Cath Lab Digest - October 2007 - (Page 63)

63 artery catheterization showed that the former had a higher number of procedural failures (7.2% versus 2.4%; p < 0.001). In addition, patients who require larger catheters for intervention or a balloon pump cannot undergo this approach. Radial artery spasm remains the most dreaded and frequent procedural complication of radial artery catheterization, reported in 7% of patients;18 however, its frequency has been drastically reduced with the use of hydrophilic sheaths,19 intra-arterial injection (nitroglycerin, heparin, verapamil), and improved operator experience.20 Study limitations. The major limitations of this study are that it is not randomized or prospective, and operator discretion in the choice of radial versus femoral technique may have skewed the data. Also, the conclusions of this manuscript apply only to a demographic of white males, whereas radial artery spasm is known to be more prevalent in females. In addition, the absence of procedural complications prevents us from discerning to what extent such complications might have overshadowed the cost savings with the radial approach. Finally, recovery time costs are dependent on many extraneous factors, such as who monitors the patient and what the hourly rate of pay for those individuals might be. These costs will vary widely around the country, and no doubt, the cost differentials may be much greater, or much narrower, than what we observed. Transradial artery coronary angioplasty. Am Heart J 1995;129:1–7. Cooper CJ, El-Shiekh RA, Cohen DJ. Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison. Am Heart J 1999;138:430–436. Rondan J, Lozano I, Moris C, et al. Cardiac catheterization via the right radial artery with a Judkins left catheter. Rev Esp Cardiol 2005;58:868–871. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous diagnostic and interventional procedures: Systemic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–356. Wyman RM, Safian RD, Portway V. Current complications of diagnostic and therapeutic cardiac catheterization. J Am Coll Cardiol 1998;12:1400–1406. Hildick-Smith DJR, Lowe MD, Walsh JT, et al. Coronary angiography from the radial artery – Experience, complications and limitations. Int J Cardiol 1998;64:231–239. de belder AJ, Smith RE, Wainwright RJ, Thomas MR. Transradial artery coronary angiography and intervention in patients with severe peripheral vascular disease. Clin Radiol 1997;52:115–118. Archbold R, Robinson NM, Schilling RJ. Radial artery access for coronary angiography and percutaneous coronary intervention. Br Med J 2004;329:443–446. Amoroso G, Sarti M, Bellucci R, et al. Clinical and procedural predictors of nurse workload during and after invasive coronary procedures: The potential benefit of a systematic radial access. Eur J Cardiovasc Nurs 2005;4:234–241. Grinfeld L, Berrocal D, Rojas Matas C, et al. What is the most effective vascular approach for a diagnostic cardiac catheterization? A randomized trial using the femoral, brachial or radial approaches. J Am Coll Cardiol 1996;27(Suppl A):901. Louvard Y, Pezzano M, Scheers L. Coronary angiography by a radial artery approach: Feasability, learning curve: One operator’s experience. Arch Mal Coeur Vaiss 1998;91:209–215. Labrunie A, Silveira W, Contero L. Transradial approach to coronary angiography: The reality of the learning curve evaluated in a comparative, randomized, multicenter study. Am J Cardiol 2001;88(Suppl 5A):111G. Steinbrook R. Nursing in the crossfire. N Engl J Med 2002;346:1757–1766. Bednash G. The decreasing supply of registered nurses: Inevitable future or call to action? JAMA 2000;283:2985–2987. Benit E, Vranckx P, Jaspers L, et al. Frequency of a positive Allen’s test in 1,000 consecutive patients undergoing cardiac catheterization. Cathet Cardiovasc Diagn 1996;38:352–354. Mandel MA, Dauchot MD. Radial artery cannulation in 1000 patients: Precautions and complications. J Hand Surg 1977:6:482–485. Ruiz-Salmeron RJ, Mora R, Velez-Gimon M, et al. Radial spasm in transradial cardiac catheterization. Assessment of factors related to its occurrence, and of its consequences during follow-up. Rev Esp Cardiol 2005;58:504–511. Koga S, Ikeda S, Futagawa K, et al. The use of hydrophilic-coated catheter during transradial cardiac catheterization is associated with a low incidence of radial artery spasm. Int J Cardiol 2004;96:255–258. Chen CW, Lin CL, Lin TK, Lin CD. A simple and effective regimen for the prevention of radial artery spasm during coronary catheterization. Cardiology 2006;105: 43–47. Table 4. Fluoroscopy, procedure, and recovery time by access categories. Data are presented as means ± standard deviation. Comparisons are made by t-test. 1p-value < 0.05 for comparison between radial and femoral group, 2p-value < 0.05 for comparison between radial and femoral with closure group, 3pvalue < 0.05 for comparison between femoral and femoral with closure group. 3. 4. Time (in minutes) Amount Fluoroscopy Procedure Recovery Radial Group 7.4 ± 6.51 20.8 ± 12.5 126 ± 361,2 Femoral without Closure Group 4.5 ± 3.3 20.5 ± 9.4 240 ± 423 Femoral with Closure Group 5.9 ± 5.1 20.2 ± 11.4 150 ± 48 5. 6. Table 5. Cost of cardiac catheterization by access categories (total and for individual components). Data are presented as means ± standard deviation. Comparisons are made by t test. 1p-value <0.05 for comparison between radial and femoral group, 2p-value < 0.05 for comparison between radial and femoral with closure group, 3p-value < 0.05 for comparison between femoral and femoral with closure group. 7. 8. Cost (in dollars) Amount Access Catheters Contrast Closure devices Recovery Total cost Radial Femoral without Group Closure Group 93 ± 9.51,2 40.5 1,2 19.7 ± 12.7 31.1 ± 9.3 26.9 ± 172 32.6 ± 18.93 61.4 ± 12.91,2 36.4 ± 24.93 1,2 185.2 ± 52.7 337.5 ± 593 369.5 ± 74.61,2 446.9 ± 60.23 Femoral with Closure Group 40.5 30.9 ± 9.6 42.9 ± 25 245 208 ± 70.4 553.4 ± 81 9. 10. 11. Femoral Group, as has been described before, but we also noted that it was lower compared to the F ± C Group. While access cost in our study was significantly higher in the radial group attributed to the use of hydrophilic sheaths, catheter cost was less due to reduced need to use multiple catheters with the radial approach. Contrast cost was higher in the F ± C Group due to additional dye consumption in this process. Closure device cost, as expected, contributed to additional expense in the F ± C Group. The significantly shortened recovery time with the radial approach resulted in significantly lower recovery cost compared with both femoral groups. The reduced catheter, contrast and recovery costs with the radial approach resulted in a significantly lower overall procedural cost compared with both femoral groups. Recovery cost savings in the F ± C Group were outweighed by the cost of the closure device, bringing the total variable cost to $553.4 ± $81.0 (p < 0.001) compared to $369.5 ± $74.6 in Group R, and $446.9 ± $60.2 in Group F. Nurse staffing represents an important burden on resource consumption and hospital economics to the extent that even a 1–2% change in nurse staffing results in huge shifts in annual expenditure in the order of $140,000–$220,000.14 In addition, a shortage of adequately trained cardiac registered nurses is frequently encountered, with no solutions on the horizon.15 The potential of cost savings with the radial approach compared with the femoral (with or without closure device) approach could significantly impact the budget of cardiac catheterization laboratories and recovery units. It should be recognized that the radial approach has some limitations and contraindications. Currently, there is less familiarity and comfort with this approach, as very few U.S. cardiovascular training programs have emphasized the importance of learning this technique. Cannulating the radial artery successfully and without complications involves a steep learning curve.12,13 Furthermore, this approach cannot be used in about 10–23% of patients who need a diagnostic cardiac catheterization due to an abnormal Allen’s test and a risk for hand ischemia.16,17 A metaanalysis analysis by Agostoni et al5 comparing 1,668 patients who underwent radial catheterization compared to 1,556 patients who underwent femoral 12. Conclusion In conclusion, although the cost savings per case may appear small (between $77.40 and $183.90 per patient), with more than 1 million diagnostic cardiac catheterizations performed yearly in the United States, there is potential for tremendous cost savings using the radial approach. ■ The authors report no conflict of interest regarding the conten herein and can be contacted via Dr. Nabil Jarmukli at: nabil.jarmukli@med.va.gov. Visit www.invasivecardiology.com to read the commentary on this article by Ferdinand Kiemeneij, MD, PhD, entitled “Cost-effectiveness of Transradial Coronary Access,” published in the August 2007 issue of The Journal of Invasive Cardiology. 13. 14. 15. 16. 17. 18. 19. References 20. 1. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3–72. 2. Kiemeneij F, Laarman GJ, de Melker E. http://www.invasivecardiology.com

Table of Contents Feed for the Digital Edition of Cath Lab Digest - October 2007

Saints Medical Center Fibromuscular Dysplasia in Children and Adolescents Cerebral Vascular Accident Following a Pulmonary Embolism: Search for the Hidden Patent Foramen Ovale Contents Clinical Editor’s Corner Meetings Calendar CEU Education Center Radiation Tracking in the Cardiac Catheterization Lab Letter to the Editor Carotid Stenting: An update Release from Stent-jail: Beneficial Snow-Plowing? Patient Management Guidelines Searching for a Cardiovascular Position? Tips for Creating a ‘Stand-Out’ Resume Long-Term Implications of Short-Term Closure Decisions – The Evolution to Vascular Access Management and the Boomerang Catalyst System The Ten-Minute Interview with… Angie Bowles, RN, CCRN CMS Issues Final FY 2008 IPPS Rule ACVP• Membership Page Experience with a New Workhorse Guidewire Ask the Clinical Instructor: Q&A for Those New to Cath Lab A Glimpse of the Future of Clinical Education: Boston Scientific’s SimSuite Bus Visits Carnegie Institute 2007 Educational Fair Held at the Washington Hospital Center Research Update: Original Contribution Abstracts from The Journal of Invasive Cardiology What Do You Think? A Virtual Cath Lab Viewer (VCL): The Development of an Online 3D C-arm Simulator and Coronary Anatomy Viewer Clinical & Industry News Cost-Effectiveness of the Radial versus Femoral Artery Approach to Diagnostic Cardiac Catheterization

Cath Lab Digest - October 2007

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.