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- Morton J. Kern, MD⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Morton Kern, University of California Irvine, Building 53, Route 81, Room 100, 101 The City Drive, Orange, California 92868
“… two roads diverged in a wood, and I—
I took the ‘one less traveled' by, And that has made all the difference.”
—Robert Frost (1)
You are at the sign post of 2 roads. One sign reads, “quicker, easier, but with more complications.” The other reads, “more difficult, takes more skill and time, but no complications.” Which road do you take? This is the essence of the radial versus femoral vascular access debate.
Once medical experience and data demonstrate the superiority of a treatment or procedure, the natural devolution and extinction of an outmoded method occurs. This was evident for cardiac catheterization. The Mason Sones' brachial artery cut-down is long gone, having given way to the Judkin's femoral artery approach. Soon, if not already, the percutaneous brachial technique will yield to the radial artery approach. Since Kiemeneij et al. (2) demonstrated the safety of stenting from the radial artery without the severe bleeding risks engendered by femoral artery access in the intensely anticoagulated patient, the evolving data favoring the radial over femoral approach has led to strong opinions among invasive cardiologists aligned with one technique over the other. Which technique is safer, quicker, has less radiation exposure, costs less, and is more comfortable and repeatable? Of course, neither technique can be used in 100% of patients, and, hence, there is a requirement for operators to employ both and an obligation of the cath lab trainers to teach both techniques. While there is a perceived unresolved controversy among the many reports, one can find consistent facts to guide the operator in his selection of best vascular access for particular patients.
In this issue of JACC: Cardiovascular Interventions, Brueck et al. (3) present another detailed study randomizing 1,024 patients to 1 of the 2 vascular access methods. Femoral access had slightly higher procedural success rates (97% transradial, 99.8% transfemoral, p < 0.0001). Transradial access had longer procedure times (40 min vs. 37 min, p = 0.046), and slightly more radiation exposure (42 Gycm2 vs. 38 Gycm2). Unique to this study compared with other reports is the fact that despite the use of femoral vascular access closure devices (used in 93% of the 179 PCI patients), the transfemoral access group still had 6 times the vascular access site complications (3.7% vs. 0.6%, p = 0.0008) compared with the radial group.
This study points again to the single greatest advantage of the radial approach, namely, reduced bleeding and vascular access complications. Every center that predominately performs the radial technique, like Laval Hospital, Quebec City, Canada, or WakeMed Hospital, Raleigh, North Carolina, delight in reporting no retroperitoneal hematomas, femoral pseudoaneurysms, fistula, painful large hematomas, artery occlusions, or emboli (4). The vascular complications from radial artery access are trivial compared with femoral complications with the worst of it being loss of radial artery pulse ranging from 3% to 9%. Strong data also support the radial approach for PCI. Jolly et al. (5) in a meta-analysis found that radial artery access reduced major bleeding 73% compared with femoral access (0.05% vs. 2.3%, p < 0.001) and interestingly identified a trend for reductions in composite of death, myocardial infarction, and stroke (2.5% vs. 3.8%, p = 0.058). There was no difference in death alone between the 2 techniques. For PCI, a higher trend for inability to the cross lesions from radial compared with femoral access was noted (p = 0.21). Radial access reduced hospital stay by 0.4 days (p = 0.001) and was associated with reduced major bleeding and strong trends for reduction in ischemic events compared with femoral artery access.
Yet radial access is still only slowly being adopted in this country. Rao et al. (6) report the volume of radial PCIs increased from approximately 1.3% to 3.5% by the first quarter of 2007 for those participating in the American College of Cardiology–National Cardiovascular Data Registry database. Given the disparity of vascular complications despite a more technically demanding route, should the femoral approach remain dominant when complications from radial access are so much lower? Many centers in Europe, Canada, and some sporadically located within the U.S. have already decided, “no.” Of course, many angiographers, especially those older than 50 years of age, trained and practiced for decades using the femoral approach are reluctant to travel a new road (i.e., embrace a new access approach). Given the occasional negative experience with the difficult patient in whom they are forced to use the radial technique, it is understandable and no surprise to hear, “Routine use of the radial approach for me? No way. I do not have the (fill in the blank—time, interest, need [read desire] to change, save money, or reduce complications).” This reluctance also includes the 2 major findings of Brueck et al. (3), that is: 1) an increased procedure time (albeit only 3 min); and 2) a higher radiation exposure (4 Gycm2), both attributable to more difficult catheter manipulation and requirement for higher operator skill. Although Brueck et al. (3) note that radial access increases radiation exposure, this small difference would not be nearly as much as having the procedure done by some less-accomplished femoral operators. Unlike Brueck et al. (3), most comparative studies provide no standardization of radiation protection making true conclusions difficult. Certainly when the radial learning curve is overcome, the difference in radiation exposure is minimal.
In the current debate, femoral advocates eschew adopting the radial approach wholesale further arguing: 1) fellows-in-training need to learn the femoral access approach first; 2) patients with prior bypass surgery and left internal mammary artery require a left-sided approach; 3) femoral access is faster; 4) femoral bleeding is reduced with vascular closure devices; 5) there are more options for percutaneous coronary intervention guide catheter sizes and support devices, like intra-aortic balloon pump; and 6) the post-procedure radial artery may not be suitable for coronary artery bypass grafting surgery. All appear as reasonable arguments. In the end of this debate we must concluded that to treat all patients, superior operators and labs should be very good at both approaches. For the best outcomes, femoralists should be become better radialists, and vice versa.
However, without a concerted effort, transforming the femoralist into an accomplished radialist will not be automatic no matter how much favorable data is provided. The perpetuation of a femoralist's negative prior experience will always limit accepting a more difficult road despite a better safety record. It is true that the radial approach is not great for a tortuous subclavian system, a small and vasospastic radial artery, or forearm anatomical variants (e.g., an ulnar loop) and if not done carefully has the potential for a cerebrovascular event. Nonetheless, most technical radial problems can be overcome with experience and persistence much like that required to conquer the occasional difficulties encountered in the femoral approach.
The study of Brueck et al. (2) notwithstanding, angiographers, like every other procedure-related specialist, should be performing the best procedure for the appropriate patient that has the best outcomes, lowest complications, lowest cost, and most patient comfort (Table 1). For this reason alone, modern angiographers should be thinking, “radial first then femoral” whenever possible. Our teaching and technique must rise to the occasion over personal reasons to achieve the best approach (i.e., specifically reducing vascular complications) for our patients. The new generation of interventionalists should be able to do procedures from both approaches with the same facility and safety, taking the road less traveled, leading to the best rewards for our patients.
Dr. Kern is a speaker for St. Jude Medical and Volcano Therapeutics, manufacturers of the pressure wire.
↵⁎ Editorials published in JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology.
- American College of Cardiology Foundation
- ↵The Road Not Taken. Available at: http://en.wikipedia.org/wiki/The_Road_Not_Taken_(poem). Accessed September 30, 2009.
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