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ORLANDO -- Experienced interventional cardiologists at a single center had no problem switching from femoral artery to radial artery access for most procedures in the cath lab, a researcher reported here.

Routine use of the radial artery as an access point resulted in fewer bleeding complications and less pain without substantial increases in procedure time, according to Tim Schaufele, MD, of the MediClin Heart Center Lahr/Baden in Germany.

In addition, radial access resulted in the use of significantly fewer staff hours, he reported at the American Heart Association meeting.

Although using the radial artery resulted in more radiation exposure for the interventionalist for diagnostic procedures, the difference disappeared when a percutaneous coronary intervention was performed.

"The data . . . demonstrate that experienced invasive cardiologists can easily shift their practice towards radial access without trading off for patient and operator safety."

The radial approach has been shown in previous studies to result in less bleeding, more rapid ambulation, increased patient comfort, and use of fewer human and hospital resources, but the femoral artery remains the access point of choice in many parts of the world.

In some European and Asian countries, up to 50% of cardiac procedures are performed through the radial artery, but in the U.S., that number drops to less than 5%.

Interventionalists who favor the femoral approach cite familiarity with that approach and concerns about the radial approach over possible entry site failure, unsuccessful arterial puncture, higher radiation doses, longer procedural times, and occlusion or spasm of the artery.

In the U.S., in particular, "there's been an inertia really to switch over to the radial access site," according to Alice Jacobs, MD, director of the cath lab at Boston Medical Center.

She admitted, however, that it might be time to consider using the radial approach for more procedures.

"I think it's important to realize that, given these new potent antiplatelet agents, the increase in bleeding, and the relationship between bleeding and mortality, that it may be prudent to start to think about that," said Jacobs, who served as a panelist at the presentation.

Schaufele reported results of the RAPTOR trial, which set out to assess the feasibility of shifting an interventionalist's strategy from using the femoral artery as the primary access point to using the radial artery, and associated outcomes.

In a prospective, randomized trial, interventionalists at the MediClin Heart Center were assigned to use one strategy as the primary approach.

Over one year, 421 patients were included in the study. Those who underwent a procedure that used the femoral artery were slightly older (66 versus 64, P=0.02).

For diagnostic catheterizations, puncture time (3.8 versus 0.9 minutes), total procedure time (10.9 versus 8.4 minutes), radiation exposure (6.4 versus 4.4 minutes), and radiation dose (29.7 versus 22.6 Gy cm²) were greater when using the radial approach (P<0.01 for all).

However, each difference became nonsignificant for procedures in which an intervention was performed.

Although that still equates to a higher radiation dose for the interventionalist using the radial approach as a primary strategy, Schaufele estimated that the cumulative difference would account for 96 more deadly cancers in 100,000 people over 40 years, compared with 20,000 cancers that would occur naturally.

In terms of the use of staff resources, the radial approach resulted in a greater time spent handling the patient in the cath lab for diagnostic procedures only (17.3 versus 14.3 minutes, P=0.02). There was no difference for interventions.

For both diagnostic procedures and interventions, using the radial artery significantly shortened the amount of time needed for manual compression of the access site and total time the nurse needed to spend with the patient (P≤0.02 for all).

Taken together, 17.9 minutes less in staff time is needed for diagnostic procedures and 47.2 minutes less is needed for interventions when the radial approach is used, Schaufele said.

In a medium-sized center with about 3,000 procedures per year, including 1,000 percutaneous interventions, use of the radial approach would save about 1,383 hours of staff time, he said.

The femoral approach led to more hematomas (19 versus four), cases of pain in the back or at the puncture site (43 versus eight), puncture site bleedings (18 versus four), and vagal reactions (19 versus zero) (P<0.01 for all).

There were eight access site failures in each group.

Patients tolerated the punctures and procedures equally well in each group, but patients who had a procedure using the radial approach had less pain due to compression and preferred the alternative access route, Schaufele said.

Schaufele concluded that interventionalists should commit to making the switch to the radial approach because they will never feel comfortable if they only use it occasionally.

"The last thing that you should do is use it only as a bailout procedure," he said.

One U.S. interventionalist seemed to acknowledge that the radial approach would eventually take on more importance in the cath lab.

Peter Block, MD, of Emory University in Atlanta, said, "I think we in the U.S. are just sort of kicking and screaming all the way to the altar because sooner or later we are going to be responsible for how much cost we generate in the cath lab and this is a good way of decreasing cost."

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