Variation on old heart procedure lowers cost, cuts complications
For decades, physicians treated blocked heart vessels by snaking a thin tube from an artery in the groin up to the heart area. But now some cardiologists are adopting a method that goes through the wrist instead of the groin, an approach European physicians have used for years.
Using the wrist -- to look for a blockage or to treat one -- causes fewer complications and allows almost immediate mobility afterwards. The procedure, known as radial artery catheterization, usually involves less time in the hospital -- which means lower costs -- and requires a short recuperation period, according to cardiologists.
"Patients love it. If they've had a catheterization done from the groin and then through the wrist, they never want to go back," said Dr. Janet Strain, director of cardiac clinical research at The Valley Hospital in Ridgewood.
Still, interventional cardiologists -- the doctors who do the procedure -- across the nation have been slow to embrace the method, she said. "It's a challenge for us because we've been doing it through the groin for so long we can basically do it in our sleep," she said. "So we have to relearn certain skills."
At first, physicians in the U.S. had difficulty with the method because the tubes, known as catheters, were too bulky for the smaller arteries in the wrist.
"The catheters used to be the size of a drinking straw and now they're the size of a stirring straw," said Dr. Stanley Szwed, a cardiologist at St. Mary's Hospital in Passaic, N.J.
In Europe, doctors had access to smaller catheters earlier. "New drugs, technologies and procedures are approved much quicker in Europe than they are here," said Dr. Jeffrey Matican, cardiology section chief at Englewood Hospital and Medical Center. "So they've had much longer to work with the new equipment."
Good results are fueling interest in the procedure among cardiologists, Szwed said.
"What's really driving this right now is the lower amount of complications," he said. "Some studies show a significant reduction in the amount of bleeding, which is the biggest complication."
Because catheters are usually put into arteries near blood pressure points, getting the blood to clot and stop flowing out of the insertion hole can be difficult. When the catheter is threaded through the groin, patients can bleed for a long time without anyone being aware of it.
"If someone is bleeding in the wrist area you can see it right away," Strain said. "But with the groin, especially if you have an obese patient, you can't see that they're bleeding and there have been cases where patients have bled to death."
The groin procedure requires patients to lie on their backs, usually for four or more hours with a weighted device on the area. This pressure usually stops the bleeding, yet patients must still remain immobile for another few hours. Patients are typically in the hospital for almost 24 hours and then must be careful for several more weeks so they don't reopen the wound.
Thomas Kane, a 62-year-old grandfather from Rutherford, N.J., said it was very disruptive to have to limit his movements so long after the procedure. "I was restricted from movement for about 12 hours with a sandbag on my leg so the hole wouldn't open up," Kane said. "Then for three or four weeks after it I couldn't drive or carry anything heavy."
That was two years ago. Recently he had a radial artery catheterization for another blockage.
"I was pretty comfortable compared to what I had been through," Kane said. "They wrapped my wrist up tight for about 15 to 20 minutes and that was it."
The trade-off for patient convenience is physician discomfort. Matican said doctors "have to get out of their comfort zone to do this. There's a learning curve to doing it through the wrist."
Cardiologists typically stand on the right side of the patient during the groin procedure and know exactly how to coax the catheter through the various angles to the heart. When they enter through the wrist, they have to adapt to a different series of twists and crooks in the arteries. They also usually have to stand on the opposite side of the body, which makes some physicians uncomfortable because it puts them closer to the x-ray machine and the added time it takes to do the unfamiliar procedure results in more radiation exposure. But other cardiologists say the limitations are outweighed by the new method's track record of lower complications.
"I think eventually 90 percent of patients will be able to have this," Matican said.