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The Radialist

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Radial approach: a safe and patient-friendly technique, with lower risk of complication and very few limitations.

Cardiac catheterization

Cardiac catheterization is a medical procedure used to diagnose and treat certain heart conditions. It is usually done after a patient experiences chest pain or shows abnormal results on an electrocardiogram (ECG) or an exercise stress test. The procedure involves threading a long, thin, flexible tube (called a catheter) through an artery of the leg (the femoral artery in the groin) or the arm (the radial artery in the wrist) into the blood vessels supplying the heart (also called coronary arteries). When the catheter is in place, it is used to visualize the coronary arteries and to treat them if they are diseased and blocked.

What is radial approach ?

Using the radial artery in the wrist as an entry point for cardiac catheterization was first tried in the late 1980's in Canada. Called the transradial technique, or radial approach, or transradial access, it has become an alternative to using the femoral artery.

The radial approach is the preferred access site for cardiac catheterization by a majority of interventional cardiologists throughout Canada, Europe and Asia. Compared to the traditional femoral access, radial access offers many advantages: fewer bleeding and complications at the catheter entry site, better postprocedural comfort for the patient and more immediate ambulation, and greater cost effectiveness.

The radial approach is the preferred access site for cardiac catheterization by a majority of interventional cardiologists throughout Canada, Europe and Asia
Lower risk of bleeding and better comfort

The femoral artery, because of its large size, can accommodate almost any size catheter. However, the femoral artery can be difficult to access especially in overweight individuals because it is located deep within the body. Furthermore, stopping the bleeding once the procedure has been completed requires heavy pressure at the groin. Patients then need to remain in the hospital lying quietly on their back for as long as four to six hours. This can be difficult and painful for some, particularly elderly patients and those with hip or back pain. In some cases, there can be retroperitoneal bleeding that is not immediately visible because of the femoral artery location within the body.

In comparison, the radial artery in the wrist is close to the skin surface, making the catheter entry more straightforward and less uncomfortable for the patient. When the procedure has been completed, a band similar to a wristwatch is placed around the wrist, which supplies pressure and prevents bleeding. Most patients are able to get up almost immediately and walk. Unlike the femoral artery, there is fewer bleeding from the radial artery, and if it occurs, it is readily apparent and easily detected.

Radial approach for the patient

Is the radial approach for everyone?

There are a few prerequisites for patients to be a candidate for the radial approach. The major one is confirmation of a dual blood supply to the hand. The radial artery loops around the hand and joins a second artery (called the ulnar artery). Both arteries supply blood to the hand and fingers. It is precisely this dual blood supply that makes the radial technique safe. Should the radial artery close up (a complication seen in a small percentage of cases) the clinical result tends to be benign, because the ulnar artery continues to function.

Although there are very few limitations, some contraindications exist, such as the need to use larger devices during the angioplasty, pre-existing bypass grafts in certain areas of the heart or tortuous vessels that may prevent the catheter from navigating to the coronaries from the arm.

Same-day procedure is a current reality

Several studies have shown that when there is no contraindication based on patient's condition, same-day discharge after transradial approach coronary intervention is safe and effective, and patient satisfaction appears to be high. A hospital stay of less than 24 hours is also possible with the femoral technique, but taking into account the risks of bleeding associated with femoral access, few cardiologists seem to feel comfortable with this idea.

Patient comfort

For patients who have experienced both radial and femoral access, there is a strong preference for the transradial approach due to increased comfort and ability to walk almost immediately and autonomously. Patient satisfaction is confirmed by cardiologists that use the radial approach. If patients are more informed of the benefits of this technique, they will be able to request it more readily. And if interventional cardiologists dismiss transradial approach, patients will understand that it is not because it is an inferior approach but because those interventionists do not have the training and/or infrastructure to offer it.

Impact of radial approach

Radial approach throughout the world

In certain regions of the world (like the U.S. for example) radial approach utilization remains infrequent. The major reason is the lack of interventional cardiologists trained in the technique. By contrast, Canada, parts of Europe and Asia perform 40%, and up to 90% in some specialized centers, of their cases using the radial artery.

The other reasons that limit the use of radial approach are the lack of economic incentive (due to the reimbursement structure), and the lack of patient awareness that this alternative exists. The situation, however, is changing. More and more health professionals are beginning to see the advantages in lower complication rates, increased patient satisfaction and even cost-savings (complications can be expensive to manage). For example, at the end of 2007, only 1.3% of all coronary interventions in the U.S. were performed via the radial artery. By the end of 2009 this has grown to 4.5%, and recent estimates is 10%.

Economic impact

In the current economic climate with budget reductions in health care systems, use of the transradial approach for cardiac catheterization and coronary intervention may become an integral part of cost-containment strategies, by improving the safety profile of the procedure while maintaining quality and procedural success.

Cost analyses comparing radial and femoral access sites have consistently shown a significant reduction in hospital and system costs with transradial approach: reduction of procedural costs, nursing care costs, length of stay, and costs related to complications after procedure. Same-day coronary intervention, made truly possible by transradial approach, also reduces health care costs.

What the future holds

Transradial approach is expected to be increasingly recommended by clinical practice guidelines and to become a benchmark for quality of care. Future interventional cardiologists will continue to develop and improve the techniques, including the radial technique, and this will constitute one of the main advances initiated by their predecessors.

Finally, in addition to coronary catheterization, the transradial approach has been adapted to other catheterization procedures, like those for carotid arteries and arteries in the kidneys. Therefore, a lot more patients are beginning to enjoy the safety and convenience of radial catheterization.

Watch the TV report on Radio-Canada for more information (in French).

What is radial approach

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