Dr. Quinn Capers, IV
"Femoral closure devices give operators a false sense of security. Statistics show that the femoral closure devices do not reduce complications," said Dr. Christopher J. White, an interventional cardiologist and medical director of the John Ochsner Heart & Vascular Institute in New Orleans. "The prevalence of radials will continue to increase, eventually reaching parity with [the usage rate in] Europe and South American, perhaps in 5-10 years," he said in an interview.
"I first used radial access when I practiced in the United Kingdom for 3 years, but when I returned to America in 1997 I had six partners who were all femoral-access doctors," Dr. White recalled. "Now, 15 years later, three of those doctors are predominantly radialists, two use it occasionally, and the sixth, the oldest, remains stubbornly an exclusive femoralist. It is hard to teach an old dog a new trick, particularly when PCI procedures can result in life-threatening complications. Why should an expert at femoral access become a novice at radial access?" Radial access "is not for every case, and perhaps not for every interventionalist, but younger cardiologists and trainees are the ones changing the balance. The next generation of interventionalists will be the radialists of the future," Dr. White predicted.
Interventionalists "who do 50 or 75 PCIs a year don’t have the time to retrain with radial, and there is no imperative for a 50-year old to switch to radial access to only do PCIs for another 5 or 10 years," said Dr. Bates. Ideally, "radial is something every interventionalist ought to learn to do – it’s a complimentary technique" to femoral access, but he agreed that it will primarily be the interventionalists who become proficient with radial access during training who will drive a change in American practice.
The data Dr. Feldman reported came from the CathPCI Registry of the National Cardiovascular Data Registry, organized and sponsored by the American College of Cardiology. During the nearly 5 years studied, the participating hospitals, about 70% of U.S. centers that perform PCI, treated 2,135,994 patients who underwent PCI via femoral-artery access, and 94,729 who had PCI with radial-artery access. Quarterly rates of radial-access use stood at 1.2% during early 2007, and remained below 2% through the first quarter of 2009, but then began to rise steadily, reaching the highest level so far, 11.4% of all PCIs, in the third quarter of 2011.
Dr. Ian C. Gilchrist
The data also showed notable regional variations in PCI access sites, with radial-artery access more widely used in northeastern states. By mid 2011, radial PCI represented about 20% of all PCIs done in the northeastern U.S. region, compared with rates that peaked at about 8%-10% in the West, Midwest, and South.
The analysis also showed that 94.7% of the radial cases and 93.8% of the femoral cases produced procedural success. Bleeding complications affected 2.8% of the radial-access patients, compared with 6.1% of the femoral-access patients. In a multivariate analysis that adjusted for several case-specific differences, PCI done through the radial artery led to a statistically significant 56% reduction in any bleeding complication and a significant 65% reduction in any vascular complication, and a significant 14% increase in procedural success compared with femoral access, Dr. Feldman reported.
Patient subgroups with the biggest reductions in bleeding complications from radial access compared with femoral access were women, patients with ST-elevation myocardial infarctions, and patients who were at least 75 years old.
The data reported by Dr. Capers came from a comparison of post-PCI complications among the 414 patients who underwent PCI at Ohio State during the first quarter of 2010, and the 343 patients who had PCIs performed during the fourth quarter of 2011. During the earlier period, 5% of patients treated with PCI at Ohio State had access via the radial artery, while at the end of 2011 50% of patients had radial-access PCI. This shift in PCI access started in 2010, when the seven attending cardiologists who perform PCIs at Ohio State agreed to all share a "radial-first mindset" for all elective procedures, Dr. Capers said.
The shift linked with statistically significant reductions in the rates of bleeding complications, blood transfusions, and major access-site complications during the first 72 hours following PCI, and also a reduction in post-PCI shock of about two-thirds that just missed statistical significance.
"These data are compelling" as a rationale for broader use of radial-access PCI, Dr. Capers said. "I think our use of radial access will continue to go up. We realize that we should do more radial cases. A lot is driven by the fellows [who know how to perform radial-access PCI] and by patients who ask for it," he said.