Local Docs Concur Wrist Angioplasty Is Right For Some Patients

By John Voket

At New Milford Hospital, Dr Lawrence Laifer has been performing wrist angioplasties on qualified patients for several years. So he was not surprised this week to learn that a major American Heart Association (AHA) study is giving the procedure high marks in relation to its minimizing of bleeding and discomfort for patients over the traditional method, which inserts a potentially life- saving stent through the groin.

Responding to questions from The Newtown Bee this week, Dr Laifer, who is the hospital’s director of cardiac catheterization and interventional cardiology, said the useful wrist technique has become increasingly utilized over the past several years as the equipment for angioplasty has become progressively miniaturized.

 According to the AHA, about a million artery-clearing angioplasties are performed in the United States each year, and the usual route is to thread a tube to the heart through an artery in the groin. Recently, the organization released results of a major study confirming the wrist procedure can significantly lower the risk of bleeding — without the discomfort of lying flat for hours while the incision site seals up.

Just one in 100 angioplasties is done via the wrist, and the approach is not for everyone. But the August 18 study release promises to spur more specialists to use the method.

“In experienced hands, it can be done more,” said Dr Sidney Smith, heart disease chief at the University of North Carolina at Chapel Hill and a past president of the AHA, who was not part of the study. “This approach, when done by experienced operators, has advantages.”

Angioplasty is prized as a quick, minimally invasive way to restore blood flow in a clogged artery. A tiny balloon is inflated at the site of the blockage, pushing back the clog. Doctors often also insert a mesh tube called a stent to keep the artery propped open.

It can be done during a heart attack, to alleviate worsening symptoms that signal a heart attack is imminent, or for nonemergency relief of recurring chest pain.

Who is the best candidate for an angioplasty versus other treatments is hugely controversial. But once that decision has been made, the new study addressed whether the through-the-wrist route works as well.

Cardiologists have preferred working through the femoral artery in the groin because it is a larger blood vessel than the wrist’s radial artery, easier to tug catheters through. When the procedure is over, heavy pressure — often a sandbag — is applied for several hours until the puncture site quits bleeding and essentially seals itself.

But heavy bleeding and related complications are a risk, happening in anywhere from two percent to sometimes as many as ten percent of patients.

Catheters have gradually gotten smaller and more flexible, and previous small studies had suggested the wrist approach could be safer because that puncture site can be bandaged. In one earlier study, the wrist method even trimmed hospital costs because patients were discharged sooner.

Dr Hal Wasserman, director of the cardiac catheterization lab and interventional cardiology at Danbury Hospital, agrees that the cost-saving implications of the wrist angioplasty are real. But while he has performed the wrist procedure, Dr Wasserman told The Bee he prefers the groin catheterization.

“Most cardiologists today still train with the groin, and I think it is a bit lower risk for the patients because the artery is larger,” he said. “Bleeding complications do tend to be higher in the groin, but there are some postprocedure concerns with the wrist as well.”

He said in pre-op, it is important to ensure the blood supply to the hand is coming from both the thumb and pinky side, because in patients with only one artery to the hand, surgeons have to be careful not to compromise the blood flow by tapping the only artery.

And Dr Wasserman said as far as he is concerned, both the wrist and groin procedures have advanced to the point that allows for more rapid patient discharge.

For the national study, Duke University researchers turned to a national registry — analyzing more than half a million angioplasties performed at 600 US hospitals between 2004 and 2007 — to see how often wrist angioplasties are done, and the results. One key caveat: These were first-time, nonemergency cases.

But just 1.3 percent of the angioplasties were done through the wrist. Both methods were equally effective at clearing heart arteries, lead researcher Dr Sunil Rao reported in the Journal of the American College of Cardiology: Cardiovascular Interventions.

The wrist method cut the bleeding risk by nearly 60 percent: nearly two percent of patients treated the usual way bled, compared with slightly fewer than one percent of those treated via the wrist.

The method may be gaining steam: in early 2007, the researchers measured a sudden jump, as the wrist method accounted for about 3.5 percent of angioplasties performed then. In New Milford, Dr Laifer likes having fewer bleeding complications, and the fact that the wrist procedure often permits earlier ambulation in his patients.

“I have routinely utilized this wrist approach for patients at high risk of bleeding — those with risk factors including obesity, those of the female gender, elderly, those with known preexisting bleeding problems, known anemia, or low platelet count,” he said. “This approach is also beneficial in people who have difficulty with flat bed rest postprocedure — this would include patients with arthritis, lower back pain, or COPD.”

Dr Laifer added that radial artery cardiac catheterization and angioplasty would be a strongly preferred approach in Jehovah’s Witnesses, since they would not accept blood transfusion in the event of significant bleeding.

“There are a few patients were the radial approach is not desirable; an assessment of collateral circulation to the hand is required prior to utilizing the radial artery approach,” Dr Laifer said. “Overall, the radial artery approach is a valuable technique which should allow interventional cardiologists to lessen potential bleeding complications, and enhance patient comfort following cardiac catheterization and/or angioplasty.”

Dr Rao himself uses wrist angioplasty almost exclusively, but it takes extra training that many cardiologists have not received.

Still, the Heart Association’s Dr Smith said training is not difficult, and the need may be growing: obesity can limit traditional access, plus more patients today have disease-damaged leg arteries.

“The procedure is not one that would be recommended for everybody,” Dr Smith cautioned. But, “there are definitely groups of patients where this can be done with the same results and fewer complications.”