medical professionals and patients, focusing in on angioplasty procedures, with a dedicated section on transradial access.  A must for patients and physicians.

PAMEAS.org  – PAMEAS is a not-for-profit patient advocacy organization “dedicated to improving healthcare delivery and the patient experience.” It offers healthcare news and education involving multiple disease states, including PCI via TRI.

TransradialUniversity.com – This interactive website offers on-demand informational modules intended to provide physicians and other medical professionals interested in expanding their use of transradial access with an introduction to various aspects of transradial cases from arterial access through hemostasis, including tips and tricks, with contributions from leading transradialists.

TransradialWorld.org  – This website is provided by Total Cardiovascular Solutions (TCVS), a group of interventional cardiologists specializing in TRI procedures.