A Left-handed Complement to PCI

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 - Left hand

The transfemoral approach for PCI continues to dominate clinical practice, but among operators who perform transradial PCI, another option has emerged: left radial access. While most operators prefer a right radial approach, left radial access offers some clinical and operational advantages that have begun to win over converts.

Acknowledging TALENT

Two years ago, a team of researchers in Rome published results of a randomized, two-center study designed to evaluate the safety and efficacy of left vs. right radial access for coronary angiography. The study was among the first to coax out differences between the two radial approaches, and it put Italy on the map as a leader in left radial access for cardiac catheterization.

It also helped to nudge the left approach into everyday clinical practice, at least at some centers.

TALENT randomized 1,467 patients into either a right or left radial access group, where all patients received diagnostic coronary angiography (Am Heart J 2011;161:172-179). Additionally, 344 patients in each group underwent PCI. The researchers found that patients in the left radial access diagnostic group had on average a shorter fluoroscopy time and reduced dose absorbed compared with the right access group.

Left’s upper hand was particularly pronounced in elderly patients, largely for anatomical reasons. Right-side subclavian tortuosity is more common in the elderly, which can impair procedural success and prolong the length of the procedure. In TALENT, operators reported two cases of subclavian tortuosity in the right radial access group and none in the left group. TALENT also showed that left access was easier for less experienced operators because catheter handling was similar to the more traditional transfemoral approach.

Preferred Site for Transradial Access
Right Radial %89.49289.593.294.683.2
Left Radial %10.6810.56.85.416.8
Source: J Am Coll Cardiol Intv 2010;3:1022–31

In its 2013 consensus document on the radial approach to PCI, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) gave left radial access a nod, noting that operators determine which approach to use (EuroInterventions, online January 2013). But the authors addressed the challenges of tortuosity and urged operators to be cautious when using a right radial approach.

Uptake of transradial has been slow in the U.S., but nonetheless TALENT’s findings have influenced PCI practice. “TALENT identified two groups in whom left radial access is associated with lower procedure times,” says Sunil V. Rao, MD, who was an international reviewer for the EAPCI document. Those groups included not only patients who are 70 years old and older, but also patients under 5 foot 5 inches because shorter people also tend to have more subclavian tortuosity on their right side than on their left side.

As director of the Cardiac Catheterization Laboratories at the Durham Veterans Affairs Medical Center in North Carolina and an interventional cardiologist at Duke University Medical Center, also in Durham, Rao and his colleagues have made a point of integrating TALENT’s lessons into their PCI protocol. Physicians tend to use a left approach on older and shorter patients, if appropriate, as well as all patients who have had a previous left internal mammary artery bypass graft.

Fellows also learn to perform both approaches.  

“Our cardiology fellows train radial from day one, and they train left radial from day one in a patient who has had bypass surgery,” Rao says. He estimates that about 30 percent of their cases involve post-bypass patients, “so we do a fair percentage of our cases [as left radial] and are very comfortable with that.”

Still an underdog

Rao’s center may be the exception, though, for the U.S. and globally. In a survey sent to more than 1,000 interventional cardiologists in 75 countries, Rao and colleagues asked operators about their transradial practice patterns (J Am Coll Cardiol Intv 2010;3:1022–31). The survey showed transradial is gaining traction worldwide for diagnostic and PCI purposes, but right access by far dominates the cath lab today. Overall, operators used the left approach only 10.6 percent of the time. European and Canadian physicians’ preferences hovered near the average at 10.5 percent but the U.S. ranked lower, at 8 percent. Japanese operators had the highest adoption rate for left radial access, at 16.8 percent.     

Many operators cite discomfort as a top reason for the left’s potential disfavor. Most work from the patient’s right side, and consequently need to reach over the patient to access the left arm. When the patient is rotund, or the operator is petite, that poses a challenge. “The big limiting factor in most westernized or developed countries is the fact that a patient’s girth can sometimes limit how feasible it is reaching the left radial arteries from the right side of the table,” Rao says.

But potential radiation exposure to the operator also raises concerns. TALENT researchers evaluated only radiation dose absorbed by the patient, and not the operator, who must lean over the patient to manipulate the catheter.  

“Most people don’t even try it,” observes Roberto M. Diletti, MD, an interventional cardiologist at Thoraxcenter of the Erasmus Medical Center in Rotterdam, the Netherlands. “They imagine [left access from the right side] is an uncomfortable procedure and they think they can have an increase in radiation exposure, but that is not the case.”   

Diletti and his colleagues attempted to address those concerns with a prospective trial that compared operators’ radiation exposure based on the radial access site (Heart, online Jan. 23, 2013). The trial enrolled 413 patients, randomized to either right or left radial procedures, with operators wearing a dosimeter on the left side of their necks. Unlike TALENT, the study included only diagnostic procedures in native coronary arteries; patients who had a previous coronary artery bypass, for instance, were excluded.  

Radiation dose was significantly lower in operators who treated patients in the left radial access group, at 33 μSv vs. 44 μSv for those using right radial access. The results held up in an analysis of experienced and less experienced operators. Radiation exposure in senior operators using right access was 19 μSv vs. 9 μSv using left. In less-experienced operators, it was 59 μSv using the right and 48 μSv using the left.

There was no significant difference is fluoroscopy time, dose-area product or contrast medium delivered, although the researchers reported a trend toward lower levels of fluoroscopy time and dose-area product with the left approach. “We focused on operator radiation exposure, but our data also suggest we can have a reduction in overall procedural time, fluoroscopic time and catheter use,” Diletti says.

Given the option, Rao prefers right radial access. Diletti admits that left radial access strains the operator’s back, and most cath labs require operators to work from the right side of the table, as is traditionally done with the femoral approach. But new techniques and technologies may reduce or eliminate the potential awkwardness of bending over the patient. Diletti and colleagues have developed an approach that involves elevating the patient’s left arm with a dedicated support to create a more comfortable experience for the physician. Rao adds that at least one vendor offers a mobile cath lab suite that allows access to the patient from either side.

Anecdotally, Diletti sees signs of an uptick in the use of left radial access as research points in its favor. “Left radial access maintains all the advantages of right radial access but it can overcome many of the disadvantages,” he says.

Radial Rings in Cost Savings
It is a no-brainer, says Steven P. Marso, MD, an interventional cardiologist at St. Luke's Mid America Heart Institute in Kansas City, Mo. Hospitals that want to compete in today's PCI market need strategies to reduce costs, and transradial PCI may help accomplish that goal.

In a cost comparison between transradial and transfemoral PCI, Marso and colleagues calculated that inhospital costs using transradial PCI provided a savings of $553 compared with transfemoral PCI (Am Heart J 2013;165:303-309). The cost of care was similar for both approaches on the day of the procedure, but post-procedure costs were much lower with transradial—mostly due to a 0.31 day decrease in post-procedure length of stay.

"To survive in this marketplace, you are going to have to put forth a high-value product: quality over cost," Marso says. "I think transradial access might be one way that affects both quality and cost."

Transradial PCI has been shown to reduce bleeding, vascular complications and length of stay. The study by Marso and colleagues showed savings trending higher in groups at moderate and high risk of bleeding, with a decrease in total adjusted inhospital costs of $585 for moderate-risk patients and of $1,046 for high-risk patients compared with the transfemoral approach.

"From a cost standpoint, [transradial] drives down bleeding complications, which are associated with a $10,000 to $15,000 cost and increased length of stay," he says.

Marso sees a strategy that takes advantage of transradial's reduced length of stay. Their study focused on inhospital procedures and did not include same-day discharge. Same-day discharge is possible with transradial PCI, though, because the approach allows some patients to ambulate quicker. That potentially frees up hospital resources.

"The way I see this going forward," Marso says, "if health systems want to recoup cost they would convert to transradial and then have strategies in place to greatly reduce their length of stay, because that is where the money is."