Radial access for stents: Fewer complications, shortened LOS
LOS reduced 4.5 days to 3; charges lowered by 15%
More and more of your colleagues are using radial instead of femoral access as an entry site for cardiovascular stenting. A new study conducted by cardiologists in Raleigh, NC, concludes that wrist artery access leads to fewer access site bleeding complications, earlier ambulation, shorter hospital stays, and lower costs than traditional groin artery access.1 The Raleigh investigators found total hospital stay reduced from 4.5 days for patients accessed through the femoral artery to three days in the radial group. Hospital charges were lowered in the radial group by 15%. (See Cost Management in Cardiac Care, February 1997, p. 13, for a story on the group’s preliminary findings.)
Traditionally, interventional cardiologists puncture a hole in the groin to gain access to the femoral artery for angioplasty and stent placement. Following the femoral procedure, the puncture site is subject to bleeding complications. Patients have to remain in a supine position, and that leads to back pain and difficulty voiding. Bleeding complications are especially likely in patients who have acute coronary syndromes because they typically receive high levels of anticoagulants and blood thinners.
By contrast, because of its size and position, the radial artery in the wrist is less prone to bleeding complications. "Patients love it because they can get up and walk much earlier than before," says lead study author Tift Mann, MD, of the Wake Heart Center in Raleigh. The research team randomized 142 patients who were receiving a stent for an acute coronary syndrome to have their procedure performed from either the femoral or the radial access site. Stents were successfully implanted in 96% of the patients in each group. Bleeding complications at the access site occurred in three patients in the femoral group compared with no patients in the radial group. All patients received 325 mg aspirin prior to the procedure. Heparin, 5,000 units, was administered during catheterization, and additional heparin was given on a weight-adjusted basis prior to the interventional procedure. Abciximab was administered during the procedure. (See related article on abciximab, p. 136.) All patients received ticlopidine, 500 mg, at completion followed by 250 mg for two to four weeks.
Jerri DeVaney, RN, BSN, care manager of the cardiac service line at St. Francis Hospital and Health Centers in Beech Grove, IN, says her department started doing radial access almost a year ago and have performed the surgery on 50 patients with no complications thus far. "It relieves the patient of the necessity to lie flat and allows more mobility and comfort," she says.
The superficial location of the radial artery allows easy hemostasis. The radial artery sheath is removed immediately at completion of the procedure. The St. Francis team uses a compressive dressing at the catheter insertion site on the wrist for about an hour so patients can sit up and eat. The bandage is removed gradually to assure bleeding has stopped. Soon, patients can resume normal activities. "Patients are happier with radial access," DeVaney says. "When we go in through the groin, their backs hurt and they can’t turn."
Edward Oruci, MD, an interventional cardiologist at Long Island Interventional Cardiology in Roslyn, NY, points out that elderly men have difficulty urinating while lying on their backs. "A Foley catheter often has to be placed, and that can be traumatic. So being able to get up quickly is important."
"Most of our radial access patients go home the same day," says DeVaney, "and that saves a whole day’s hospitalization charges." Radial access patients at St. Francis go to a step-down unit or the cardiac procedures recovery unit — the facility’s short stay observation area — instead of a coronary care unit (CCU), so use of those resources are decreased too. Within about two hours, the patient is fairly mobile; using groin access, patients are flat on their backs for four to six hours in the CCU.
David McRoberts, RN, director of the catheterization lab at St. Francis says an important advantage of radial access is that the procedure allows easier and more cost-efficient post-op care. "Patients would be able to walk off the table if it were not for the conscious sedation. We go in through a small puncture at the radial artery. Once the catheter is engaged, everything else is done as you would if you went in through the groin."
Oruci says he has done radial access safely and successfully more than 100 times. In his words, "It’s feasible and appropriate." The femoral approach is associated with complications such as blood clots, the need for blood transfusion, surgical repair of vascular problems, and lingering pain that limits mobility. All those problems are preempted by the radial approach. "The patient is allowed to get up out of bed quickly, back on his feet, without complications," he says.
New systems shorten learning curve
Because the radial artery is smaller than the femoral artery, the radial access technique makes use of a miniature catheter system. Procedure time and cost of operating room time are equivalent to the traditional methods of angioplasty and stent placement. The significant economic benefit to hospitals involves a shorter length of stay and the need for fewer diagnostic and therapeutic procedures for stent-related bleeding complications.2-4
"Not only can patients leave the hospital sooner," Oruci says, "radial access lessens their anxiety state. It seems to make them more at ease when they see how easy it is for us to enter the heart from the arm. And that seems to motivate them to begin taking care of themselves."
Patients are kept overnight after the radial access procedure just as after the standard femoral approach at Oruci’s hospital. "But none so far has had to spend more than that one night," he says.
There’s a class of patients who should not be approached with radial access, he warns. They are among a small percentage — 5% of the population — with only one artery supplying the hand. About 95% of the population has one artery on the radial side and one on the ulnar side of the wrist offering a dual blood supply to the hand. Prospec tive patients are screened to determine the adequacy of blood flow. "You wouldn’t want to jeopardize that single blood supply to the hand," he says, "because while you work in the radial artery, blood flow into the hand is temporarily stopped."
Until recently, stent size had to be considered when planning radial access, says Oruci, but because of new stents approved by the Food and Drug Administration, "we now have available a large selection that we can access through the smaller sheath size that we use for the radial approach." (See photo of stents, above, courtesy of Cook Cardiology in Bloomington, IN.)
Stenting from the radial approach involves a significant learning curve, but that should be shorter with the newer delivery systems. (See article, above, on a system recently withdrawn from the market.)
Radial access can be employed as well for methods of clearing blockages, such as the rotablator technique which uses a diamond-tipped catheter to drill away plaque.
1. Mann T, Cubeddu G, Bowen J, et al. Stenting in acute coronary syndromes: A comparison of radial versus femoral access sites. J Am Coll Cardiol 1998; 32:572-576.
2. Kiemeneiu F, Laarman GH, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by radial, brachial, and femoral approaches. J Am Coll Cardiol 1997; 29:1,269-1,275.
3. Mann T, Cubeddu G, Schneider J, et al. Right radial access for PTCA. J Invas Cardiol 1996; 8(Suppl D):30-35.
4. Cohen D. Outpatient transradial coronary stenting: Implications for cost-effectiveness. J Invas Cardiol 1996; 8(Suppl D):36-39.