A Better Route for Clearing Arteries

Aug. 22, 2008 -- Clogged coronary arteries can be more readily accessed through a patient's wrist rather than routing a catheter through the leg, according to the first large-scale study of one of the world's most common cardiac procedures.

Angioplasty practices at more than 600 hospitals in the United States -- including many in New York -- were reviewed by a team of researchers at Duke University who found dramatically less bleeding and fewer complications for patients who underwent the procedure through their wrists.

The finding is significant because angioplasty ranks as one of the most common invasive medical procedures performed daily in the United States. About 1 million angioplasties are performed annually, according to the American College of Cardiology, which published the research yesterday.

Despite the obvious safety of the wrist-oriented procedure, which Duke investigators found reduces bleeding risks by nearly 60 percent, only 1 in 100 angioplasties nationwide currently access the heart through the radial artery in the wrist. Most doctors still favor -- and are taught -- the traditional path through the femoral artery in the leg.

"There is a steep learning curve," said Dr. Barry Kaplan, director of the catheterization laboratories at Long Island Jewish Medical Center in New Hyde Park, who noted the technique is not the simplest to learn.

Angioplasty is designed to restore the free-flow of blood to the heart and is often preferred over coronary bypass surgery.

Kaplan said he and his colleagues have been accessing coronary arteries through patients' wrists for more than a decade. At least 50 percent of patients treated at his center receive the wrist procedure. Not all patients qualify for it. For example, those who have undergone cardiac bypass surgery or those on renal dialysis aren't eligible.

Long Island Jewish Medical Center was the only hospital in New York to receive a double-star ranking earlier this year from the state Health Department in its periodic angioplasty assessment. The center had the lowest rate of complications and mortality, which Kaplan attributes to the wrist technique.

"We started looking into the radial technique as an alternative to the groin in the late 1990s," he said yesterday. "The risk of major bleeding was markedly lower than from the groin."

The Duke study, meanwhile, led by Dr. Sunil Rao, found patients not only tolerated the procedure well, they resumed their usual activities sooner. Rao focused on nonemergencies.

Dr. Howard Cohen, director of cardiac intervention at Lenox Hill Hospital in Manhattan, said contrary to conventional wisdom, transradial angioplasty can unblock an artery during a heart attack. "I just did one yesterday," Cohen said.

He estimates that 95 percent of the angioplasties he and his colleagues perform are through the wrist. The Lenox Hill team does between 40 and 50 a day.

Overall, Cohen said, the wrist technique is less expensive. The femoral route requires a closure device that costs about $200. For wrists, it costs about $25.

Angioplasty

Coronary angioplasty is a minimally invasive technique during which a balloon-tipped catheter is guided through an artery -- usually in the thigh -- to reach a blockage inhibiting blood flow to the heart.

When the balloon is opened the obstruction is removed. A stent, a tiny mesh tube, is often placed in the artery to keep it propped open.

What they found

Researchers reporting in the Journal of the American College of Cardiology found when the catheter is guided through an artery in the wrist, known as transradial angioplasty, there were fewer complications.

They also found the wrist technique is tolerated better by many candidates for angioplasty, including those who are elderly or obese.

Traditional angioplasty through the femoral artery in the leg often requires heavy pressure afterward (sometimes with a sandbag) until bleeding stops at the puncture site. Performing the procedure via the wrist eliminates need for heavy pressure when the catheter is removed.

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