SCAI: A 12-step program for 'femoral-aholics'
PHILADELPHIA--There are a variety of excuses why people won't adopt the radial approach to PCI. "If you are using any of them, you may be a femoral-aholic, and just like with any addiction, there is a 12-step program to help," said Pinak B. Shah, MD, at the Transradial Interventional Program sponsored by the Society for Cardiovascular Angiography and Interventions (SCAI) Jan. 15.

The list of excuses, suggested Shah, from the cardiovascular division at Brigham and Women's Hospital in Boston, includes:
  • Cases are longer and the staff gets upset;
  • The patient uses his hands for a living and I don't want to jeopardize it;
  • The patient has had prior CABG or needs a right heart catheterization;
  • I don't want to switch access routes for tough PCIs;
  • Hematomas are not so bad;
  • With closure devices, there is no difference between the femoral and radial approach; and
  • Hey, I can quit femoral and go radial anytime.

Shah then outlined his 12-step recovery program for femoral-aholics.

Step 1: We all have to accept the shortcomings of femoral access.

Femoral access may be easier and quicker for you now, but it is clearly a source of major and life-threatening bleeding, he said. There also are other complications that increase morbidity that include pseudoaneurysms and AV fistulas. Femoral access can be a high risk in certain patient subgroups such as those with morbid obesity and peripheral vascular disease.

"The morbidity of hematomas may be a much bigger deal than we've appreciated for many years," he said.

Bedrest is an issue with femoral access, and even with closure devices, people still have to be on their backs for a few hours. There also is a cost to vascular closure devices and closure device complications are often more exotic than standard manual pressure complications.

Step 2: As a corollary to Step 1, recognize the benefits of radial access.
The data are convincing, but more are needed. Everyone can agree that there is less major bleeding, Shah said, and as a result, there are fewer transfusions, which may be a link to lower mortality.

Patient comfort is a big plus, including immediate ambulation, immediate nutrition ("We still have a policy at our hospital that you can't eat until your femoral sheath is out, in case you vomit") and immediate urination—the normal way, "which is huge for many of our elderly patients."

Recovery area flow can be improved because patients don't have to be on their backs for so long. "There is emerging data that, as a result, we may be more cost effective with using radial access rather than femoral access."

Step 3: Educate yourself.
"While there is no substitute for personal experience, we can learn much from experts prior to starting a radial program."

Learn about the data and attend radial sessions at meetings. Also, be aware of the pitfalls and downsides.

Step 4: Educate your staff and identify champions who will help you move this forward.
Shah called this the most crucial step. It's a multidisciplinary approach between technical staff, nursing and physicians.

The prep is different between femoral and radial access and it can even be different between the left and right wrist. There are different equipment needs for radial cases and for the nursing staff, there may be different pre- and post-procedural assessments.

Step 5: Take a field trip.

Much can be learned by watching others, not just how they perform the cases, but also how they prep for them.

Involve the technologists, nurses and fellows, who are "key to bringing radial access to the forefront in the U.S.," Shah said.

Step 6: You need the right equipment before you start.

You will need a completely different access system, including the needle. "We typically use micropunture needle—21 gauge—with a narrow-caliber guidewire.

Different sheaths are required. The standard is to use hydrophilic sheaths, ranging from 11 to 16 cm in length, with a variety of French sizes—at a minimum, 4F to 6F is sufficient, Shah said.

You need some wires that you may not typically use for the femoral approach. "I'm a big fan of floppy-tipped straight 0.035 wires such as the Wholey, Glide and Tiger. It also is good to have some intervention wires, particularly 0.018 hydrophilic wires and smaller 0.014 wires. These are instrumental in getting through tortuous radial anatomy and getting your sheath, and ultimately your catheters, into the ascending aorta."

In terms of catheters, there are a variety of radial-specific devices. Shah prefers the Judkins catheter, but with it, you have to switch catheters. However, the familiarity of it might be perfect for when starting out with the radial approach, he said, to minimize variables, and then move onto other catheters as you gain experience.

Step 7: Pick your first cases carefully. You want to maximize your chances for success.
Try to pick diagnostic cases only and stay away from cases that could turn into a PCI. Pre-op valve cases are excellent to perform when starting out and choose patients with very palpable radial pulses and a good modified Allen's tests.

In addition, avoid shorter people because they have less aorta to work with for catheter manipulation, which could lead to longer cases.

"It might be easier to convince yourself to perform the radial approach in patients where the femoral access may not be ideal, such as the morbidly obese, those with known femoral arterial disease or patients who are unable to lie flat for bedrest afterwards," he said.

Also, consider left radial access in the beginning because it's easier than right radial access. There are fewer areas for resistance when coming from left to right.

"Start out with 5F sheaths and catheters because they are easier to manipulate in tortuous anatomy," he said.

Step 8: Avoid cases where your inexperience may lead to harm.

There include patients with bad radials or poor Allen's tests, high likelihood for PCI, cases where time is of the essence such as STEMI, and cases where patients cannot tolerate a long procedure.

Step 9: Start slow and ramp it up.
When starting out, radial cases will slow down the lab a bit. Commit to one case per day for the first few weeks. Once the nurses and other staff become more comfortable with the radial approach, increase the frequency to two cases per day. Also, continue to add more as you gain experience.

"With continued commitment, every case will be a radial case and you will feel guilty for doing femoral," he said.

Step 10: Get colleagues onboard.

This happens automatically for broader reasons, but once you start doing it, it will catch on. One of the main reasons is the patients will start demanding it.

At Brigham and Women's, Shah and colleagues made radial their default strategy last year. It has since increased from 10 to 55 percent of all cases.

Step 11: Talk to your patients, particularly those who have had prior femoral cases.
Their satisfaction will be clear and will motivate you to keep working at it.

Step 12: Stay committed.

There will be some tough times when you start out. Your first cases are not always going to be easy. Your initial femoral conversion rate is going to be higher than you like. Be patient and practice and the cases will get easier.