Give a hand to angioplasty

Coronary catheterization from the wrist rather than the groin saves money and is just as safe.

taglit.sendarticle (photo credit: )
(photo credit: )
If you had a clogged coronary artery and were given the choice of a treatment barely more stressful than a dental implant which allowed you to go home a few hours later or having your groin shaved and staying overnight in the hospital, which would you choose? Most people would select the first option. This is no longer science fiction. Coronary catheterization for diagnosing vessel blockage in the heart, angioplasty (balloon treatment) and stenting (inserting metallic supports inside the arteries to keep them open) can be performed via the radial artery in your wrist instead of the femoral artery in the groin. Last year, transradial angiography for diagnosis and treatment constituted 52 percent of all percutaneous coronary interventions (PCI); in Bulgaria over 50% and in Germany 30%. In the US, it is much rarer - despite convenience to the patient - because hospitals lose money if patients are discharged a few hours after undergoing the procedure. The radial artery technique has been proven to be no more risky than when the catheter is threaded into the femoral artery if performed by a well-trained and experienced cardiologist. In Israel, the radial technique saves money, as the health funds pay the hospital the same fee for the day procedure and overnight bed space can be allocated to a patient who needs it. It has been available here for a decade, and whole books have been devoted to the technique. In 2004, the prestigious British Medical Journal published a clinical review by cardiologists from the London Chest Hospital that strongly endorsed the radial artery in most cases. The British authors found that complications using the radial artery, which is only two or three millimeters wide, are negligible even in patients receiving drugs to thin their blood, while complications when using the femoral artery range from 2% to 8% of cases. The size of the hole in the wrist is the same as that made when giving blood. In addition, most patients are much happier when the catheter goes into their wrist instead of the groin. The authors quoted a typical patient: "When I had my first angioplasty just over a year ago the entry point was the right groin, and I assumed that it would be the same for my second treatment. I was informed by Dr. Archbold that he was going to enter via my wrist. This came as a surprise, but I thought it couldn't be any worse than the other treatment. The procedure took about 20 minutes and was no more uncomfortable than going to the dentist. You all know how the groin treatment works, so I will describe what I feel are the plus points for the wrist entry. The preparation is easier and involves no shaving. I did not have to lie awkwardly to allow the surgeon access. I could feel the wire at some points going up my arm, but it was not at all painful. "As the treatment finished, Dr. Archbold attached what I can best describe as a wristwatch type of thing to my wrist, covering the entry wound; he injected air into this, which sealed the wound. I could get off the trolley onto my bed virtually unassisted. This is so much better than the old method. I felt well on returning to the ward, apart from a slightly heavy arm, which soon subsided as the air pressure was reduced inside the dressing. The nursing staff only had to reduce the air pressure in my dressing periodically until the wound stopped bleeding. I did not have to have a nurse pressing hard on my groin for 20 minutes, and there was no associated bruising. I did not have to lie in one position for six hours, and could get up and use the toilet. "Overall, I feel the wrist entry was a lot less intrusive and generally more pleasant than the groin entry method." BUT RADIAL-ARTERY procedures remain uncommon in Israel. What has been holding the radial artery-route procedure back here? Shaare Zedek Medical Center interventional cardiologist Dr. David Meerkin says it is "a certain conservatism, the fact that cardiologists need time to become skilled in the procedure, and that older ones may have poorer hand-eye coordination. The first angioplasties were performed from the arm, he told The Jerusalem Post in an interview in his 10th-floor hospital office. "But cardiologists decided to use the femoral artery instead because catheters then were much bigger, so the groin artery was more convenient, and if you had a problem with the radial artery, you ran a risk of affecting the whole hand, so people were not that keen on it." The pioneer was Dr. Lucien Campeau at the Montreal Heart Institute, who used it for diagnosing coronary artery problems in the late 1980s. Then in 1992, a Dutch physician named Dr. Ferdinand Kiemeneij performed the first angioplasty using stents. Within a few years, says Meerkin, it became more common. Meerkin, a senior cardiologist and director of experimental cardiology at the Jerusalem medical center, has performed thousands of radial-artery angioplasties, first in Canada and now in Israel. "I'm the only one at Shaare Zedek so far to do the radial procedure, and if I'm on vacation, then someone else does it from the femoral artery. I myself do 95% of cases from the wrist. Patients really appreciate it. My patients ask me why every interventional cardiologist doesn't do it. I explain that it takes time to become good at it." Soroka University Medical Center in Beersheba has, at 50%, the next-highest percentage of radial artery procedures, says Meerkin. "At Hadassah University Medical Center, for example, they do them only if the femoral artery is blocked." There is no ideological opposition among cardiologists to using the radial artery, but some claim that if you've threaded a catheter into it, if the patient needs the artery for open-heart bypass surgery at some time in the future, it is less effective. So I always use the radial artery of the patient's dominant hand, as heart surgeons always take the bypass vessel from the non-dominant hand." MEERKIN SAYS there is no age limit. "In older patients, those in their 80s, the procedure is more difficult and takes more time because there are more twists in the arteries, which are also usually calcified. Studies have shown that hemorrhaging from the femoral artery in patients over 80 is significantly more common, but it's safer on such patients when done from the wrist." Amazingly, patients who receive Coumadin, heparin and other anti-clotting drugs can still undergo radial-artery PCI without having temporarily to stop taking them. It can also be performed on diabetics. There is perfect control of the artery, he says, demonstrating a kind of plastic bracelet with a little air pump and a piece of polystyrene that puts pressure on the artery. He recalls a 78-year-old woman who had a life-threatening clot in her coronary artery. "But a few hours after her radial angioplasty, she went to her hairdresser and then to a bar mitzva at night. People she told were amazed that her doctor let her go, but it was perfectly safe," Meerkin says with a smile. "The concept is that in the future, the PCI ward will be built like an airport lounge, with comfortable chairs but no beds. Patients will come in and see an informative video about the procedure and hostesses will receive them. Radial-artery angiography is the leanest and most patient-friendly way of working. It's painfree within one hour," says Meerkin. But the Australia-born, Canadian-trained cardiologist won't agree to discharge every patient the same day. "I have criteria. I certainly wouldn't do it to a patient who has just had a heart attack. I wouldn't do it for a patient who had no heart attack but complained of chest pains for half an hour or more; then we keep them overnight. And if a patient with serious heath problems doesn't have an adequate psychological comprehension of his clinical condition - if he smokes, is overweight or has a dangerous lifestyle - I purposely won't let him go home in a few hours because it will be too easy for him and he won't change his habits. Then I will keep him overnight; I find this can make a difference." Last March, Meerkin - a father of eight who came on aliya with his wife and children in 1988 - organized at Shaare Zedek the country's first workshop on transradial coronary intervention. The one-day event was attended by about 70 senior cardiologists from about 15 hospitals around the country. "We had expected 25 to come. The participants left impressed by the advantages of the technique and eager to learn it," he said. "I was at the Montreal Heart Institute between 1997 and 1999, and spent part of the time learning the technique and doing it. A good interventional cardiologist can learn how to do it successfully himself after participating in 20 cases, but to be very competent, one would have to have participated in 100 or 200." He thinks that in the coming years, the share of radial-artery procedures will increase significantly if the public demands it. "Today, most people want to return to their lives and homes and not stay overnight in the hospital if it can be avoided. Veteran cardiologists don't like the feeling of having to learn something new, especially if there is not enough demand," Meerkin concludes. Asked what he thinks of the radial-artery method, Health Ministry deputy director-general Dr. Yitzhak Berlovich, who is in charge of its medical branch, says: "I hope hospitals will use the radial approach whenever possible, as it saves money and beds and is safe if performed by well-trained personnel. As demand increases, the number of doctors who train for it will increase."