SCAI Paper Outlines ‘Best Practices’ for Radial Access

As support grows for interventional procedures performed via transradial access, the Society for Cardiovascular Angiography and Intervention (SCAI) has published a document outlining how to achieve the best outcomes while optimizing procedural safety. The guidance was published online October 23, 2013, ahead of print in Catheterization and Cardiovascular Interventions.

Sunil V. Rao, MD, of the Duke University Medical Center (Durham, NC), and others on the SCAI Radial Committee sought “to provide consensus opinion on what is considered ‘best practice’ for facets of radial procedures where there is supportive evidence in order to maximize the benefits, standardize certain practices to minimize complications, and summarize areas that need further study.”

‘Small, Subtle Differences’ to Keep in Mind

The SCAI report makes recommendations in 3 main areas:

• Monitoring for and prevention of radial artery occlusion
• Reducing radiation exposure to patients and operators during radial cases
• Training new operators adequately before attempting transradial primary PCI

“I think some people will find that their practices are a little bit different from our recommendations,” Dr. Rao said in a telephone interview with TCTMD. But the advice given within the new SCAI document is based on solid evidence, he stressed, “so hopefully [when clinicians notice any differences, they] will use it as a chance to improve their practices by following the guidelines.”

All 3 topics represent areas where radial access departs from femoral, Dr. Rao said. “These are all small, subtle differences, but there are things that people need to be aware of.”

Occlusion is a bigger concern “just by virtue of the fact that the radial artery is smaller” than the femoral, he explained. In addition, the potential for radiation exposure with transradial access “is sometimes in the back of interventional cardiologists’ minds but really should be something they should think about. Because if you’re doing a lot of cases, you really have to be cognizant of the fact that exposure is an issue,” Dr. Rao said.

For primary PCI, he continued, data “suggest that there is a mortality benefit to using the radial artery in patients with STEMI, but of course all of that data has been generated by very experienced interventional cardiologists who are very proficient at the radial approach.”

There is a tradeoff between door-to-balloon time and the learning curve, Dr. Rao noted. As such, the document recommends: “Operators and sites should not start performing transradial primary PCI until they have performed at least 100 elective PCI cases with a ‘radial first’ approach and their femoral crossover rate is [less than or equal to] 4%.”

“My guess is that that’s going to be the most controversial part of our statement,” Dr. Rao acknowledged, “because for some US operators that may be more than a year’s worth of cases.” Ample opportunities are now available for radial training, he said, suggesting that interested clinicians should look at the SCAI Web site.

In addition, the new document summarizes areas where additional research is needed before consensus can be reached. Among them are the role of preprocedural evaluation of dual circulation in the hand, the optimal antithrombotic strategy for transradial PCI, and the specific elements required for a successful transradial training program.

One-on-One Training Key

R. Lee Jobe, MD, of North Carolina Heart and Vascular (Raleigh, NC), agreed that most of the recommendations in the document are already being followed by experienced radialists. Dr. Jobe, who said he has been using transradial access for 17 years and training other operators for more than a decade, told TCTMD in a telephone interview that “this article really puts together in 1 document what the vast majority of us teach in our courses.”

These courses can occur at large national meetings and also on a smaller scale at hospitals. The value of the latter approach, he said, is that a cath lab staff member can participate along with the operator and learn about how nurses prepare patients prior to the procedure, how the room is set up differently for radial cases, and how patients are managed post-procedure.

“That’s the kind of thing that people can’t get . . . sitting in a room looking at slides. I think individualized training like that is very important for experienced operators who are now trying to pick up transradial,” Dr. Jobe commented, adding that many fellows are now exposed to radial access during their training.

Also in a telephone interview with TCTMD, J.P. Reilly, MD, of Ochsner Medical Center (New Orleans, LA), agreed that the SCAI report provides useful information to clinicians. “I don’t think there’s anything new here for radial operators, but there is some variation out there,” he said, noting that ‘best practices’ documents are valuable in that they allow clinicians to compare their own approach with the gold standard. “For people who are new to it,” Dr. Reilly added, “of course it’s a great resource.”

 

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Source:
Rao SV, Tremmel JA, Gilchrist IC, et al. Best practices for transradial angiography and intervention: A consensus statement from the Society for Cardiovascular Angiography and Intervention’s transradial working group. Cath Cardiovasc Interv. 2013;Epub ahead of print.

 

 

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