Is the transradial approach just another access or a new patient-centric care model?

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Marcelo Guimaraes

Initially, I thought radial access was a great alternative for obese patients. However, it has quickly become my default arterial access after receiving patient feedback. In the last three years, I have adopted it as the default access in most transarterial procedures, writes Marcelo Guimaraes, Charleston, USA.

 

Radial artery access has been used for coronary interventions for at least 15 years. Large prospective randomised comparative clinical trials (RIVAL, RIFLE and MATRIX) have provided robust evidence in favour of transradial vs. transfemoral in coronary interventions. Recently, transradial interventions have gained considerable interest among interventional radiologists, largely due to the perception that it provides greater patient satisfaction, early ambulation and potential reduction in global cost. The debate whether transradial is “just another alternative access” has also occurred in coronary interventions many years ago. Today, radial access has become part of the standard of care in cardiology and it has been recommended as the default access by different interventional cardiology societies. In 2015, it is clear to me that radial access offers a new patient-centric care and one that is aligned with upcoming changes in healthcare reform.

Initially, I thought radial access was a great alternative for obese patients. However, it has quickly become my default arterial access after having the patient’s feedback in follow-up clinic visits. In the last three years, I have adopted it as the default access in most transarterial procedures. Transradial intervention is a simple and safe technique, as long as basic principles are followed. First, the patient must have a positive Barbeau’s test and an ultrasound-checked radial diameter of >2mm, and these are essential criteria. With the screening, our conversion rate from radial-to-femoral access is zero. Second, appropriate left arm and procedure table positioning and adequate and at hand devices are critical for an uneventful procedure. 

As radial access requires less intensive observation/care post procedure, the patient-to-nurse ratio can be potentially increased to 3:1 or 4:1 (instead of the typical 2:1). In the physical space typically reserved for two recovery beds, three or four recliners can be accommodated. This is part of what we call the “radial lounge” concept. It provides an opportunity for optimisation of personal and space and for cost savings without compromising safety. 

The “patent haemostasis” concept is used to decrease the risk of bleeding or thrombosis at the puncture site: an external pneumatic radial compression band applies enough pressure on the artery to prevent bleeding while patency is maintained.

There is a concern about stroke in transradial intervention. Left radial artery (prevents crossing of supra-aortic arteries), systemic heparin, adequate technique and devices are important factors to prevent it. A cardiology study followed about 5,000 patients for five years and the rate of stroke was 0.11–0.2%. Other complications, such as vasospasm, can be prevented using a vasodilator (200μg of nitroglycerine right after sheath insertion and just before its removal) and a hydrophilic radial sheath.

I believe there will be an opportunity to review the guidelines that recommend blood products infusion in coagulopathic patients who will have transradial interventions.

In our experience, radial artery access for interventional procedures is an example of “best practice” because it offers opportunities for reduction of complications, faster patient discharge, early ambulation/mobility and greater patient satisfaction.

As the current interventional radiology literature is sparse regarding this access route, we are carrying out a prospective, randomised clinical trial that compares transradial vs. transfemoral interventional in transarterial liver embolizations (ACCESS trial). The results will be available in the first quarter of 2016.

Currently, there are interventional radiology and cardiology devices that in combination allow us to carry out most visceral embolization procedures (interventional oncology, trauma, splenic, kidney, bronchial, thyroid) and visceral, cervical and proximal lower extremities angioplasty. There is a great opportunity for the industry as well. However, making longer devices is not enough. They must perform adequately in order to have safe and quick visceral and peripheral interventions.

Marcelo Guimaraes is director, Vascular and Interventional Radiology and associate professor of Radiology and Surgery, Medical University of South Carolina, Charleston, USA. He is a consultant to Cook Medical, Terumo Interventional Systems and Baylis Medical. He holds two patents with Cook Medical and is on the Advisory Board of Terumo Interventional Systems.