Transradial angioplasty – a handy fix for blocked coronary arteries
February 26, 2020
In many hospitals, the femoral artery is the preferred access point for angioplasty – a catheter-based procedure used to diagnose or fix a blocked coronary artery.
Located in the groin area, the femoral artery is large and relatively easy to access, and minimally invasive angioplasty carries fewer risks than open heart surgery. However, opening such a large artery presents a bleeding risk, particularly for patients who have had heart attacks and are taking blood thinners.
Enter the transradial access (TRA) angioplasty, a minimally invasive approach that allows us to reach the heart via the radial artery in the wrist. The radial artery, best known as the blood vessel you place your fingers over to feel your pulse, is smaller and more easily accessible than the femoral artery. And research has shown that TRA reduces bleeding risk and recovery time compared to the femoral approach.
More labs – including UT Southwestern – have begun to offer TRA, which I recommend whenever possible. In my career, I've done more than 2,000 TRA angiographies and angioplasties. If I had to have an angioplasty, I would want it done radially.
The cardiac catheterization team at UT Southwestern is experienced in both femoral and TRA angioplasty. We work together to determine the best option for each patient – and the conversation always starts with answering our patients' frequently asked questions.
Answers to FAQs about transradial angioplasty
Is the TRA approach available at all hospitals?
No. TRA is the recommended approach in Europe and Asia, and it is recommended as a class I indication (preferred method) by the 2015 European guidelines. However, in the U.S., adoption has been slower, and it has yet to become the standard of care. However, there has been a push in recent years to go "radial-first" due to TRA's safety and effectiveness.
Many doctors feel more comfortable with the femoral approach, which was introduced in the 1980s and has a long history of success. TRA, which came along a couple of decades later, has a longer learning curve because the proceduralist uses smaller catheters and is working in a smaller space within the radial artery. Today, approximately a third of U.S. percutaneous cardiac interventions (angioplasty with stent) are done via TRA.
Will I be able to use my hands after TRA angioplasty?
TRA is a relatively low-risk approach. Several of my patients have had repeated TRAs without any hand complications. We've even performed angioplasty on professionals who rely on their hands for their livelihood, such as a pianist, and they’ve done well and had no long-term issues.
A 2017 study of hand functionality and strength after TRA revealed that less than 0.2% of patients had nerve damage after TRA. Approximately 1.52% of patients experienced tingling, numbness, or loss of sensation in the hand. Fewer than 0.3% had grip strength changes, power loss, or hand disablement.
Approximately 2% of patients have transient radial artery occlusion (RAO) – temporarily disrupted blood flow to the hand – after TRA when a small catheter is used. The hand is supplied with blood from both sides of the wrist, so symptoms, if any, are generally mild and resolve within a few weeks.
What is the bleeding risk with TRA?
After a patient has a heart attack, they typically take blood thinners to reduce their risk of having another. Unfortunately, blood thinners also increase their risk of bleeding from the small catheter insertion points.
Research has shown that TRA reduces the risk of bleeding and death, which has been cited as high as 5% with the femoral approach. The radial artery is much smaller than the femoral artery, and it is easier to access and compress to stop bleeding if necessary. The femoral artery is also the only source of blood to the leg, while the radial artery is not the only source of blood flow to the hand.
TRA has been shown to reduce the risk of heart attack, stroke, or need for additional intervention for narrowing arteries within 30 days.
How long does it take to recover?
Femoral and TRA procedures are both performed under local anesthesia with concomitant conscious sedation. After a femoral procedure, patients must lie flat without moving for several hours. Walking or moving too much can cause the insertion site to open and start bleeding, which can become serious quickly due to the size of the artery.
Depending on the level of sedation and bleeding, the patient might need to stay overnight for monitoring. With the femoral approach, we typically recommend patients take some days off work to avoid complications.
Recovery after a TRA procedure usually takes less time. The radial artery is smaller and so is the insertion opening. Its location makes it less likely to reopen during normal activity. Patients can typically go home within a few hours after the procedure, reducing their cost of care. Many go back to work the next day, provided they don't have to lift anything heavier than a few pounds.
Specialist spotlight: Get to know Dr. Dharam Khumbani
Dr. Kumbhani is the Director of Interventional Cardiology at UT Southwestern Medical Center and Director of the Cardiac Catheterization Laboratory at Clements University Hospital. He specializes in interventional cardiology.
How much radiation will I be exposed to?
TRA angioplasty delivers slightly more radiation exposure than the femoral approach. The radial artery is smaller with more twists and turns. So, TRA procedures might take a little more time, resulting in more radiation.
However, this also depends on the operator’s experience. Currently, I perform radial procedures as quickly as femoral procedures. Even for patients presenting with an acute heart attack, where every minute counts, I prefer going radial due to the benefit seen in clinical trials, without being concerned about compromising the time required to open up the blockage(s).
To put things in perspective, the total radiation from angiography (radial or femoral) is usually similar or less than what one would be exposed to with a nuclear stress test.
When is the femoral approach the best option?
Most structural heart repairs such as valve replacements must still be done through the femoral artery due to its size.
In less than 5% of patients, we must switch to a femoral approach due to unforeseen issues with the radial artery. In some situations, we opt for a femoral approach from the start, such as if the patient has an occluded radial artery, if the radial artery was used as a conduit for bypass surgery, or if we must use large catheters.
If a patient has a 100% blockage, we sometimes use a dual approach, inserting a catheter into both the radial and femoral arteries. The dual approach provides access to the blockage from two angles.
Inside our heart catheterization lab
The lab is a high-tech environment, and our large team is choreographed to move together quickly. We have to be ready in seconds to handle unexpected patient complications, such as a heart attack or cardiac arrest.
For every procedure, we staff the lab with a catheterization doctor, a specialized nurse, a physician assistant or fellow, and two technicians. For complex cases, we expand the team to include an anesthesiologist, a structural heart surgeon, and a perfusionist – an expert in using our heart-lung machine.
Transradial angioplasty is effective and generally low risk. If you are considering angioplasty, a cardiac catheterization expert can help you understand your options and feel confident in your decision.