Monday, January 07, 2013

TRANSRADIAL ANGIOGRAM AND ANGIOPLASTY. IS IT READY FOR PRIMETIME

There is an interesting article on this topic in the Dec 26th online edition of the American Heart Journal on neurological complications after transradial percutaneous coronary interventions. The first author is Dr Karim Ratib from the University Hospital in North Staffordshire, UK. He and his colleagues reviewed the British Cardiovascular Interventional Society database. Their aim was to compare the PCI complication rate between the transfemoral and the transradial route. Reviewing the database from 2006-2010, there were atotal of 348092 interventions performed, of which 124616 were done through the transradial route ( about 35.8% ). The number of strokes in each arm were about the same ( 0.11% in each arm ). This shows that using the transradial route was not associated with a higher stroke rate. This was one of our initial fears, as we needed to change catheters across the arch and ascending aorta frequently, and this may dislodge clots or atheromatous material. Alas, this is not so.
This also gives me an opportunity to trace our own history.
Transradial angiogram and intervention ( a quick search in Google ) began in Montreal, Canada. Initially it was via transradial cutdown ( this was the era post Mason Sones ) when the Seldinger technique for arterial cannulation had not yet gain universal acceptance. Later in 1986, Campeau did the first 88 cases or so cases of transradial coronary intervention with good success. Across the pond, this was followed by the successful transradial work of Dr Kiemeneij of Netherlands published in 1993. One of his disciple in this field is Dr Shigeru Saito from japan. I was fortunate enough to learn this technique from Dr Saito in 1995. Having learn the technique and also acquired the catheters, I did a study of 30 cases of patients of various age group and both sexes, to see the size of their radial artery, at the completion of their transfemoral intervention. This was subsequently published in the Malaysian Medical Journal. I discovered that most transradial artery was 2.5-30mm in diameter, and so could easily take a 6F ( 2.0 mm diameter ), or a 7F ( 2.3mm diameter catheter ). I was then confident that I will not do harm. I was ready to start a transradial interventional program..Like all the previous giants before us, I began by doing default transfemoral ( as taught by my teachers in Glasgow, 1978 ), and only chose to do transradial in those with a very strong radial and ulnar pulse, males, young age, no previous bypass surgery, and not in acute coronary syndrome.
This went well, Initially we have a transradial cannulation failure rate of about 10-20% ( as we climbed the learning curve ). I also had a coronary angiogram failure rate of about 10% from difficult coronary anatomy and arterial spasm. These are also documented in another paper on our initial experience of 100 transradial coronary angiogram. The patients like transradial althougha few did complain about the compression band pain following the interventional procedure. The initial TR band ( vascular compression band to stop bleeding post procedure, by Terumo ) was elastic and this meant that it tighten and caused hand swelling and pain as it was too tight.
As we did more, we got better. We were faster and spasm was much less of an issue. Also over the last 3-4 years, we have been supplied with an air-compression band, which was much more comfortable for the patient post procedure, and there was much better patient acceptance and less hand swelling.
We have now got a 17 year experience and transradial is now default strategy, and transfemoral as a standby. We still have a failure arterial cannulation, but it is rare and easily in single digit. No more papers as we think that this procedure is now well established. In Europe, transradial form about 60-70%, USA about 10%, China about 60-70% ( in Beijing Fu Wai, where I had worked previously, it is 90% according to Prof Yang. ). In Malaysia, we are about 50-60% ( guesstimate ). It looks like the younger interventionist are transradialist, and the more senior ones are still clinging on to the transfemoral route. I find that the trasradial route is better for the patient, and more comfortable. Groin bleeding is now no longer a problem. With the current state of poor nursing care, this is a real relief for me. I understand that some transfemoralist use a vascular access closure device to avoid graoin bleeding. The vascular access closure cost about RM 8oo each, adding significantly to cost of procedure. I always tell them that they could save RM800 if they do it the radial way, which I believe is the way to go.

My way, the radial way.

1 comment:

Gaban said...

recently in my hospital, there was a transfemoral approach with dissection of the iliac artery. patient went into hypovolaemic shock and had to be blue-lighted to the regional vascular surgery unit. she lost 4 litres of blood into the abdomen by then.