VANCOUVER, B.C. – Ready to get started doing transradial percutaneous interventions? Begin under the guidance of an experienced practitioner, perform simple cases in lower-risk patients, and progress to more difficult cases as expertise builds, advised Dr. Asim Cheema, an interventional cardiologist at St. Michael’s Hospital in Toronto.
It’s best to start with a solid foundation in transfemoral PCI, and begin using the radial approach in stable patients who have single vessel disease and are presenting for angiography or some other elective procedure, he said.
Dr. Asim Cheema
"After about 40 patients, you can gradually start to become more comfortable doing multivessel PCI. Then, you can move on to an [acute coronary syndrome] setting, but still not STEMI [ST segment elevation myocardial infarction], and still predominately in larger males" because they have larger radial arteries. In the transition from transfemoral to transradial PCI, don’t hesitate to "switch to femoral [access] for unusual anatomy, technical difficulties," or other problems, Dr. Cheema said at the18th World Congress on Heart Disease.
At first, it’s best to avoid smaller and older patients. Transradial failure rates are greatest for those over age 75 years, in part because of subclavian tortuosity. Also, "if you are dealing with a small woman, she might have very small radial arteries that increase the chances of failure." Prior bypass grafting is a red flag for newer operators, too; among other problems, the grafts may be occluded. "Young patients and big patients and elective cases are where you want to start," he said.
Primary and complex PCI involving saphenous vein grafts or left main disease should not be attempted before doing more than 150 transradial procedures," recommended Dr. Cheema, who is a transradial PCI practitioner and researcher.
Familiarity with the technology is another important consideration, he said.
Hydrophilic sheaths, tapered and with a slippery coating, are important "because the radial artery is a small caliber vessel, [so] it’s more prone to spasm than the femoral artery. If you use a regular sheath, it causes spasm and you cannot maintain access," Dr. Cheema said.
"You want to use a 260-cm" exchange-length guide wire, as well, instead of the 180-cm wires used in femoral cases. "When you are doing radial [PCI], you have to be very careful about maintaining the wire position. You need a longer wire so it stays in place and your catheter can be exchanged," he said.
Dr. Cheema said he has no disclosures.