Shortening the Learning Curve Is Key for Increased Adoption of Transradial Primary PCI

By Kurt G. Barringhaus, MD, FSCAI
Director, Transradial Program
UMassMemorial Health Center

Five years ago we stopped denying the facts. The heightened acuity of patients presenting to our center was placing them at risk for developing periprocedural bleeding.  Although our access-site complication rates were far better than the national average, avoidable bleeding was no longer tolerable, whereupon we committed ourselves to becoming a ‘Radial First’ center.
A preponderance of the evidence at the time suggested that transradial access reduced complications related to vascular access but at the cost of decreasing procedural success and increasing procedural duration.  We anticipated that these shortcomings could become further amplified under an emergent setting, particularly given that the primary operators at our institution had only limited experience with transradial (TR) PCI.  External and intrinsic pressures to optimize door to balloon time were real.  But we remained convinced that improved patient outcomes justified the transition to the TR approach for those at highest risk.
Technical challenges related to TR access and PCI are well defined, and we set out to overcome each of them with technological refinements (provisional ultrasound-guided access; 25 cm sheaths to eliminate the role of vasospasm; improved catheter design for coronary intubation and support).  The pace of our program accelerated, and critical mass was achieved.  We consistently perform over 80% of our primary PCIs transradially, and bleeding complications have been virtually eliminated.
The changing landscape suggests that adoption of TR access by operators is more a question of ‘when to’ rather than ‘whether to.’  How to do so has been somewhat problematic.  Current dogma suggests that the learning curve may be overcome primarily with dedication and time commitment.  Indeed, those attributes were critical to the success of our program, and there is no substitute for experience as we show in our publication in the Journal of Invasive Cardiology.  However, I am likewise convinced that technical refinements now and in the future will be critical to enhancing a successful transition.  The solution is not to withhold patients from undergoing TR primary PCI until an operator has completed a learning curve defined by an excessively high number.  Rather, the solution lies in shortening that learning curve, a task that can be best achieved by further technical advancement and information exchange both collectively and through mentoring programs.
When is the right time for an operator to adopt TR access for emergent procedures?  Our study suggests that an appropriate volume for many operators may be in the tens rather than the hundreds.  However, each circumstance is unique, and generalizing the findings from our high-volume tertiary care referral center should be met with caution.  Additionally, we emphasize the importance of patient selection when operators make the transition.  We hope that our study will continue the conversation on this important topic and that greater refinements will be achieved as more and more operators become primary transradialists.

A selection of recent Radial Intervention articles available at http://www.invasivecardiology.com

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