WEBVTT
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- Hey, Cathmasters. This is Amit Gohil. In addition
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- to your regular programming, we are proud to
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- share select gems from the Maine Cardiutants podcast
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- that are particularly relevant to the practice of
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- interventional cardiology.
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- This episode is from our Decipher the Guideline
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- series which breaks down the twenty twenty five
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- ACS guidelines using case based board style questions
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- with insights from the guideline authors themselves.
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- This was planned in collaboration with the American
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- Heart Association and developed by the Cardiators Interventional
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- Cardiology Council led by Council Chair Doctor. Nesli
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- Okomash.
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- The following question refers to section 7.3
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- of the 2025
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- ACS
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- guidelines.
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- The question is asked by Thomas Jefferson, medical
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- student, and CardiNerd's Academy intern, doctor Grace Chu,
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- answered first by University of Michigan fellow and
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- CardiNerd's fit ambassador, doctor Kayla Secrest, and then
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- by expert faculty, doctor Sunil Rao. Doctor Rao
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- is an interventional cardiologist professor of medicine at
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- NYU Grossman School of Medicine, deputy director of
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- the Leon h Charney division of cardiology and
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- the director of interventional cardiology at the NYU
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- Langone Health System. He is the editor in
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- chief for Circulation Cardiovascular Interventions and was the
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- chair of the writing committee for the 2025
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- ACS guidelines. Doctor Rao, it is an honor
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- to have you with us. Gosh. Thanks so
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- much for having me. It's an honor to
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- be here. So first up, we have a
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- 68 year old man with a history of
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- hypertension, hyperlipidemia,
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- stage three chronic kidney disease, and prior tobacco
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- use presents to a local emergency department with
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- reports of chest pain while raking leaves at
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- home. Upon arrival, he is hemodynamically
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- stable with a heart rate of 86 beats
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- per minute and a blood pressure of one
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- thirty three over 85.
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- His EKG reveals ST elevations in the septal
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- and anterior leads b one through b four.
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- He is given three hundred twenty four milligrams
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- of aspirin and is promptly evaluated by the
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- interventional cardiology team who elects to take him
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- emergently to the catheterization
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- lab. Upon arrival to the catheterization lab, the
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- nurse asks the interventional fellow which access sites
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- they should prep for this case. How should
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- the interventional
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- fellow respond? Option a, right radial artery only,
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- option b, radial and bilateral femoral, or option
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- c, bilateral femoral only.
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- The correct answer is B, radial and bilateral
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- femoral. Radial artery access is the preferred nosular
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- access site for coronary angiography
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- and PCI patients with ACS.
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- Transradial access has been shown to reduce mortality,
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- bleeding, and vascular complications
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- compared with transframural
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- access. This is a class one level of
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- evidence a recommendation.
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- Radial access also allows earlier ambulation and is
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- associated with greater patient comfort.
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- Although the right radial artery is the most
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- widely studied upper extremity access site, alternative sites
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- such as the ulnar and distal radial arteries
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- have demonstrated similar outcomes.
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- However, the radial artery may be required as
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- a bypass conduit for CABG.
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- In institutions
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- where the radial artery is routinely used for
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- surgical grafting,
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- this potential future use should be considered when
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- selecting vascular access.
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- In addition, transfemoral
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- access, preferably performed with ultrasound guidance,
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- should be considered in patients in whom temporary
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- mechanical circulatory support is anticipated
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- or in those for whom radial access is
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- not feasible due to anatomical or technical constraints.
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- Prepping bilateral groins, in addition to the radial
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- artery, provides a backup strategy for urgent MCS
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- placement
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- or for transition to femoral access should radial
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- access fail. For these reasons,
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- prepping both the radial artery and bilateral groins
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- is the most appropriate response.
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- Radial only preparation is incorrect because although radial
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- access is preferred,
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- patients with STEMIs may still require emergent MCS
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- or an alternate access if the radial artery
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- is unsuitable.
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- Preparing only the wrist without backup femoral access
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- may delay care should hemodynamic instability occur. Femoral
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- only preparation
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- is incorrect because transradial access provides superior outcomes
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- in ACS, including significant reductions in all cause
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- mortality,
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- major bleeding, and vascular complications.
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- RCTs and meta analyses, including the matrix, which
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- showed lower MACE and net adverse clinical events
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- with radial access, and SAFARI STEMI trials, which
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- showed no difference in mortality but was underpowered,
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- support radial as first line access when feasible.
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- So what is the main takeaway here? For
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- patients with ACS undergoing PCI,
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- radial access is strongly preferred to reduce mortality,
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- bleeding, and vascular complications.
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- Doctor Rao, I would love it if you
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- have any additional thoughts or would like to
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- expand on this particular guideline further.
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- Yeah. Thanks so much. It's a great question.
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- And I think that you really summarized the
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- data well. You know, in the revascularization
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- guidelines,
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- radial approach was mentioned for the first time
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- in any guidelines document. And based on the
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- trials that you mentioned in acute coronary syndrome,
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- the comparison of radial versus femoral has shown
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- a reduction in vascular complications, bleeding, as well
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- as mortality. And that's really what led to
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- the class one recommendation in the guidelines. In
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- the acute coronary syndrome guidelines,
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- we basically transferred that guideline recommendation from the
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- ReVASC guidelines into the ACS document. One of
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- the fundamental kind of principles of writing the
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- guidelines documents is that unless there are compelling
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- new data to refute or change a prior
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- guideline recommendation, we really carry it forward. And
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- I think that the data have been pretty
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- definitive with respect to the benefit of radial
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- access over femoral access, particularly in patients with
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- acute coronary syndrome. That's incredibly helpful. Drawing upon
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- your experience, are there common scenarios that you
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- find yourself crossing over from radial to femoral?
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- And if so, what factors are leading up
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- to that decision? Yeah. That's a great question.
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- You know, years ago,
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- Sky put out a document on best practices
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- for transradial procedures. And in that document,
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- there was a decision algorithm about when you
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- should consider switching vascular access sites from radial
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- to femoral, particularly in the setting of ST
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- segment elevation MI,
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- largely because of the door to balloon time
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- metric. I think that the crossover rates really
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- have gone down over time. If you look
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- at kind of national data, as the adoption
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- of radial approach now is exceeding seventy five
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- percent of The United States, people are becoming
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- really, really facile with it. And you know,
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- the crossover rates, which occur really for three
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- major reasons, it's either failure of access, failure
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- to traverse the arm, or failure to seat
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- the guide catheter. All of those things tend
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- to improve with experience. The other thing that
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- I think has led to a decrease in
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- crossover rates is that now there are long
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- vascular access introducer sheets that can go from
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- the radial site all the way into the
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- ascending aorta. That basically mitigates subglavian tortuosity and
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- facilitates catheter manipulation. So I think crossover rates
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- have gone down. Now, when would we consider
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- crossing over? I think the major issue that
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- really causes people to cross over to femoral
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- access is radial artery spasm, which still is
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- an issue. You generally tend to encounter it
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- in small statured individuals who have small radial
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- arteries. And so, you know, if you're doing
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- a radial procedure and the patient is very,
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- very uncomfortable because of pain from manipulating the
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- catheter, that's really kind of what causes people
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- to switch over to a femoral access approach.
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- And I think that's entirely reasonable. The whole
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- reason that we do radial approach is that
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- it's a safer, more comfortable approach for a
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- patient. So if patients are uncomfortable, you know,
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- it's really kind of negating the benefit of
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- that, and that's where you would consider switching.
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- That's incredibly helpful. You had mentioned kind of
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- the smaller stature for certain patients leading to
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- a crossover.
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- Are there certain ECG patterns or patient variables
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- that would make you shy away from even
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- starting radial and just going femoral?
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- I don't think so. I don't think there's
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- anything you know, when you examine the patient,
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- if there are no radial pulses, obviously, it's
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- complicated.
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- But I think a lot of us are
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- using ultrasound access now. One thing that I
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- will tell you related to the short stature
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- is that there have been two papers now
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- that show that patient height below five foot
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- five inches,
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- a left radial approach will lead to, decrease
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- in femoral crossover rates and a much faster
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- procedure because of less subclavian tortuosity
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- on the left side. So I don't think
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- it's anything clinically that would lead someone to
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- use a femoral approach. I think it's more
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- really about the dimensions of the patient with
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- one big caveat, which is that if you
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- really think that this patient is in, you
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- know, SKY stage B or C shock, and
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- you're thinking about going to mechanical circulatory support,
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- either during the case or you're worried that
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- you may need mechanical circulatory support as a
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- bailout, you might wanna consider going with a
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- primary femoral approach because you're gonna need that
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- femoral access site for the MCS.
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- That's interesting.
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- You mentioned left radial. Are you ever exploring
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- other upper extremity arteries?
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- Yeah. Good question. I mean, the other two
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- possible sites are the distal radial, which is
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- in the anatomical softbox,
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- or ulnar approach. Distal radial really was in
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- vogue probably
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- about two years ago. And there have been
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- some randomized trials that have compared
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- distal radial with traditional proximal radial showing that
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- distal radial reduces the risk of proximal radial
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- artery occlusion. The challenge with distal radial is
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- that it is much harder to get vascular
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- access in the anatomical snuffbox. And in general,
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- we recommend ultrasound guidance for any snuffbox access
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- because there is a little bit of tortuosity
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- in the anatomical snuffbox and the artery is
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- a little bit smaller there. It can be
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- very, very helpful for a left radial approach,
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- which is ergonomically for the operator. Using the
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- left snuffbox is a little bit more comfortable.
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- Ulnar approach also has several randomized trials to
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- support it. There have been randomized trials that
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- have compared ulnar with radial showing that it
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- is a feasible access site. There's a slightly
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- higher rate of forearm hematoma with ulnar access
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- largely because it's deeper in the arm and
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- it's a little bit harder to get hemostasis
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- after the procedure.
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- I think in contemporary labs where ultrasound guidance
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- is being used, oftentimes we will ultrasound the
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- radial artery as well well as the ulnar
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- artery. And if the ulnar artery is much
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- bigger, in other words, the dominant artery, we'll
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- just go ahead and use a a priori
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- ulnar artery approach. Wow. That's excellent. Thank you
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- so much for expanding.
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- Hey, Cathmasters. This is Amit Gohil. In addition
2
00:00:02.720 --> 00:00:05.040
- to your regular programming, we are proud to
3
00:00:05.040 --> 00:00:07.759
- share select gems from the Maine Cardiutants podcast
4
00:00:07.759 --> 00:00:10.000
- that are particularly relevant to the practice of
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- interventional cardiology.
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- This episode is from our Decipher the Guideline
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- series which breaks down the twenty twenty five
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- ACS guidelines using case based board style questions
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- with insights from the guideline authors themselves.
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- This was planned in collaboration with the American
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- Heart Association and developed by the Cardiators Interventional
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- Cardiology Council led by Council Chair Doctor. Nesli
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- Okomash.
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- The following question refers to section 7.3
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- of the 2025
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- ACS
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- guidelines.
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- The question is asked by Thomas Jefferson, medical
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- student, and CardiNerd's Academy intern, doctor Grace Chu,
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- answered first by University of Michigan fellow and
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- CardiNerd's fit ambassador, doctor Kayla Secrest, and then
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- by expert faculty, doctor Sunil Rao. Doctor Rao
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- is an interventional cardiologist professor of medicine at
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- NYU Grossman School of Medicine, deputy director of
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- the Leon h Charney division of cardiology and
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- the director of interventional cardiology at the NYU
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- Langone Health System. He is the editor in
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- chief for Circulation Cardiovascular Interventions and was the
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- chair of the writing committee for the 2025
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- ACS guidelines. Doctor Rao, it is an honor
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- to have you with us. Gosh. Thanks so
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- much for having me. It's an honor to
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- be here. So first up, we have a
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- 68 year old man with a history of
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- hypertension, hyperlipidemia,
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- stage three chronic kidney disease, and prior tobacco
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- use presents to a local emergency department with
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- reports of chest pain while raking leaves at
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- home. Upon arrival, he is hemodynamically
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- stable with a heart rate of 86 beats
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- per minute and a blood pressure of one
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- thirty three over 85.
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- His EKG reveals ST elevations in the septal
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- and anterior leads b one through b four.
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- He is given three hundred twenty four milligrams
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- of aspirin and is promptly evaluated by the
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- interventional cardiology team who elects to take him
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- emergently to the catheterization
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- lab. Upon arrival to the catheterization lab, the
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- nurse asks the interventional fellow which access sites
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- they should prep for this case. How should
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- the interventional
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- fellow respond? Option a, right radial artery only,
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- option b, radial and bilateral femoral, or option
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- c, bilateral femoral only.
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- The correct answer is B, radial and bilateral
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- femoral. Radial artery access is the preferred nosular
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- access site for coronary angiography
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- and PCI patients with ACS.
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- Transradial access has been shown to reduce mortality,
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- bleeding, and vascular complications
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- compared with transframural
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- access. This is a class one level of
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- evidence a recommendation.
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- Radial access also allows earlier ambulation and is
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- associated with greater patient comfort.
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- Although the right radial artery is the most
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- widely studied upper extremity access site, alternative sites
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- such as the ulnar and distal radial arteries
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- have demonstrated similar outcomes.
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- However, the radial artery may be required as
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- a bypass conduit for CABG.
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- In institutions
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- where the radial artery is routinely used for
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- surgical grafting,
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- this potential future use should be considered when
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- selecting vascular access.
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- In addition, transfemoral
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- access, preferably performed with ultrasound guidance,
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- should be considered in patients in whom temporary
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- mechanical circulatory support is anticipated
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- or in those for whom radial access is
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- not feasible due to anatomical or technical constraints.
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- Prepping bilateral groins, in addition to the radial
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- artery, provides a backup strategy for urgent MCS
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- placement
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- or for transition to femoral access should radial
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- access fail. For these reasons,
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- prepping both the radial artery and bilateral groins
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- is the most appropriate response.
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- Radial only preparation is incorrect because although radial
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- access is preferred,
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- patients with STEMIs may still require emergent MCS
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- or an alternate access if the radial artery
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- is unsuitable.
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- Preparing only the wrist without backup femoral access
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- may delay care should hemodynamic instability occur. Femoral
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- only preparation
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- is incorrect because transradial access provides superior outcomes
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- in ACS, including significant reductions in all cause
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- mortality,
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- major bleeding, and vascular complications.
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- RCTs and meta analyses, including the matrix, which
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- showed lower MACE and net adverse clinical events
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- with radial access, and SAFARI STEMI trials, which
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- showed no difference in mortality but was underpowered,
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- support radial as first line access when feasible.
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- So what is the main takeaway here? For
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- patients with ACS undergoing PCI,
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- radial access is strongly preferred to reduce mortality,
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- bleeding, and vascular complications.
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- Doctor Rao, I would love it if you
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- have any additional thoughts or would like to
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- expand on this particular guideline further.
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- Yeah. Thanks so much. It's a great question.
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- And I think that you really summarized the
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- data well. You know, in the revascularization
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- guidelines,
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- radial approach was mentioned for the first time
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- in any guidelines document. And based on the
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- trials that you mentioned in acute coronary syndrome,
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- the comparison of radial versus femoral has shown
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- a reduction in vascular complications, bleeding, as well
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- as mortality. And that's really what led to
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- the class one recommendation in the guidelines. In
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- the acute coronary syndrome guidelines,
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- we basically transferred that guideline recommendation from the
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- ReVASC guidelines into the ACS document. One of
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- the fundamental kind of principles of writing the
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- guidelines documents is that unless there are compelling
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- new data to refute or change a prior
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- guideline recommendation, we really carry it forward. And
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- I think that the data have been pretty
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- definitive with respect to the benefit of radial
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- access over femoral access, particularly in patients with
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- acute coronary syndrome. That's incredibly helpful. Drawing upon
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- your experience, are there common scenarios that you
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- find yourself crossing over from radial to femoral?
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- And if so, what factors are leading up
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- to that decision? Yeah. That's a great question.
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- You know, years ago,
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- Sky put out a document on best practices
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- for transradial procedures. And in that document,
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- there was a decision algorithm about when you
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- should consider switching vascular access sites from radial
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- to femoral, particularly in the setting of ST
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- segment elevation MI,
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- largely because of the door to balloon time
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- metric. I think that the crossover rates really
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- have gone down over time. If you look
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- at kind of national data, as the adoption
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- of radial approach now is exceeding seventy five
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- percent of The United States, people are becoming
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- really, really facile with it. And you know,
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- the crossover rates, which occur really for three
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- major reasons, it's either failure of access, failure
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- to traverse the arm, or failure to seat
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- the guide catheter. All of those things tend
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- to improve with experience. The other thing that
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- I think has led to a decrease in
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- crossover rates is that now there are long
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- vascular access introducer sheets that can go from
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- the radial site all the way into the
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- ascending aorta. That basically mitigates subglavian tortuosity and
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- facilitates catheter manipulation. So I think crossover rates
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- have gone down. Now, when would we consider
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- crossing over? I think the major issue that
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- really causes people to cross over to femoral
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- access is radial artery spasm, which still is
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- an issue. You generally tend to encounter it
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- in small statured individuals who have small radial
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- arteries. And so, you know, if you're doing
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- a radial procedure and the patient is very,
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- very uncomfortable because of pain from manipulating the
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- catheter, that's really kind of what causes people
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- to switch over to a femoral access approach.
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- And I think that's entirely reasonable. The whole
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- reason that we do radial approach is that
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- it's a safer, more comfortable approach for a
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- patient. So if patients are uncomfortable, you know,
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- it's really kind of negating the benefit of
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- that, and that's where you would consider switching.
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- That's incredibly helpful. You had mentioned kind of
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- the smaller stature for certain patients leading to
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- a crossover.
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- Are there certain ECG patterns or patient variables
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- that would make you shy away from even
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- starting radial and just going femoral?
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- I don't think so. I don't think there's
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- anything you know, when you examine the patient,
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- if there are no radial pulses, obviously, it's
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- complicated.
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- But I think a lot of us are
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- using ultrasound access now. One thing that I
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- will tell you related to the short stature
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- is that there have been two papers now
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- that show that patient height below five foot
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- five inches,
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- a left radial approach will lead to, decrease
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- in femoral crossover rates and a much faster
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- procedure because of less subclavian tortuosity
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- on the left side. So I don't think
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- it's anything clinically that would lead someone to
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- use a femoral approach. I think it's more
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- really about the dimensions of the patient with
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- one big caveat, which is that if you
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- really think that this patient is in, you
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- know, SKY stage B or C shock, and
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- you're thinking about going to mechanical circulatory support,
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- either during the case or you're worried that
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- you may need mechanical circulatory support as a
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- bailout, you might wanna consider going with a
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- primary femoral approach because you're gonna need that
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- femoral access site for the MCS.
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- That's interesting.
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- You mentioned left radial. Are you ever exploring
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- other upper extremity arteries?
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- Yeah. Good question. I mean, the other two
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- possible sites are the distal radial, which is
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- in the anatomical softbox,
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- or ulnar approach. Distal radial really was in
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- vogue probably
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- about two years ago. And there have been
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- some randomized trials that have compared
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- distal radial with traditional proximal radial showing that
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- distal radial reduces the risk of proximal radial
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- artery occlusion. The challenge with distal radial is
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- that it is much harder to get vascular
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- access in the anatomical snuffbox. And in general,
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- we recommend ultrasound guidance for any snuffbox access
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- because there is a little bit of tortuosity
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- in the anatomical snuffbox and the artery is
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- a little bit smaller there. It can be
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- very, very helpful for a left radial approach,
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- which is ergonomically for the operator. Using the
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- left snuffbox is a little bit more comfortable.
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- Ulnar approach also has several randomized trials to
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- support it. There have been randomized trials that
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- have compared ulnar with radial showing that it
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- is a feasible access site. There's a slightly
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- higher rate of forearm hematoma with ulnar access
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- largely because it's deeper in the arm and
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- it's a little bit harder to get hemostasis
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- after the procedure.
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- I think in contemporary labs where ultrasound guidance
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- is being used, oftentimes we will ultrasound the
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- radial artery as well well as the ulnar
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- artery. And if the ulnar artery is much
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- bigger, in other words, the dominant artery, we'll
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- just go ahead and use a a priori
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- ulnar artery approach. Wow. That's excellent. Thank you
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- so much for expanding.
