Catheterization through wrist artery proves safe and effective

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After James Hager began experiencing chest pain, he had a stress test, which was abnormal. His doctor prescribed a heart catheterization, which was performed late last month by David Lasorda, director of the interventional cardiology program at Allegheny General Hospital.

During the catheterization, a long thin tube called a catheter was inserted into the radial artery in his wrist and threaded through blood vessels to his heart while diagnostic X-rays were taken. Mr. Hager, 73, of Uniontown, was under light sedation to keep him relaxed, and the site of the catheter's access had been numbed with a local anesthetic.

Afterward, Mr. Hager, had to lie still for about a half hour with a bracelet-like tourniquet called a HemoBand on his wrist to prevent bleeding. Then he was free to move around.

Sometimes, heart disease treatments like angioplasty and placement of a stent to open a blocked artery are done during catheterizations. In an angioplasty, a tiny balloon is temporarily inserted and inflated to help widen the artery. Mr. Hager's procedure was simply diagnostic because it showed he had significant multivessel coronary artery disease, and Dr. Lasorda wanted to discuss Mr. Hager's options with him, his surgeon and family. The decision eventually was made to open the blockages by placing stents through another catheterization.

The wrist approach to catheterizations is a marked change from the usual method of doing them in the United States. Here, according to the American College of Cardiology, 95 percent of the millions of procedures done over the past two decades have been done by threading the catheter through the femoral artery in the groin.

But that's been changing in recent years, and if patients had their way, they'd be having their catheterizations done as Mr. Hager's was all the time. That's because the femoral is a much bigger artery and underneath flesh. To prevent bleeding, the patient has to lie still several hours afterward with compression on the access point.

Howard Cohen, director of cardiovascular intervention at New York City's Lenox Hill Hospital and formerly of UPMC, said he's had a lot of patients over the years who have had both procedures and all say they prefer to have it done through the wrist. In fact nowadays, he does 90 to 95 percent of them that way, he said.

Dr. Cohen, like other doctors, has experienced fewer bleeding complications and found it best suited for patients with health risks, such as obesity, back problems, inherited bleeding problems or clotting issues that require blood-thinning medication. Less hospital care also is needed, some doctors and studies have said, which lowers health costs.

Now, a recently published trial involving 7,021 patients at 158 hospitals in 32 countries -- the largest randomized study ever done -- has compared the two approaches. The major findings of the so-called RIVAL trial: That both techniques are safe and effective, but that a lower rate of bleeding complications, particularly where the catheter is inserted, may be a reason to use the wrist approach.

If there were any surprises, said lead author and interventional cardiologist Sanjit Jolly, it was that patients who had the catheter inserted in the groin had results that were very safe in terms of life-threatening events, particularly with experienced doctors. Dr. Jolly, assistant professor at the Michael G. DeGroote School of Medicine at McMaster University in Hamilton, Ontario, said he uses the wrist approach in about 80 percent of his cases. The rate is somewhere between 30 and 50 percent in Canada, he said.

The wrist catheterization was first performed in 1989, according to a 2008 study on the procedure printed in the Journal of Invasive Cardiology. Before that, back in the 1950s and '60s, catheterizations were performed in the arm right around the elbow, a procedure called the Sones technique after the cardiologist who invented it, said Mark Kozak, interventional cardiologist at Penn State Milton S. Hershey Medical Center.

The Sones technique itself began giving way to the femoral artery access in the '70s, Dr. Kozak said.

But for various reasons, including a lack of early technology like properly sized catheters, the wrist approach has not been widely used despite the positive feedback of patients.

Now, however, technology has improved and more interventional cardiologists have been trained in the wrist procedure, which, they say, has a longer learning curve than the femoral, in part because the radial artery is smaller and more circuitous.

Publication of the RIVAL study in the British medical journal Lancet, which was widely anticipated, is expected to prompt more interventional cardiologists to take the time to learn it.

"When it came out, a real buzz came out because this is the largest trial that has been done," said Krishna Tummalapalli, an interventional cardiologist at UPMC Shadyside and UPMC Mercy. "This will propel the radial approach more and more into the future because more cardiologists will pay attention."

The Society for Cardiovascular Angiography and Interventions has been doing one-day educational events on the wrist approach, and they're booked well in advance, said Tony Farah, AGH's chief medical officer and a trustee and spokesman for the society. Attendees include not only young trainees but also "cardiologists in practice for some time."

In Pittsburgh, AGH now has at least a half-dozen interventional cardiologists who perform the wrist technique, said Dr. Farah, medical director of the hospital's cardiac cath lab.

Trained in the Sones technique years ago, he has easily made the transition to the wrist and now does some 25 percent of his catheterizations that way. He said he could do many more if AGH weren't a teaching hospital. "We try to balance the need to train graduating cardiologists to perform both." Dr. Lasorda, who also did the Sones and who began doing the radial about eight years ago, estimated he goes through the wrist on 35 percent of his catheterizations.

An analysis done in March at UPMC Passavant showed that 21 percent of its catheterizations overall were done through the wrist, said John Schindler, director of the hospital's cath lab. Trained by Dr. Cohen as a fellow, he put his own rate of wrist procedures at Passavant at about 50 percent, although at UPMC Presbyterian his percentage drops to about 10. All 11 interventional cardiologists at Presby do radial catheterizations, and "the overwhelming majority" do likewise at Passavant, he said.

Dr. Tummalapalli, who also was trained in the Sones, began switching "more and more patients" to the radial approach in January. Now doing between 40 and 50 percent of his catheterizations that way, he said, his goal is to reach 80 percent.

Other interventional cardiologists are asking that he teach them the procedure, he said.

Not all patients are candidates for radial catheterizations. Dr. Schindler put the number at 30 percent, but Hershey's Dr. Kozak said that percentage drops to between 5 and 10 percent as a cardiologist's experience grows. Over the past 15 years, Dr. Kozak estimated he's done 3,000 or 4,000 radial catheterizations, about 60 or 70 percent of his total.

The RIVAL study found that 7.6 percent could not be done through the wrist.

One subgroup that should be excluded from wrist procedures are patients who fail to pass a so-called Allen's test given before catheterizations. It is to determine whether the ulnar artery, the other big artery in the hand, would maintain circulation should the radial artery shut down during the procedure. If the ulnar wouldn't take over blood flow -- and that is the case in a small percentage of patients -- the radial approach should not be used.

Other patients, more females than males, have a condition called Raynaud's phenomenon, in which the artery clamps down during the procedure.

Diabetics who are on or may need dialysis also should not take the risk of having something go wrong with the radial artery, which is needed for dialysis, Dr. Kozak said.

Doctors who do the wrist approach believe their number will grow slowly but steadily.

"When you're talking about procedure innovation, it takes time," said the RIVAL trial's Dr. Jolly, "and the change will happen gradually, which is probably the best way in terms of physicians starting and learning and feeling comfortable."


Pohla Smith: psmith@post-gazette.com or 412-263-1228.


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