October 11, 2010 - By John Sanford
Stanford Hospital is at the forefront of performing angiograms, angioplasties and coronary-stent placements through the radial artery in the wrist instead of through the femoral artery in the groin.
You can have a percutaneous coronary intervention through your femoral artery or radial artery. Put another way, you can have a catheter stuck into your groin or your wrist. Not sure which you’d prefer?
Then consider Richard Francis, a local accountant and ex-Navy pilot, who had stents inserted through the radial artery in his wrist at Stanford Hospital & Clinics on July 15, two days before turning 67.
A coronary stent is a tiny mesh tube that helps open up blood vessels clogged with cholesterol, fat and other stuff that leads to heart disease. Stenting is usually preceded by angioplasty, which involves expanding a balloon inside the artery to crush the plaque. Sometimes angioplasty is used exclusively.
In any case, the procedures practically guarantee a night in a hospital bed if done the traditional way — through the femoral artery.
But Francis left the hospital just a few hours after the procedure. “It was a heck of a birthday present,” he said.
He owed his fast exit to cardiologist Jennifer Tremmel, MD — or, more specifically, to the minimally invasive technique she has mastered for diagnosing clogged blood vessels, performing angioplasties and placing stents.
Instead of going through the femoral artery, Tremmel inserted a slim catheter into a small puncture in Francis’ left wrist and slid it up through his arm, via the radial artery, until it reached his heart. Then she placed stents into his left anterior descending artery and his left circumflex artery.
More than 1 million angioplasties and stent placements, known collectively as percutaneous coronary interventions, or PCIs, are performed each year in the United States. But it’s tough to find a hospital that will do them transradially — that is, through the wrist.
A 2008 report in the Journal of the American College of Cardiology Interventions found that of nearly 600,000 PCIs between 2004 and 2007, only 1.32 percent were transradial.
However, the technique is rapidly gaining ground in the United States. Tremmel, who is director of the Transradial Interventions Program at Stanford Hospital, said that the transradial approach now accounts for almost 5 percent of all PCIs nationwide.
Cardiologist Jennifer Tremmel (right) manipulates the guidewire through the patient’s radial artery, viewing its position on a screen, as part of a transradial angiography procedure at Stanford Hospital & Clinics. Tannon Carroll (left), a fellow in cardiovascular medicine, assists her.
Tremmel regularly travels around the country speaking about transradial PCI, and has turned Stanford into a West Coast training center where she trains two to three interventional cardiologists per month in the technique. In the spring, she will oversee a big course on it at Stanford.
“I actually feel a little guilty when I have to use the femoral route,” said Tremmel, who is also an instructor in cardiovascular medicine at the School of Medicine. She performs almost all of her PCIs and angiography, a diagnostic technique using special dye and X-rays to look for heart disease, transradially.
Several studies have shown that transradial PCIs reduce bleeding complications, shorten hospital stays and cost less compared with the femoral approach. A meta-analysis published last year in the American Heart Journal found that transradial PCI reduced the risk of major bleeding by 73 percent and the length of hospital stays by about half a day as compared with femoral PCIs. For women, the risk of bleeding complications from transfemoral PCI are two to three times greater than for men, Tremmel said, which makes women ideal candidates for transradial PCI.
Patients can sit up and walk almost immediately after the transradial procedure. And most patients, like Francis, can even leave the hospital the same day.
Transradial PCI also helps to free up time for nurses, who, after a transfemoral PCI, often have to hold pressure on the patient’s groin for about a half-hour to help stop bleeding. The only thing a typical transradial patient needs to stop the bleeding is a kind of see-through bracelet (for compression) and a small bandage.
“I think the major advantage is patient comfort,” said Alan Yeung, MD, director of interventional cardiology at Stanford Hospital. “From the medical side, it’s easy to compress the radial artery to stop bleeding; there’s no tissue in the way of it, unlike the femoral artery.”
After undergoing PCI through the femoral artery, patients must lie flat on their backs for as long as six hours, and they almost always are kept overnight for observation, mainly to ensure there are no bleeding complications.
Another downside to the femoral route is that it is relatively close to a major vein and nerve, which run the risk of being nicked during the catheterization.
Francis, the patient who had the procedure at Stanford in July, knows the advantages of transradial PCI firsthand. A couple of months before his stent procedure with Tremmel, he had an angiogram at another local hospital through the femoral artery. While recovering — that is, trying to lie still on his back for several hours — he moved his leg a little and the artery began hemorrhaging. “The doctors struggled with getting it to stop,” Francis recalled. The upper part of his leg turned purple, and it was painful to walk for the next couple of weeks. He said he hopes the transradial procedure becomes more widely available for heart patients. “It’s a whole lot easier on the body,” he said.
John Sanford is a writer in Stanford Hospital’s communications office.
Stanford Medicine integrates research, medical education and health care at its three institutions - Stanford University School of Medicine, Stanford Health Care (formerly Stanford Hospital & Clinics), and Lucile Packard Children's Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu.