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Research supports heart catheter procedures that start in the arm.

Accessing the heart through an artery in the arm leads to less bleeding than going in through a leg artery. But sometimes doctors have no choice.

The majority of coronary catheter procedures are still done by inserting the catheter in the femoral artery in the upper leg and guiding it up to the heart. But recent research suggests that going in through an artery in the arm--using the radial or ulnar arteries--may be a safer choice.

Indeed, the lead researcher on a study presented at the 2015 American College of Cardiology Scientific Sessions says radial access should be the "preferred method" for catheter-based heart procedures.

Cardiologist Stephen Ellis, MD, section head of Invasive/ Interventional Cardiology at Cleveland Clinic, agrees with that assessment. But he acknowledges that it will take greater physician training and experience before radial access becomes the dominant approach.

"There's definitely a learning curve for physicians who have been using the femoral approach," Dr. Ellis says. "For a while it takes longer to do. But after a physician has some experience, that's less of an issue."

He adds that in recent years, catheter-based heart procedures using radial access have gone from about five percent of all such procedures to 50 percent at Cleveland Clinic.

When femoral access is better

Despite the advantages of radial access, some patients require the traditional femoral approach. It may be due to a patient's small radial arteries. Or the patient may have had a complicated heart bypass surgery that restricts access through the radial artery.

The femoral approach is also better if the physician doing the procedure has little experience with radial access.

"A lot of the approach decisions are driven by physician experience," Dr. Ellis says. "If you really want it done through the radial artery, you should probably ask your doctor what kind of experience he or she has with that approach."

Going in through the arm also may not be possible if there are anatomical barriers in the elbow or shoulder.

The ulnar alternative

There are actually two main arteries in the wrist that can be used for catheter procedures. While the radial artery is the primary option, the ulnar artery on the opposite side of the wrist is a viable option in some cases.

A study presented at the 2015 American College of Cardiology Scientific Sessions found that there were no significant differences in outcomes among patients who underwent radial access vs. ulnar access. Ulnar access is seldom used, but Dr. Ellis says that is due mainly because of advantages unique to the radial artery. He explains that the radial artery is often bigger than the ulnar artery, which makes catheter access easier. Also, the radial artery puncture site is near a bone, which allows for easier compression and a much lower risk of bleeding.

Other considerations

Dr. Ellis notes that for patients on major blood-thinning medications, radial access is definitely preferred. This is because femoral access already raises the risk of bleeding complications. And a patient on blood thinners would be at an even greater risk of bleeding problems after the procedure.

One of the reasons why the femoral approach has a greater bleeding risk is because there is so much tissue between the artery and the skin, Dr. Ellis explains. The femoral artery also runs adjacent to the abdominal cavity. An inadvertent puncture of the femoral artery could lead to serious blood loss.

One other disadvantage of femoral access is that patients must lie down for several hours after the procedure. That also means patients can't eat for several hours either. Radial access allows patients to sit up immediately after the procedure.

For some patients, such as those having a heart attack, there is little time to consider all the alternatives and patient preferences. "In the case of a heart attack, radial is better," Dr. Ellis says.

Recovery time is also shorter for patients after the radial approach. But Dr. Ellis notes that a patient's anatomy and health history are considered carefully before a decision is made. Poor blood flow to the hand or prior wrist surgery could make radial access impossible.

But as more research supports radial access, and more physicians become trained with that approach, Dr. Ellis says that when there is an option, radial access will often be the preferred choice.
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Title Annotation:TREATMENT
Publication:Heart Advisor
Geographic Code:1USA
Date:Jun 1, 2015
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