YOUR TRANSRADIAL ACCESS UPDATE WHAT’S NEW IN THE CATH LAB?
Transradial access (TRA) for the purpose of cardiac angiography and percutaneous cardiac intervention (PCI) has become an accepted approach within the United States and throughout the world. One of the first published accounts of TRA was in 1989 by Lucien Campeau of the Montreal Heart Institute. In a study of 100 patients, Campeau reported that TRA was safer than percutaneous access of the brachial artery with an 88% success rate. In 1992, KIiemenjj reported the first successful coronary stent placed via the TRA approach. While the TRA approach demonstrated an effective and safe alternative to the traditional transfemoral approach (TFA), this technique struggled to gain the same level of physician acceptance within the United States as it enjoyed in the rest of the world. Between 2004 and 2007, only 1.32% of all PCIs in the U.S. were performed using the TRA approach, compared to 10% worldwide and an even higher rate in Canada. The TRA approach continued to gain acceptance, and between 2008 and 2011, it grew to an estimated 27% within the U.S. and over 70% worldwide. A recent survey of cath lab leadership within the Pacific Northwest indicated well over 75% of those surveyed were performing TRA in their cath labs. Clearly, the TRA approach is growing in acceptance, and all indications are that this approach will become a future standard. Today, there is an abundance of data regarding TRA’s benefits, including a lower rate of bleeding and overall complications, especially regarding significant vascular complications. Most studies support that TRA has a lower overall cost as compared to the TFA approach, with the bulk of these savings centered on a reduced length of stay and reduced costs due to fewer vascular complications. As significant as all of these benefits are, the one that often stands out is a higher patient satisfaction rate, which supports an overall increase in quality of life. In some situations, early adoption of the TRA approach was forced on physicians when patients who had a previous angiogram performed via TRA asked for, or even insisted on, their next angiogram being performed via the radial artery as opposed to the femoral artery. TRA acceptance has also been supported by a variety of other elements. A huge increase in catheters, wires, and other equipment specifically designed for this approach has had a significant impact on the ease of use during the procedure, the overall success rate, and the reduction
in complications. Many physicians, especially graduating cardiology fellows, now view TRA as a standard. It has also been widely accepted by cath lab staff.
As noted, a key aspect of the TRA approach is postprocedure care, particularly regarding patient comfort and overall length of stay. Patients who experience this approach can ambulate much more quickly and do not have the bed rest and mobility restrictions associated with TFA. Some facilities have now incorporated a “lounge chair” approach for patients having a TRA procedure. One important aspect of TRA postprocedure care is quick and effective hemostasis. Like the catheters and wires specifically designed for TRA, products designed for radial artery hemostasis have also advanced in quality. Hemostasis bands are a crucial piece of equipment utilized to ensure quality outcomes. Important elements to consider when evaluating hemostasis devices include patient comfort, ease of application, visibility of the access site, cost, and ease of use specific to training. Ease of use and initial training are especially important for facilities that do not have a pre- or post-area associated with the cath lab but instead send their postprocedure patients to a step-down nursing unit. These nursing units often have additional staff, including staff who “float” from other units, all of whom need to understand the proper use of the hemostasis device. A device that meets the noted requirements will ensure optimal quality and outcomes. The future of TRA includes areas outside of the cardiac arena. The TRA approach is now being utilized for cerebral, abdominal, and peripheral vascular procedures. Advancements in technology are supporting these expanded techniques and treatments. Every facility should consider TRA as a basic component of quality patient care.
–Dan Scharbach INDEPENDENT HEALTH CARE CONSULTANT AND FORMER REGIONAL DIRECTOR FOR PROVIDENCE HEALTH SYSTEM
REFERENCES Fischman A. (2013). The time is now for transradial intervention. Endovascular Today Fornell D. (2016). Radial access adoption in the united states. DAIC
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