Transradial Access in Primary PCI: A Call to Arms

Bernard J. Gersh, MB, ChB, DPhil; Malcolm R. Bell, MD; Mackram F. Eleid, MD


February 10, 2014

In This Article

Transradial Delays Declining

Dr. Eleid: Historically, there has been a lot of reluctance to use the transradial approach for STEMI patients because of the longer procedural duration and the higher amount of experience required to use the transradial approach and also perhaps more delays in door-to-device time.

Dr. Gersh: What is the magnitude of time of prolongation with the radial technique?

Dr. Eleid: In the National Cardiovascular Data Registry data that just came out, there was about a 4-minute increase in door-to-device time with the transradial approach.[6]

Dr. Gersh: That shouldn't make a difference. Right now, door-to-balloon or door-to-device times are very low. They shortened so much nationally that we have room to play with. I can't believe that 4 minutes would make a difference.

Dr. Bell: Similarly, we have seen here that door-to-balloon time hasn't reduced mortality. Still, this is perceived as one of the disadvantages, and that is one of the points to make here. We are not talking about a 3- or 4-minute difference, but this is in experienced hands.

Dr. Gersh: You did allude to the fact that it's more difficult. There is a learning curve.

Dr. Eleid: Right, and that is another point that we were trying to bring out, a call to action that we raise awareness that this appears to be a safer technique. We can start using it for more basic cases and then slowly graduate up to the patients with acute coronary syndrome, as well. The experience in our catheterization lab has been that experienced operators in the femoral approach will adopt the transradial approach pretty quickly. They master those skills quickly.

Dr. Gersh: I accept that, but we also have to accept that it has taken us an awful long time to get to this point, even with elective percutaneous coronary intervention (PCI). The radial approach was being advocated 15 years ago for elective PCI and STEMI.

Dr. Eleid: It was more than that -- 20 years.[7]

Dr. Gersh: For instance, the radial approach has been far more widely used in Europe than it has in the United States, and some of the very early work in North America came out of Edmonton, Canada, not the United States. They were one of the first very large series of the radial approach.

So what is it about the United States that has created this delay? For a long time, people have been saying, "We do it in Europe. Why don't you do it?"


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