Six Tips for Starting a Radial Program
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.
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:
“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.
“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, warns Pancholy. However, once on board, they will appreciate radial’s advantages. Eight years ago, his staff opposed the procedure. “Today, they are so much in favor of the radial approach they insist that I do radial even when I am leaning toward the femoral approach,” he says. “We have come a full 180 degrees from an attitude standpoint.”
“The physician and the cath lab team all must have the mind set of using transradial in every patient,” Pancholy agrees.
There are cost savings as well as procedural benefits. Wristband closure devices used for radial cost $20 to $25, while vascular closure devices sometimes used during the femoral approach range from $150 to $250. In a poster contribution at ACC.12, Amin et al found that the radial approach reduced length of stay and costs in a single-center study (J Am Coll Cardiol 2012; 59:186). Transradial procedures reduced the length of stay from 1.9 days to 1.4 days. In addition, overall radial costs were $1,140 lower, totaling $14,468.
“In elderly patients with neuropathy or abnormal ankle brachial indexes, the radial approach is a nice addition, because we can get these patients out of the hospital and home in an hour and a half,” Heuser says. “We usually don’t think about using radial access in these peripheral artery disease patients, but because of the enhanced ambulation we should start.”
Heuser says starting a radial program could help rejuvenate hospital marketing efforts if patient care, bleeds and patient satisfaction are improved. Patients are discharged nearly three hours post-procedure compared with the two to six hours the patient would remain bedridden after a femoral PCI. Radial access also provides better patient ambulation, which means freeing up more beds, getting in more patients and possibly reducing healthcare costs.
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, warns Pancholy. However, once on board, they will appreciate radial’s advantages. Eight years ago, his staff opposed the procedure. “Today, they are so much in favor of the radial approach they insist that I do radial even when I am leaning toward the femoral approach,” he says. “We have come a full 180 degrees from an attitude standpoint.”
Tip #3: Go all in
“You need to commit to performing radial procedures consistently,” Nathan urges. “You need to be all in. You can’t be a freelancer.” If physicians decide to “try out” the radial approach, using it sporadically in practice will impede their ability to become competent.“The physician and the cath lab team all must have the mind set of using transradial in every patient,” Pancholy agrees.
Tip #4: Know the benefits
One retroperitoneal bleed when using the femoral approach can make the difference between a malpractice case and costing the hospital hundreds of thousands of dollars, says Richard R. Heuser, MD, chief of cardiology at St. Luke’s Medical Center in Phoenix. “All you need is one or two cases of retroperitoneal bleed or transfusions in an overweight patient who is at high risk for the femoral approach to say, ‘I should have gone radial,’” Heuser says. “That should be enough to convince you and your administration to switch.”There are cost savings as well as procedural benefits. Wristband closure devices used for radial cost $20 to $25, while vascular closure devices sometimes used during the femoral approach range from $150 to $250. In a poster contribution at ACC.12, Amin et al found that the radial approach reduced length of stay and costs in a single-center study (J Am Coll Cardiol 2012; 59:186). Transradial procedures reduced the length of stay from 1.9 days to 1.4 days. In addition, overall radial costs were $1,140 lower, totaling $14,468.
Tip #5: Up the ante
There may be room to expand the use of the radial approach, says Heuser, particularly for peripheral artery disease interventions. While catheters are not yet long enough to work on infrapopliteal patients from the wrist, he has begun doing the diagnostic work-up with an antegrade stick or contralateral approach to create a roadmap of where he needs to do work. This can help operators decipher the proper location for placement. Heuser says using the radial approach is helpful, especially for patients with severely diseased iliac arteries and femoral arteries.“In elderly patients with neuropathy or abnormal ankle brachial indexes, the radial approach is a nice addition, because we can get these patients out of the hospital and home in an hour and a half,” Heuser says. “We usually don’t think about using radial access in these peripheral artery disease patients, but because of the enhanced ambulation we should start.”
Tip #6: New marketing tool
Starting a radial program comes with modest costs, especially compared with other programs like transcatheter aortic valve replacement (TAVR), says Nathan. Also, there may be many peripheral benefits seen as well as opportunities to reach more patients.Heuser says starting a radial program could help rejuvenate hospital marketing efforts if patient care, bleeds and patient satisfaction are improved. Patients are discharged nearly three hours post-procedure compared with the two to six hours the patient would remain bedridden after a femoral PCI. Radial access also provides better patient ambulation, which means freeing up more beds, getting in more patients and possibly reducing healthcare costs.