Reaching the Heart Through the Wrist
MONDAY, Aug. 18 -- Threading a catheter into the heart from the wrist rather than the groin reduces the incidence of bleeding problems during angioplasty, a new study finds.
The approach, using the radial artery in the wrist, is not widely practiced in the United States, according to an analysis of almost 600,000 catheterizations in a national database, said a report in the August issue of the Journal of the American College of Cardiology.
"It's done in about 1.5 percent of all procedures in the U.S.," said study author Dr. Sunil V. Rao, director of the cardiac catheterization laboratory at the Durham VA Medical Center.
The study found that bleeding complications in angioplasties done through the femoral artery in the groin were twice as common as for the radial approach, with 1.83 percent of persons having the femoral approach suffering excess bleeding, compared to 0.79 percent with the radial approach. The angioplasty success rate was as high for the wrist method as for the groin approach.
The study also found that bleeding complications with the radial approach were less common in people at higher risk, such as the elderly and those with acute coronary syndromes.
In angioplasty, a balloon-tipped catheter is threaded into a blocked heart artery and is inflated to reopen the artery. In most cases, a stent, a flexible tube, is inserted to help keep the artery open.
"We need powerful blood techniques to help prevent restenosis," Rao said. "Bleeding is a major problem. The majority of bleeding problems are related to the access site, and a bleeding problem is related to long-term survival."
Rao said he uses the wrist artery for angioplasty in about 85 percent of his cases. He reserves the groin approach when it appears that using the wrist artery will compromise blood flow to the hand.
The radial approach is more common in Canada, Europe and southeast Asia than in the United States, Rao said, although statistics on its use are not generally available. "Traditionally, that has been the way our people do it," he said of the groin method.
There are several reasons why the wrist method is not popular in the United States, said Dr. Howard A. Cohen, director of cardiovascular intervention at the Lenox Hill Heart and Vascular Center in New York, who uses it for most angioplasties.
"Generally, it hasn't been taught here," Cohen said. "There is a steep learning curve. You need 100 to 200 cases to feel confident with the technique. It takes a couple of years in a practice with a high volume. Also, it is technically more difficult in terms of the whole operation."
Safety is the main reason for using the wrist approach, Cohen said. "Also, it is much preferred by patients," he said. "It doesn't prolong the period of bed rest they need."
Another possible reason why the radial approach is not widely used in the United States is that the companies which sell equipment for angioplasties tend to emphasize the groin method, Rao said.
The radial approach "doesn't appear on their radar screen," Rao said. "They have equipment for the radial approach, but they just don't push it. Now that this study has been published, there might be an incentive to do it."
Angioplasty is explained by the U.S. Heart, Lung, and Blood Institute.
Posted: August 2008
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