Outpatient stent procedures: NC doctors show it’s possible
Stenting from the radial artery achieves best results, study shows
A cardiologist with Wake Heart Associates in Raleigh, NC, believes coronary stenting eventually could be performed in outpatient settings at a savings of millions of dollars nationwide.
Doctors at Wake Heart, who perform surgery at the Wake Heart Center, which is part of the Wake Medical Center, also in Raleigh, have adopted coronary stenting from the radial artery as the procedure of choice because their experience has proven that to be the most cost-effective and successful method, says J. Tift Mann III, MD, FACC.
"The stent procedure can be performed on the same day as the angioplasty, and the patient can go home that afternoon," Mann explains.
"We use a simple wrist device which is applied," Mann explains. Stents are crimped on a pre-dilatation balloon and delivered to the angioplasty site through six French guide catheters.
Other research has shown stented vessels do well over the long term, and stent use has increased to about half of all coronary interventions done each year in the United States. But its main drawback has been that stenting has been more expensive than procedures of angioplasty alone. Mann asserts this will change once cardiologists learn to stent through a radial access.
Mann and other researchers completed a study, published recently in The Journal of Invasive Cardiology,1 that shows how a group of patients who were stented from the radial artery and then treated with ticlopidine and aspirin had an average, post-procedure length of stay of 2.2 days. This compares with an average, post-procedure length of stay of 4.4 days for patients stented from the femoral artery and treated with warfarin. (See cost comparison chart, p. 15.)
It was also a vast improvement over the average post-procedure length of stay of more than three days for patients stented from the femoral artery and treated with ticlopidine and aspirin. The fourth group studied had been stented from the radial artery and then treated with warfarin. This group’s average length of stay was 3.9 days.
In explaining the radial stenting procedure, Mann notes the average length of stay includes patients with myocardial infarction and other complications. The typical patient goes home the next day; 35 out of 300 patients studied went home the day of the surgery.
Mann says criteria for pre-selection developed by a surgeon in Amsterdam, play a big role in choosing which patients have the radial stenting procedure.2 Patients are generally stable cases with an isolated single lesion, Mann says.
Also, the study showed that access-site complications occurred only in patients stented from a femoral access site. Subacute closure occurred only in groups managed with warfarin.
The cost savings can be substantial. Mann and colleagues examined the clinical and economic outcomes of 719 patients who underwent coronary stenting between December 1994 and August 1996. They found that the total hospital charge was 19% less for patients who underwent coronary stenting using the radial access site. Their average charge was $19,675, compared with an average $24,218 for the femoral patients. (See cost comparison chart, p. 15.)
Their comparison also concluded that the radial approach can be as successful as the femoral approach with fewer vascular complications. About 5% of the patients who were stented from the femoral access site had vascular complications. This compares to 0.3% vascular complications among the patients stented from the radial access site.
Patients liked the transradial approach despite the minor discomfort during the procedure, Mann says, because they were able to get out of bed and move around after surgery. "They walk out of the cath lab. They could use the bathroom and not have to stay in bed for eight to 12 hours. These benefits far outweighed the minor discomfort."
Mann adds, "The major complaint patients had in the past is back pain associated with lying in bed overnight."
Procedure has some limitations
There is one major problem with stenting from a radial access site, Mann acknowledges.
"The major drawback is everyone can’t have it done this way; only 80% of the patients we see are candidates for radial procedures," Mann says. "The reason is we must have dual blood flow to the hand."
There is a 5% incidence of radial artery occlusion in which the artery was totally blocked after the procedure, he explains. "We need accessory blood flow to take over after doing vascular procedures to the hand."
The patients’ arms had to be tested for dual blood flow, and about 20% had insufficient blood flow, Mann adds.
Another drawback to the procedure is that it takes time to master and this has prevented some cardiologists from attempting to learn it, Mann says. "Many cardiologists, especially low-volume operators, are fairly intimidated because the technique involves a large learning curve."
Wake Heart Center did its part to introduce the procedure to cardiologists by holding a national symposium on Transradial Coronary Angioplasty and Stenting in October. About 150 cardiologists attended and learned the technique, Mann recalls.
Mann recommends that cardiologists who would like to learn more about the radial procedure attend a symposium on the subject and read all the available literature. Within a few years, Mann predicts, this procedure will become easier to perform because technology will provide better catheterization and stents.
"In Europe, there are multiple catheters and stents available that make the radial approach much easier, and the transradial approach is gaining acceptance," Mann states. When the FDA approves more stent designs, it will make the radial procedure more widely accepted, he notes. Wake Heart doctors are now using the stents off label since they have to first remove the manufacturer’s delivery device to allow the radial approach. Mann says.
Reference
1. Mann, J. Clinical evaluation of current stent developments strategies. Journal of Invasive Cardiology 1996; 8:30D-35D.
2. Kiemeneij, F. Transradial palmaz-schatz coronary stenting on an outpatient basis: Results of a prospective pilot study. Journal of Invasive Cardiology 1995; 7:5A-11A.
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