Taking a Radial Approach
Dr. Bell: Absolutely, and we would agree 100%. But we have to be very careful that we don't say that the transradial approach is taking over from the transfemoral approach, and the transfemoral approach is dead. There are times when you would use the transfemoral approach, so it is important that people are properly trained in both approaches.
What if you go back to the question about reducing bleeding and mortality? If this were a drug and you showed an NNT of 50, with 40%, 50%, or 60% reductions in these major endpoints, we would want to be using that drug, and it would already be in the guidelines. Currently, this is not even in the guidelines. It is fascinating, and that is why we need to have people talking about this more.
Dr. Gersh: It is going to be time to change the guidelines; clearly, it can't be ignored. We have a couple of minutes left for a few words of caution. Who should not be treated with the radial approach, right from the get-go?
Dr. Eleid: In the advanced elderly, there will be a higher risk for significant tortuosity in the arm vessels that may make an operator want to start upfront with the femoral approach. The other issue is the patient who presents already in cardiogenic shock. There is an argument for the transradial in that population, as well, and putting in a support device simultaneously from the femoral approach.
Dr. Gersh: And what about people with peripheral vascular disease?
Dr. Bell: That is always a challenge, whether it is femoral or transradial. Mack is absolutely right. Very elderly patients are a little more of a challenge in that they may have arterial anomalies and a lot of tortuosity. In some high-volume transradial labs, they routinely go from the left arm. But remember, these are some of the highest risk patients. These elderly patients are at higher risk, so we should not just automatically take the femoral approach with them.
We need some common sense. You need to be experienced in this technique. This is not something that you learn overnight and start doing with STEMI cases. In experienced hands, it is very reasonable to start with a radial approach; if it's clear that you are running into problems, there should be a certain time when you say, "Okay, we are going to stop and go the transfemoral route or to the other radial."
Who else perhaps shouldn't have this procedure? We talked cardiogenic shock. Typically, our high-volume operators will go to the transradial approach and leave the femoral approach for a support device, if needed. In the patient who clearly doesn't have a radial pulse, it is understood, or a patient who has multiple bypass grafts, and those cases clearly take longer for the transradial approach.
Dr. Gersh: Thank you both very much.
Dr. Eleid: Thank you.
Dr. Gersh: Congratulations on the article, and thanks to our viewers. We hope that you will continue to watch our roundtable series, which appears on theheart.org on Medscape. Thank you.
© 2014 Mayo Clinic
Cite this: Transradial Access in Primary PCI: A Call to Arms - Medscape - Feb 10, 2014.