Heart catheterization, a procedure to detect and clear clogged arteries, traditionally involves inserting a plastic tube through a groin incision into the femoral artery. But a new study shows fewer complications if the catheter is inserted through an artery in the wrist.
The American College
of Cardiology estimates that, of the millions of catheterizations done over the past two decades, at least nine in 10 have been through the femoral artery. It’s a big artery underneath flesh so that after the procedure, a patient has to lie still for several hours with compression on the access point.
A recent study published in the British medical journal Lancet compared the two approaches, based on a trial involving 7,021 patients at 158 hospitals in 32 countries. The major findings of the trial — called RIVAL, short for radial vs. femoral access for coronary intervention — are that both techniques are safe and effective, but that the wrist or radial approach has a lower rate of bleeding complications, particularly where the catheter is inserted.
When the study was published in April, “a real buzz came out because this is the largest (randomized) trial that has been done,” said Krishna Tummalapalli, an interventional cardiologist at the University of Pittsburgh Medical Center’s Shadyside and Mercy campuses. “This will propel the radial approach more and more into the future because more cardiologists will pay attention.”
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.
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. In Canada overall, the rate is between 30 and 50 percent, he said.
Howard Cohen, director of cardiovascular intervention at New York City’s Lenox Hill Hospital, said he’s had a lot of patients who’ve had both procedures, and all say they prefer wrist catheterization. Now, he does 9 out 10 that way, he said.
Cohen said patients with wrist catheterization experienced fewer bleeding complications. He has found it best suited for patients with health risks such as obesity, back problems, inherited bleeding problems or clotting issues. Some studies indicate patients with wrist catheterization need less hospital care than their counterparts with the traditional procedure, which lowers health costs.
Wrist catheterization was first performed in 1989, according to a 2008 study on the procedure printed in the Journal of Invasive Cardiology. Back in the 1950s and ’60s, catheterizations were performed near 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 gave way to the femoral artery access in the ’70s, 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 patients’ positive feedback.
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, a spokesman for the society and chief medical officer of Allegheny General Hospital in Pittsburgh. Attendees include not only young trainees but also “cardiologists in practice for some time.”
The RIVAL study found that 7.6 percent of catheterizations could not be done through the wrist. Among those are patients who are on or may need dialysis.
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