In a KERA Health Checkup, a look at how doctors access an artery to check your heart for suspected blockage. It’s called percutaneous coronary intervention or PCI. Most doctors go in through the hip or groin. But a growing number are choosing to access the wrist area instead. Sam Baker talked about this with Dr. Joshua Jacobi of Methodist Mansfield Medical Center.
Dr. Jacobi: Transfemoral approach is gaining access from the femoral artery located next to the hip. The transradial approach is gaining approach to the radial artery, which is located next to the thumb in the wrist area. And the reason this approach is gaining popularity is because of less complications from a vascular standpoint, particularly with bleeding. And patients actually prefer it; it’s much more comfortable. Typically after a heart catheterization, from a femoral approach, most patients have to lay on their back for several hours. With a transradial approach, after the procedure, the sheath, or a plastic tube, is removed from the radial artery and a plastic band is placed around the wrist to stop bleeding. With that, the patient can actually get up and walk right after the procedure.
Sam: We’re talking about inserting a stent, right?
Dr. Jacobi: Well, we gain access with a sheath. It’s a plastic tube about the length of a pen, but much thinner – obviously to fit into the radial artery – and then we take plastic tubes about the width of an I-V, if you will, and then we take pictures with contrast dye. And so, basically, a moving x-ray picture of the arteries of the heart. And if someone has a blockage that’s suitable for opening with a stent, then we can do the procedure of putting in a stent through the wrist.
Sam: We’re talking about people with a blockage or those suspected of having blockage?
Dr. Jacobi: Yes, that’s correct.
Sam: In such cases, could the conditions leading to this procedure have been avoided?
Dr. Jacobi: Most definitely. The atherosclerotic process actually starts taking place usually in our late teens, early 20s.
Sam: This is the process of, what, plaque building up in our arteries?
Dr. Jacobi: That’s correct. And it typically consists of poor diet, genetics, hypertension, diabetes, bad cholesterol, so all the traditional risk factors for heart disease. But the process builds up over decades, if you will.
Sam: So there are things you could avoid through diet, exercise, etc.?
Dr. Jacobi: Those are the most simple things to do, but sometimes the hardest things to do.
Sam: The procedure is not new to the United States, but it has been used in Europe more than it has here?
Dr. Jacobi: In countries like France, approximately over 90 percent of cardiac catheterizations are done from a transradial approach. But it’s been gaining more popularity in the U.S.
Sam: Why the delay of the use of more use of that procedure in the U.S.?
Dr. Jacobi: Several factors. One, most training programs emphasize a transfemoral approach. So, for instance, in my training, I did a lot of my procedures from a transfemoral approach. Now I did have training in using a transradial approach as well. There is a steep learning curve to it to get really good at the technique, but when you see that you have less complications, it actually feeds upon itself in the fact you’re always the best thing you can for patients, you can always look from a point of view of “If I was the one on the table, which approach would I prefer?” and knowing what I know, I would definitely prefer a transradial approach.
Sam: So this has more to do with the training of doctors here than it does with any federal regulations or anything like that.
Dr. Jacobi: Yes. Also, sometimes it’s a hard habit to break. You’ve learned one way. You’ve done a thousand procedures one way, you’re not under any particular pressure to change your ways. I mean the transfemoral approach is a good approach. It’s very rare you have complications. They’re uncommon, but they do occur.
Sam: I listen to you with this approach, transradial, transfemoral, stents, catheters – forms of angioplasty. I’m just curious, overall, what has this done to reduce the need for open heart surgery?
Dr. Jacobi: If you look at stent use in the United States, it’s gone up, up and up, especially since it came out, and the need for open heart surgery has markedly decreased. And if you look at mortality for heart disease, it’s one of the few diseases we have where mortality has actually decreased over time.
Dr. Joshua Jacobi is a cardiologist with Methodist Mansfield Medical Center.
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