At Stanford Hospital, Coronary Procedure No Longer Requires Overnight Stay

STANFORD, Calif.--(BUSINESS WIRE)-- You can have a percutaneous coronary intervention through your femoral artery or radial artery. Put another way, you can have a catheter stuck into your groin or your wrist. Not sure which you’d prefer?

Jennifer Tremmel, MD, injects angiographic dye through the catheter as she and Tannon Carroll, MD, f ...

Jennifer Tremmel, MD, injects angiographic dye through the catheter as she and Tannon Carroll, MD, fix their eyes on an x-ray monitor. Photo courtesy of Stanford Hospital & Clinics

Then consider Richard Francis, a local accountant and ex-Navy pilot, who had stents inserted through the radial artery in his wrist at Stanford Hospital & Clinics on July 15, two days before turning 67.

A coronary stent is a tiny mesh tube that helps open up blood vessels clogged with cholesterol, fat and other stuff that leads to heart disease. Stenting is usually preceded by angioplasty, which involves expanding a balloon inside the artery to crush the plaque. Sometimes angioplasty is used exclusively. In any case, procedures practically guarantee a night in a hospital bed if done the traditional way — through the femoral artery.

But Francis left the hospital just a few hours after the procedure. “It was a heck of a birthday present,” he said.

He owed his fast exit to cardiologist Jennifer Tremmel, MD — or, more specifically, to the minimally invasive technique she has mastered for diagnosing clogged blood vessels, performing angioplasties and placing stents.

Instead of going through the femoral artery, Tremmel inserted a slim catheter into a small puncture in Francis’s left wrist and slid it up through his arm, via the radial artery, until it reached his heart. Then she placed stents into his left anterior descending artery and his left circumflex artery.

More than 1 million angioplasties and stent placements, known collectively as percutaneous coronary interventions, or PCIs, are performed each year in the United States. But it’s tough to find a hospital that will do them transradially — that is, through the wrist. A 2008 report in the Journal of the American College of Cardiology Interventions found that of nearly 600,000 PCIs between 2004 and 2007, only 1.32 percent were transradial.

However, the technique is rapidly gaining ground in the United States. Tremmel, who is director of the Transradial Interventions Program at Stanford Hospital, says that the transradial approach now accounts for almost 5 percent of all PCIs nationwide.

She regularly travels around the country speaking about transradial PCI, and has turned Stanford into a West Coast training center where she trains two to three interventional cardiologists per month in the technique. In the spring, she will oversee a big course on it at Stanford.

“I actually feel a little guilty when I have to use the femoral route,” Tremmel said. She performs almost all of her PCIs and angiography, a diagnostic technique using special dye and x-rays to look for heart disease, transradially.

Several studies have shown that transradial PCIs reduce bleeding complications, shorten hospital stays and cost less compared with the femoral approach. A meta-analysis published last year in the American Heart Journal found that transradial PCI reduced the risk of major bleeding by 73 percent and the length of hospital stays by about half a day as compared with femoral PCIs. For women, the risk of bleeding complications from transfemoral PCI are two to three times greater than for men, Tremmel said, which makes women ideal candidates for transradial PCI.

Patients can sit up and walk almost immediately after the transradial procedure. And most patients, like Francis, can even leave the hospital the same day. Transradial PCI also helps to free up time for nurses, who, after a transfemoral PCI, often have to hold pressure on the patient’s groin for about a half hour to help stop bleeding. The only thing a typical transradial patient needs to stop the bleeding is a kind of see-through bracelet (for compression) and a small bandage.

“I think the major advantage is patient comfort,” said Alan Yeung, MD, director of interventional cardiology at Stanford Hospital. “From the medical side, it’s easy to compress the radial artery to stop bleeding; there’s no tissue in the way of it, unlike the femoral artery.”

After undergoing PCI through the femoral artery, patients must lie flat on their backs for as long as six hours, and they almost always are kept overnight for observation, mainly to ensure there are no bleeding complications. Another downside to the femoral route is that it is relatively close to a major vein and nerve, which run the risk of being nicked during the catheterization.

Given the advantages of going through the wrist, it’s a bit of a mystery why U.S. cardiologists have persisted so long in using the femoral artery, Tremmel said. She chalks it up mostly to inertia.

“It’s harder to get some of the senior practitioners to do it, because relearning something is not always very comfortable for people, especially when they’re already talented at what they do,” she said.

Francis knows the advantages of transradial PCI firsthand. A couple of months before his stent procedure with Tremmel, he had an angiogram at another local hospital through the femoral artery. While recovering — that is, trying to lie still on his back for several hours — he moved his leg a little and the artery began hemorrhaging. “The doctors struggled with getting it to stop,” Francis recalled.

The upper part of his leg turned purple, and it was painful to walk for the next couple of weeks. He said he hopes the transradial procedure becomes more widely available for heart patients.

“It’s a whole lot easier on the body,” he said.

About Stanford Hospital & Clinics

Stanford Hospital & Clinics is known worldwide for advanced treatment of complex disorders in areas such as cardiovascular care, cancer treatment, neurosciences, surgery, and organ transplants. Consistently ranked among the top institutions in the U.S. News & World Report annual list of “America’s Best Hospitals,” Stanford Hospital & Clinics is internationally recognized for translating medical breakthroughs into the care of patients. It is part of the Stanford University Medical Center, along with the Stanford University School of Medicine and Lucile Packard Children’s Hospital at Stanford. For more information, visit http://stanfordmedicine.org.

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Stanford Hospital & Clinics
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Jennifer Tremmel, MD, injects angiographic dye through the catheter as she and Tannon Carroll, MD, fix their eyes on an x-ray monitor. Photo courtesy of Stanford Hospital & Clinics

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