Although the much-anticipated RIVAL trial failed to meet its primary endpoint, transradial advocates point to the procedure’s potential to reduce vascular complications, improve patient comfort and lower costs as reasons for greater utilization of the procedure. Starting a radial program takes forethought and commitment, though. Three seasoned operators offer guidance for building a successful radial program.
Tip #1: Get trained
While there is currently no formal certification required for performing radial procedures, Sandeep Nathan, MD, director of the University of Chicago Medical Center’s interventional cardiology fellowship program, says there is a distinction between those who are trained and those who grapple through in an attempt to learn radial techniques.
Nathan, who performs radial PCI in 75 percent of his cases, says the first, most important step is training. “If you try to implement a new procedure without both the educational and infrastructure already in place, it will be doomed for failure,” he says. “Likewise, if you have a string of procedural failures right up front, your administration will write off the procedure.”
A physician’s best bet is to get trained at a high-volume, experienced center. While learning curves vary, Nathan says that there are two training options:
- Didactic courses: Courses like the Chicago Transradial Summit, which provides advisory information about radial access data, case reviews with expert clinicians and transradial simulation that accurately represents the feel and response of catheters during procedures; or
- A “wet course” at a high-volume radial hospital: Go into a lab, scrub in and stand behind an experienced physician to learn the ins and outs of specific radial cases. Learn how to spot problems and troubleshoot when a difficult case arises.
“It’s naïve to think that you will wake up one day, want to go radial and be able to perform radial PCI properly,” says Samir B. Pancholy, MD, program chair at Mercy Hospital & Community Medical Center in Scranton, Pa., who has performed radial since January 2004 and uses the approach in 95 percent of cases. Physicians must first understand how to get radial access, how to achieve homeostasis and what medications are best used after a procedure.
However, the larger, unanswered question is what should the optimal, minimum case volume be for radial proficiency? Research has shown that insufficient operator experience can impede procedural success. Ball et al recommended that the minimum case volume for operators should be 50 and noted that operators who performed less than 50 cases used more contrast, saw worse outcomes and had higher fluoroscopy times (Circ: Cardiovasc Intervent 2011;4:336-341).
The Society for Cardiovascular Angiography and Interventions (SCAI) developed TRIP (transradial intervention program) to give physicians simulation radial training. Pancholy says that the course sold out for the last two years, indicating that more physicians see value in learning the procedure.
Tip #2: Get staff on board
It is important first to get buy-in from both nurses and technologists. “Attacking this initiative on multiple levels simultaneously is about the only way to ensure success,” says Nathan, adding that cath lab staff should be open with administration and outline procedural costs, benefits and need.
“In terms of resource utilization, it is important for administration to be made aware of the benefits so that they don’t have the misconception that this procedure is just a gimmick that does not require a great deal of attention or thought,” Nathan adds.
Planning is particularly important for emergent patients, in whom evidence is building for radial utilization. Data from the Italian REAL registry showed that the radial approach may cut two-year mortality and vascular complication rates in acute MI compared with the femoral approach (JACC Cardiovasc Interv 2012;5:23-25). Vascular complications occurred at a rate of 1.1 percent when the radial approach was used compared with 2.6 percent with the femoral approach. At two years, these rates were 4.9 percent vs. 6.9 percent, respectively.
In addition, the need for nursing labor will decrease because patients who undergo radial procedures are more self-sufficient and can be overseen by a single nurse. “This reduction in nursing staff has the potential to save $100 to $200 per patient,” Nathan says.
Anticipate resistance from the staff, nurses and technologists,