Every year, one million Americans undergo a procedure called angioplasty. Doctors insert a catheter with a stent into a patient's artery to open blockages near their heart. Now, a new study may have cardiologists rethinking their approach and for some patients, an easier recovery may be all in the wrist.
Judy Whipkey told Ivanhoe, "Morgan Ann is four and Harper Grace, she'll be two on the fourth of July and she is a firecracker!"
Sixty-eight-year-old Judy Whipkey loves taking care of her granddaughters and the home she shares with husband, Jay, but for weeks, she had been exhausted and short of breath .Then an incident-that Judy could not ignore.
"About 4, 4:30 I woke up with all the symptoms that you read in the books and on the TV" Whipkey explained.
Krishna Tummalapalli, MD, Interventional Cardiologist at the University of Pittsburgh Medical Center found Judy had severe blockages in the arteries around her heart.
In the United States, most doctors insert heart stents by sending a catheter through an artery in the groin. But now, another approach may be gaining ground access to the heart using an artery in the wrist.
Dr. Tummalapalli told Ivanhoe, "It is easily compressible; hence the puncture site complications and vascular complications are much less."
In a new study called the Matrix Trial, doctors at 78 European centers compared both approaches and found the wrist approach greatly reduced the risk of major bleeding and death.
Dr. Tummalapalli says recovery is easier. "The patient does not need to lay down flat for four to six hours. They can sit up immediately. They can walk around," he explained.
For Judy, a tiny puncture mark is the only reminder of the procedure that put her life back on track.
The wrist or radial approach is used in about 20 percent of all stenting procedures in the United States. Dr. Tummalapalli says with the release of information from this new study as many as 50 percent of the procedures may soon be done with the wrist approach. Dr. Tummalapalli also says patients with renal failure or kidney dialysis would not be good candidates for this approach.
Contributors to this news report include: Cyndy McGrath, Supervising Producer/Field Producer; Cortni Spearman, Assistant Producer; Jamison Koczan, Editor and Kirk Manson, Videographer.
BACKGROUND: More than one million people a year in the United States undergo an angioplasty procedure. Coronary angioplasty is a procedure that is done in order to greatly improve blood flow to the heart. The procedure is done by using a balloon to open up a blockage that is in the coronary artery in the heart. An angioplasty procedure may be used to fix many complications including: improving symptoms of CAD, such as angina and shortness of breath, reduce damage to the heart muscle due to a heart attack, and to reduce the risk of death.
(Source: http://www.med.umich.edu/cardiac-surgery/patient/adult/adultcandt/coronary_angioplasty.shtml )
TRADITIONAL ANGIOPLASTY: If your doctor finds that your coronary arteries are blocked, he may opt to perform a coronary angioplasty in order to open these arteries for efficient blood flow to the heart. Coronary stents are more commonly used for this procedure and doctors usually enter a patient's femoral artery in the groin which can be invasive. This method is referred to as the femoral approach. With the femoral approach, because the artery is deep, it can be hard to stop the bleeding after the catheter is removed and the blockage is opened. The femoral approach also has a high risk of bleeding for women and the elderly as well as a risk of acute coronary syndrome.
(Source: http://www.med.umich.edu/cardiac-surgery/patient/adult/adultcandt/coronary_angioplasty.shtml, Krishna Tummalapalli, MD)
NEW TECHNOLOGY: The radial approach is a newer approach in which doctors enter through the radial artery in the wrist. Krishna Tummalapalli, MD, Interventional Cardiologist at the University of Pittsburgh Medical Center said "The prediction is in the next few years we'll probably reach 50 percent or more, using the radial approach." According to Dr. Tummalapalli, the radial approach is gaining popularity in the U.S. Twenty percent of the stenting procedures were through the wrist in 2014. Doctors think the main reason for the growing popularity is because of patient comfort. With the radial approach patients don't need to lay down flat for four to six hours. They can sit up immediately and walk around. Dr. Tummalapalli said, "Even after a stent placement, most patients can go home the same day after a radial arterial approach."
(Source: Krishna Tummalapalli, MD)
FOR MORE INFORMATION ON THIS REPORT, PLEASE CONTACT:
HVI Cardiology
Shadyside Medical Building
5200 Centre Ave. suite 514
Pittsburgh, PA 15232
412-621-1500
If this story or any other Ivanhoe story has impacted your life or prompted you or someone you know to seek or change treatments, please let us know by contacting Marjorie Bekaert Thomas at mthomas@ivanhoe.com
Krishna Tummalapalli, M.D., Interventional Cardiologist at UPMC talks about a less common approach to re-opening arteries.
Interview conducted by Ivanhoe Broadcast News in April 2015
What is angioplasty and what is it designed to do? What problems is it working on?
Dr. Tummalapalli: Angioplasty is a term used when a small balloon is inserted into a patient's coronary artery where there is a significant blockage. This balloon will go inside the artery where the blockage is and by inflating the balloon we are opening the blockage. Angioplasty was the first technique that was developed in the 1970's and now there is a significant modification beyond that. Now, we predominately use coronary stents to open these blockages.
Can you explain to me how this approach is used to put the coronary stents in? How the procedure is done?
Dr. Tummalapalli: It is an invasive procedure where the patient's artery is entered through either the femoral artery in the groin or the radial artery in the wrist. The invasive cardiologist will advance the catheters into the coronaries and the first step is to take the angiogram to see where the blockage is. Once the blockage is identified and if it is significant, through the same catheter one could insert a tiny wire to cross the blockage and then typically, a coronary stent to go over the wire mounted on a balloon at the site of the blockage. When the balloon expands the stent expands and stays in the artery thus opening the blockage. So now the blood flow is established.
And then the balloon is deflated.
Dr. Tummalapalli: The balloon is deflated and withdrawn. Only the stent is left behind creating a scaffold to keep the artery open. Then the balloon comes out, the wire comes out and the patient will have a good blood flow to the heart.
You mentioned the femoral approach. What is it?
Dr. Tummalapalli: The femoral approach is when a common femoral artery in the groin is entered with a needle. A sheath is placed in, like a straw, and through that sheath long thin catheters are advanced to the heart and we take pictures of the coronaries. Typically we have three major coronary arteries, two on the left side and one on the right side, so an interventional cardiologist would take pictures of all three of them.
How long has the femoral approach been used? That's pretty much the standard, is it not?
Dr. Tummalapalli: Yes, actually the way the coronary angiography was developed was it initially started out with a brachial approach. In the elbow area there's a brachial artery and with the brachial approach we used to do a cut down and isolate the brachial artery, make a small incision then advance the catheters from the brachial artery in the elbow to get to the heart. Later they pre-formed the catheters and the percutaneous technique was developed. That's when the femoral approach gained more prominence.
Talk to me about the radial approach.
Dr. Tummalapalli: The radial approach actually has been around for more than two decades. But its popularity is gaining more and more in the United States for the last five to six years because of the very well-known major advantages over the femoral approach.
When you're talking about the radial approach, how are doctors going in? Can you describe it?
Dr. Tummalapalli: So just like the femoral approach where the common femoral artery in the groin is entered, in the radial approach the radial artery is entered with a needle and a small sheath. The long catheters are inserted through the sheath to get to the heart from the arm approach as compared to the femoral approach.
What is the benefit of doing it this way?
Dr. Tummalapalli: One of the major problems we had doing the femoral approach is because the artery is deep in the pelvic area, sometimes it's very hard to obtain hemostasis and stop the bleeding after the catheter is removed. There was a good chance that the patient can get a puncture site complication or a vascular complication. We found out that by doing the radial approach, the puncture site complications and vascular complications are much less compared to the femoral approach as the radial artery is small, right on the top of a bone and easily compressible.
Were the complications primarily bleeding or were there other complications too?
Dr. Tummalapalli: Yes, typically there are two types of complications that will be in vascular territory. One is bleeding because of the puncture site. The other one is what we call vascular complications, meaning if the arterial puncture bleeds, leading to a hematoma and pseudo-aneurysm. In the case of femoral approach there is a vein that is right next to the femoral artery so if the needle enters both the artery and the vein you can get fistula. Occasionally, in the femoral approach, you could have bleeding behind into the pelvis which is called retroperitoneal hematoma and sometimes that can be very lethal.
Is there an ideal patient for this kind of approach?
Dr. Tummalapalli: Based on the many previous trials, we found out which patients are at high risk for bleeding. These are usually the elderly patients, females and patients who are presenting with what we call acute coronary syndrome, meaning either they're having a heart attack, they're on the verge of a heart attack, or had a small heart attack. In addition to that, morbidly obese patients have a tendency to bleed if you approach from the femoral arterial approach.
There's a recent study that shows that this is better for patients. Can you talk to that?
Dr. Tummalapalli: We have several studies in the last few years showing the radial artery approach as superior to the femoral artery approach. About four years ago a trial was published and presented in the American College of Cardiology called RIVAL Trial. This trial looked at a large group of patients comparing the radial approach with femoral in acute coronary syndrome patients. That showed the vascular access site complications are almost sixty three percent less compared to the femoral arterial approach. They also found in a high volume radial center's patients who are having a heart attack that if you approach them from the radial artery their mortality is also lower.
You talked about someone who is having the acute coronary syndrome. Can you elaborate on that?
Dr. Tummalapalli: There was a recent trial that was just presented last month at the American College of Cardiology meeting in San Diego which is called a Matrix trial. It's a multi-center European trial involving 78 centers including a large number of patients -- almost 8,400 patients. They again compared radial versus femoral arterial approach in patients with acute coronary syndrome. They found the bleeding was much less compared to the femoral and they also found that the mortality was lower if the patient is getting a radial arterial approach.
Why has it taken so long to catch on in the United States?
Dr. Tummalapalli: Part of the reason was that in the past we did not have dedicated catheters that are easier to insert from the radial arterial approach. Now the industry has stepped up and they have made special catheters for the radial arterial approach. Also there is a slight learning curve for the physicians to be able to adopt the radial approach, so some physicians may not have time to make the extra effort to learn this technique. But we are on the ascending curve and the usage of radial arterial approach is gaining steadily across the United Sates. Now in 2014, up to 20% or more of all procedures are done radially. The prediction is that in the next few years we'll probably reach fifty percent or more radial approach instead of the femoral arterial approach. Two years ago Great Britain surpassed their fifty percent mark. They're doing more radials now than femoral arterial approach, so I think it will catch up.
Would most patients be able to tell the difference?
Dr. Tummalapalli: Oh most definitely.
Tell me about the difference.
Dr. Tummalapalli: I actually have had several patients who had procedures done both femorally and also radially and they, without any doubt, prefer radial arterial approach.
Why? What difference could they tell?
Dr. Tummalapalli: The main reason would be the patients comfort. If you have a radial arterial approach the patient does not need to lay down flat for four to six hours. They can sit up immediately and walk around. For people who are moderately obese they have pulmonary problem. If they have back pain this is much more comfortable. In fact, the recent trials also showed that in the quality of life assessment from a patient's point of view, more than three to one patients preferred radial arterial approach compared to the femoral approach.
In terms of recovery is it easier?
Dr. Tummalapalli: Yes, definitely. It's much easier from a radial arterial approach. We can send the patients home the same day. Even after a stent placement most patients can go home the same day after radial arterial approach. There's always a small chance of delayed bleeding from the femoral approach and delayed bleeding is never heard of from the radial approach. Once you've performed the procedure, the patient is stable and there's no bleeding, we are safe to send the patient home the same day
Is there anything I didn't ask you that you want to make sure people know about the radial procedure versus the femoral approach?
Dr. Tummalapalli: I think there's more need for awareness from the patient perspective. Also, patients need to ask the cardiologist which approach they're comfortable with. There are still a good number of patients who would require femoral arterial approach. The radial approach may not be for one hundred percent of people but I think it's good to know that patients do have a choice and they need to ask doctors questions.
For which patients would the radial approach not be appropriate?
Dr. Tummalapalli: That's a good question. Typically patients who are on renal failure, on dialysis, would need femoral arterial approach because we do not want to risk their radial arteries. People who have mixed connective tissue disorder such as scleroderma Raynand's phenomenon are prone to arterial spasm, so we may not want to do the radial arterial approach.
How long have you been doing radial approach here at UPMC?
Dr. Tummalapalli: I have been doing the radial arterial procedure for about four and a half years.
Are the larger centers catching on faster than some of the smaller ones?
Dr. Tummalapalli: It really depends on the center. There are some pockets in the United States where they're doing 80% of radial arteries. When I was in practice in interventional cardiology, I started out with brachial arterial approach then went to femoral arterial approach. Now, I do almost 80% or more of all my patients from the radial artery because of the significant benefits of the radial approach.