September 18, 2025 • 32 mins
In this episode of our podcast DocTalk, host Debra Schindler sits down with MedStar Health interventional cardiologist Dr. John Wang, director of the Cardiac Catheterization Labs at MedStar Union Memorial Hospital and MedStar Franklin Square Medical Center in Baltimore, to explore how cardiac catheterizations have evolved, and why the transradial approach (through the wrist) is transforming catheterization procedures.
Traditionally performed through the femoral artery in the groin, cardiac caths are increasingly going in through the wrist, offering:
· Faster recovery
Fewer complications
Greater patient comfort
Same-day discharge for many patients
Dr. Wang explains:
- What symptoms may lead to a cardiac cath
- When the procedure is performed in emergencies (like heart attacks) vs. scheduled care
- Why national cardiology guidelines recommend the transradial approach
- What patients should ask their doctors before undergoing the procedure
If you or a loved one may need a heart cath, this episode will help you understand your options, and why the accessing the heart through the wrist is a better approach.
Learn more about interventional cardiology at MedStarHealth.org/MHVI
To comment on this podcast, or suggest a topic for another episode send us an email: DocTalk@medstar.net
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
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Episode Transcript
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Speak (00:01):
- Comprehensive, relevant and insightful conversations about health
and medicine happen here.
When MedStar Health DocTalk,these are real conversations
with physician experts fromaround the largest
healthcare system in theMaryland DC region.
If you're looking for moreinformation on cardiac
(00:22):
catheterizations, this is your podcast.
Because these importantprocedures have evolved so much
through the years, andnot everyone is caught up
with the changes, whichis interesting when you
consider this fun fact.
In 1929, a young Germanphysician, Werner Forssmann,
performed the very firsthuman cardiac cath on himself.
(00:43):
He inserted a catheterinto a vein in his arm
and guided it into his heart under x-ray.
His supervisors werehorrified at the time,
but this bold act earned him a shareof the 1956 Nobel Prize in medicine.
Since then, cardiac catheterizationshave become a standard
(01:03):
procedure for physiciansto get a direct detailed look at the heart
and its blood vessels performedthrough the femoral artery in the groin.
But it seems Dr. Forssmann hadit right the first time.
Accessing the heart throughthe wrist has transformed
diagnostics and treatmentfor cardiac patients.
We're going to learn moreabout transradial cardiac
(01:25):
catheterizations with Dr. John Wang,who is truly a pioneer in
interventional cardiac proceduresperformed through the wrist.
He's the director of theCardiac catheterization labs at
MedStar Union Memorial Hospitaland MedStar Franklin Square
Medical Center in Baltimore.
I'm your host, Debra Schindler.
Welcome to Doc Talk Dr. Wang.
(01:46):
- Debra, thanks for having me.
- So when a patient comesto the cardiac cath lab,
is it usually an emergency situation?
Why does someone come in needof a cardiac catheterization?
- Well, it can be an emergency.
The most common emergency thatbrings people to the cath lab
that would require a heartcatheterization is a heart attack.
Sometimes you've heard peoplerefer to these as STEMIs,
(02:09):
and these are a type of heart attackwhere the blood vessel is acutely 100%
blocked with a blood clot.
People traditionally haveclassic symptoms like chest pain
and elephant sitting on their chestand are oftentimes quite sick.
- Some of the symptoms that youmight have people coming in,
let's go through the list.
(02:29):
- Sure. The classic one is chest painand that chest pain or pressure
or tightness can radiate to people's jaws.
They can also have neckpain or teeth pain,
and it can even radiate to the back.
But not everybody has chest pain.
You can also just haveshortness of breath,
(02:51):
and sometimes people only have nauseaand are what we call
diaphoretic, which is coldand clammy and sweaty.
So that's what makes heartattacks such a deadly disease is
that it doesn't alwayspresent with classic symptoms.
And this occurs morecommonly to not present
(03:12):
as classic symptoms in womenand in patients with diabetes.
- And not all of these casesthat come in are emergent cases.
Some of them are diagnosticor scheduled. Tell me about those.
- Right. Other than theemergent cases when people are
having heart attacks, the vast majorityof cases we do are elective
and those are scheduled cases.
(03:35):
And there are many differentreasons why people have heart
catheterizations.
So common ones include havingsome symptoms when they,
when they exert themselves,and you've heard of CT calcium scans,
and these are very commonscans now being ordered
by internist and cardiologists.
And when people have anabnormal calcium score,
(03:56):
that raises concernsbecause calcium in the wall
of the blood vessel is certainlyassociated with narrowing
of the coronary arteries.
Another common reason that brings peopleto the cath lab are positive stress tests.
Again, usually patients have symptomsor they have a strong family history
and they are being screenedwith a stress test.
(04:18):
And if the stress testshows a certain area,
the heart does not get enough blood flow.
They're oftentimes referredfor heart catheterization.
But then there's another whole hostof many different reasons,
including heart valve disease.
So in order to work up patientswith heart valve disease,
from aortic valves to mitral valves,and even the tricuspid valve,
patients are oftentimes sentfor a right
(04:41):
and a left heart catheterization,which is a catheterization
that looks to make sure theydon't have any blockages in the
blood vessels, but also onewhere they're measuring
the pressures in the heart.
And then of course,congestive heart failure.
And this is an ever-growingpopulation of patients.
And there are many patientsthat have difficulty breathing
(05:01):
and have been diagnosedwith heart failure.
And it comes in two broad categories,what's called preserved
ejection fraction heart failureor heart failure with
preserved ejection fractionwhere the heart is still
strong in beating normallyand it's actually too
strong and not able to relaxand fill properly.
And then there's somethingcalled heart failure
(05:23):
with reduced ejection fraction.
And that's when patientshave a cardiomyopathy,
which is just a fancy wayof saying the heart doesn't
beat well and it's not strong.
And because of that,they are having fluid
back up into their lungsand having heart failure symptoms,
and they can all sometimes get weight gainand swung in their legs as well.
- So sometimes your patientsmay get other tests done
(05:45):
elsewhere such as an echocardiogramor some other kind of
cardiac testing screenings,and then they come into the
cath lab for further diagnosis?
- Correct. And again, thetwo main reasons are to one,
to do a coronary angiogram,and that is to see if they
have any blockages in the bloodvessels that feed the heart.
And if they do in very severecases, those patients may need
(06:08):
to have open heart surgeryor bypass surgery to fix it.
However, the vast majority patientswith blockages in their
coronary arteries can be treatedwith these little metal
scaffold called stentsthat prop open the blood vessel.
It's all done through the wrist.
And then if the blockagesare not severe enough
and they're moderate orthey have no blockages,
(06:29):
then those patients wetreat with medications.
And those are really medicineslike cholesterol lowering
medicines and maybe baby aspirin.
And these are things to help ensurethat the blockages stay moderate
and don't progress to more severe ones.
- Do you take a baby aspirin every day?
- No. I think baby taking babyaspirin is something that,
(06:51):
believe it or not, isnot completely benign.
And it's definitely adiscussion that one should have
with their cardiologistbecause over a lifetime,
it really depends on yourrisk profile and whether
or not you have coronary disease.
And although it doesn'tseem like a big deal
to take a baby aspirin, ifyou think about the decades
that you would be on it, itcertainly is a small increase in
(07:13):
your bleeding risk.
So if you've had gastrointestinal bleedingor other types of bleeding,
it's not insignificant.
But that's something thatalthough most people
think is fairly benign,it's definitely worth the conversation
with your cardiologist andit's individualized based
on your risk profile.
- Good to know. Because if Ithought it was gonna keep me
outta your lab, I wouldtake one every day.
(07:34):
Okay. So first off, let's talk aboutwhat the standard treatment is.
As I mentioned in the introabout the femoral approach,
which has been the standardtreatment for decades, right?
Compared to this transradialor through the wrist approach.
- Right. So heart catheterizationstraditionally have been
done through the femoral artery,which is a large artery in the groin area,
(07:58):
and it's a very easy artery to access,and the procedure can usually be done very
safely from there.
This has some risks, though.
There is about a 1% chanceof a vascular complication.
1% doesn't sound like a lot,99% chance it's gonna go well.
But when it doesn't go well,it may not just be a bruise
(08:20):
or bleeding that requiresa blood transfusion,
but people have even died frombleeding complications when
it's done from the femoral approach.
When I was training up in Boston in 2003and 2004, we were doing
radial heart catheterizations.
However, the technologyin terms of the wristbands
that actually hold pressurewhen you're done as well
(08:41):
as the cathetersand the sheaths, that
technology hadn't really evolvedto the point where patients truly
benefited from that approach.
- Let let, let's back up a minutebecause I don't think everybody
hearing this will have acomplete and full understanding of even
what a cardiac catheterizationis or what happens.
So let's start with e femoral.
- Sure. - You do something.
(09:03):
Yes. You have a catheter.
- Go ahead. Yes. So what wedo is we numb up the skin
and we insert a smallneedle that allows us
to put a large IV that we call a sheath.
It's like the IV you get when you goto the hospital in your
arm, but it's larger.
And through this IVor sheath in the groin,
in the femoral artery,we're actually able to pass
(09:25):
catheters up into the heart.
And what we do is we actuallyinject dye into the left
coronary artery that lets ussee the two major branches
that come off of the left main artery,the left anterior dis he
artery and circumflex.
Then we use a different catheterto inject dye into the
right coronary artery sothat it comprises the three major blood
(09:50):
vessels that feed the heart.
Now of course, if you'vehad open heart surgery
and bypass surgery by a heart surgeon,we also have specific catheters
that look in those blood vessels too.
And what we do by injectingthe dye is we are looking
to see if there are anynarrowings in those blood vessels.
And if there are, those are the patientsthat have significant ones
(10:10):
that we treat with stentsthat prop open those blockages.
So again, the traditional procedures havebeen done through the groin.
And in 2010 we started really going fromthe radial approach.
And it was certainly a challengebecause the best analogy
(10:31):
for converting from femoralto radial approach is probably
much akin to what it's liketo have a patient who's had a
stroke that has to learn howto walk again, something walking
that we don't even think about.
For most of us, you just putone foot in front of the other
and you do it and literally effortlessly.
(10:51):
But if you watch patientsthat have had a stroke
and they have to learn how to walk again,and they have to be able to balance
and to think about their motionsand how much effort takes,
that's a very good analogy forwhat it's like for operators
that have done femoral casesfor years to convert
and learn how to do radialheart catheterizations.
(11:11):
It's much more challenging.
Getting the catheteror the sheath into the radial artery,
which is much smaller than thefemoral artery can take quite
a bit of learning curve.
Then putting those cathetersinto the left coronary artery
and the right coronary arteryis completely different in
how we do it from the armversus the femoral artery.
(11:32):
And finally, one has to learn howto insert stents into those
blood vessels safely fromthe radial approach.
So it's quite a commitmentfrom the physicians
that learn how to do this.
And there are still manyphysicians that decided not
to convert to the radial approach.
To give you an idea, when westarted this process, 2010,
(11:54):
less than 20 to 25%of the stent procedures in
America were done from theradial approach.
Now we're about 40 tomaybe 45% in America.
And to put this in perspective,at MedStar Union More
hospital, our PCI rate,or the percent of patients
that get a stent from the radialapproach is just about 90%.
(12:17):
So a quite a high number.
And it's not just doing it fromthe wrist versus the groin.
There's really verygood reasons to do this.
The first is it's about patient comfort.
So number one, when you talkto patients who've had a
heart catheterization from thegroin, and when we're done,
they have this sheath in the groinafter that's removed either
(12:39):
with a little collagen plugor a stitch, which would
be a closure device,or it's taken out
and someone has held pressureto make sure it stops bleeding.
Patients have to lay flatfor several hours afterwards.
And if you talk to patients,they say that's the worst part
of the whole procedurelaying flat afterwards.
Especially if you have backproblems, you can't sit up,
(13:01):
you can't eat, you can'tgo to the bathroom.
So these are,- And when you say several
hours we're talking- Yeah, three - Or four, maybe
- More.
Yeah. Sometimes if it bleeds,it could be four to six
and sometimes even longerdepending on the size
of the sheath that's in the groin.
Hmm. So patient comfort is a big deal.
So let's compare thatto the radial approach.
You have it from the wrist.
(13:22):
When we're done, we put what'scalled a transradial band on
there, which is a comfortable wristbandwith a little air diaphragm
that we blow up some airthat holds pressure
and patients are actually able to sit up.
They don't have to lay flat.
And not only can theysit up, they can stand up
and stand up and go to the bathroom.
(13:42):
Then they can also sit up andeat with their other hands.
So it's, it reallytransforms the whole hard
catheterization experience.
So we talked about patient comfort.
The next really important piece,probably more important
than even the comfortof the patient is the patient's safety.
So if you think about a 1%major complication rate from the
(14:05):
femoral approach, that numberfrom the radial approach is
essentially zero- Zero complications from
going in through the wrist.
- Nothing is exactly zero.
- Yeah.
- Yeah. But it's as closeto zero as possible.
- Okay. That's amazing. Compared to- 1%.
- 1%. - Okay. So when youthink about doing thousands
of procedures in a cathlab a year, all of a sudden
(14:27):
that's a big savingsand complication rates.
Right. Again,remember I mentioned earlier
on patients have even died froma heart catheterization.
Okay. Because of vascularcomplications. Why is it so safe?
It's so safe because theradio artery is so superficial
and it's so easy to control the bleedingthat even if patients
do have some bleedingor oozing from that area,
(14:51):
you can easily apply acouple fingers of pressure
and control that bleeding.
- You don't need to put astitch in the wrist to close it up.
- No, never. No, absolutely not.
And so it really is amuch safer procedure.
And when we review our complicationrates on a monthly basis
in our performance improvement meetings,our vascular complication rates
(15:13):
from these radial proceduresis routinely zero 0%.
And that is a numberwe've grown accustomed to
because so many of ourprocedures are from the radial
approach, like I said, over 90%.
And when we do have avascular complication,
it's no surprise it happensto be in one of those patients
where it was from the femoral approach.
- Oh, interesting.
- So yes, the second main benefitfor patients is really
(15:34):
the safety aspect of it.
- What about infection?
Is there a risk of infectionwith the femoral or the risk?
- There's always the, a small riskof infection anytime you break
the skin to do a procedure,even from getting an IV in.
But the infection rate is exceedingly,exceedingly low from a
heart catheterization.
(15:55):
The times that we have seeninfections from a heart
catheterization have been inpatients that have diabetes
and are somewhat obese.
And we put a closure devicein the femoral approach,
which is a little collagen plug,and sometimes that collagen
plug can get infected.
It is extremely rare,but that is the only time we
really have any infection froma heart catheterization.
(16:19):
Otherwise it's essentially non-issue.
- Does that stay there, thatcollagen collagen's closed?
- No, it gets absorbed bythe body within a few weeks.
Okay. And disappears. Yeah.
- Okay. So for the, the wrist approach,is the patient asleep?
- Yeah, it's a good question.
So the heart catheterizationshave really evolved from
a decade or two ago.
(16:40):
And when we do a radialheart catheterization,
patients get very, very light sedation.
It's a little tiny twilight,but they're able to talk
and they're able to take adeep breath if we need them to.
And we put a little bitof lidocaine into the radio artery right
before where we're gonnastick it with our needle,
a very small needle.
And it looks very much likethat wheel that's raised.
(17:04):
If you've ever had a PPDTB test under your skin,
it's a tiny little wheel oflidocaine and it numbs the skin.
And the procedure, believe itor not, to take pictures
of the blood vesselsand see how well the heart
squeezes if we don't do a stentprocedure, can take five to
six minutes and patients,- That's very quick.
(17:26):
- Yeah. Patients are always surprised.
They're like, that's it,that's all there is to it.
And I always joke with themthat, yeah, this is, you know,
easier than going to the dentistto get your teeth cleaned.
So you are opening certainly- Faster a vessel in six minutes?
- No, we're, we're able to putthe catheter into the wrist
and put our catheters up into the heartand take pictures of the blood vessels.
(17:47):
Okay. And make sure that thereare or are not any blockages.
If we have to insert a stent,it usually takes a few minutes longer.
And depending on thecomplexity of the procedure,
it can be another five, 10 minutes,or it could be a half an hour longer.
It really depends.
And it depends on how manyblockages we're fixing too.
- So inserting that stent is the sameas if you were inserting it
(18:11):
through the femoral artery? It's- Correct.
- Positioning it the- Same. Yep. It's the same.
And I think the biggest challengefor physicians when they
convert from the femoralto the radial approach is the
first challenge is becomingvery good at radial access in order
to get the radio artery again.
And remember I said it'sa much smaller artery.
The second challenge is being ableto understand the
(18:33):
differences in the anatomy.
So you can choose the right cathetersto get really good pictures of the heart,
and if need to put a stent in,in a very efficient manner.
And again, that just takes experience.
- It seems like a shorterdistance though, from the wrist
to the heart than thefemoral opening to the heart.
(18:54):
- Yeah, actually, you know what,not a significant shorter distance.
Okay. If you put your arm by your sidewhere your radio arteries is very close
and distance to whereyour femoral artery is.
So still a little ways away,but it, it's, it's got
other advantages beyond - That.
When you put it that way. Mine isprobably a longer distance.
I have very long arms.
- Yeah. - Does the patientfeel any pain when they're,
(19:15):
when you're sliding the catheter- Through the room?
No, you know, patientsare always surprised
by this heart catheterizationswhen we're actually putting
the catheters into the bodyand taking our pictures.
Patients don't feel it.
And I tryand explain to them that
there's no nerves on the insideof these blood vessels.
Imagine how distractingthat would be if you
could feel blood flowingthrough your blood vessels.
(19:39):
Oh, good point. Right.
And yes, we feel a little,maybe distention sometimes
with gas, with food goingthrough our GI system,
but you know, we don'tfeel food transiting
between our stomach toour small intestines,
to our large intestines.
So again, a lot of thisis the way we've evolved.
There are no nerves on, on theinside of these blood vessels.
(19:59):
And we use that to our advantage. Right.
So once we are in withour catheters, you know,
patients don't feel a thingand they're, they're surprised
and they constantly say atthe end of the procedure,
I didn't even realize you started yet.
I thought we were just talking.
And I said, no, no, no,we're done the procedure.
- Right. They're talkingthrough the procedure.
- Yeah, exactly.
- That's amazing.
Isn't that not distracting for you?
You've probably done it so many times.
(20:21):
- Yeah, no, it's not distracting.
It's actually quite nice.
And I think it really isgreat to put patients at ease.
- Now, a friend of minehad called me once.
He was very concerned abouthaving to go into a hospital
for a scheduled cardiac cath procedureto get some diagnostics done.
It was scheduled throughthe femoral artery.
But he was worried becausethat weekend his grandchild was due
(20:42):
and he wasn't gonna be able to travel.
And I was surprisedbecause as you said, we've
been doing it since 2010.
- Yeah.
- That they were still evenconsidering doing e femoral.
He wasn't high risk or anything.
- Patients should be their,they're their best advocate.
And when you go get a procedure,it's important to ask some questions.
And you know, I think one thatwould be important to ask is
(21:05):
that do the doctors at thisfacility, are they comfortable
with doing it from thewrist versus the groin?
It really is beneficial for patientsto have it done from the radial approach.
And the other advantage isthat when we put a stent
procedure in from the wrist,that patient about a third to
about half of those patients,if it's not a complicated procedure
(21:28):
and they didn't have a heart attackthat brought 'em into
the hospital emergently,those patients go home the same day.
And the advantage of thatis, you know, I don't have
to tell patients that theadvantages of being able
to go home and sleep inyour own bed versus having
to stay in the hospital overnight.
But if you have the proceduredone from the groin,
from the femoral artery,and you have a stent placed,
(21:51):
those patients we stillroutinely keep overnight.
And because rarely they can have bleedingcomplications at nighttime.
And so we keep them overnight.
So the radial approach hasallowed us to send home up
to about 50% of our stentprocedure patients the same day,
which has been a tremendouspatient pleaser to be able
(22:14):
to go home and sleep in your own bed.
- Well, it sure was forthis friend of mine,
because I told him aboutthe transradial approach.
He didn't know it existedand it wasn't offered to him.
I was just surprised by thatbecause I thought it was a
more widely used techniquefor cardiac catheterizations
and maybe not everywhere.
- Right. I think it's interestingbecause in a program like ours
(22:34):
where it really is the norm,I think people that have only
worked here just assume thisis the way it is at other
facilities, but really it's not.
And again, the nationalaverage for doing PCI
or stent procedures from thewrist is about 40 to 50%.
So to, to be up at 90% is really unique.
- What should patientsask for then, if they know
(22:55):
that they have to geta, a cardiac procedure?
Should, should they ask? Andhow would you want to be asked
- About this?
Yeah, I mean, I think I, Ithink if patients are gonna have
a heart catheterization procedure,they should find out a
little about their doctorand how many have they done,
how long have they done it for?
Do they have experiencefrom the radial approach?
And if there's publisheddata on the outcomes for
(23:18):
that particular hospital in termsof their complications
rate, these are all thingsthat patients could look into.
But most patients, I haveto tell you, Deb, they do
what their doctor recommends.
Right. I always saypatients should really be
their own advocates.
And when you're talking aboutAshley undergoing a procedure,
it's worth doing a little researchand find out, does this institution,
(23:41):
and particularly thedoctor you're going to,
do they do the radialheart catheterization?
Do they have a lot of experience?
What are their outcomes?
Et cetera. And those aregood questions to start with.
- I think too that it'simportant to mention,
don't just take our word for it.
Right. The American College of Cardiology,the American Heart Association,
and the Society forCardiovascular Angiography
(24:02):
and interventions explicitly recommend TRAor transradial access as the
preferred arterial accessfor coronary procedures.
So that's pretty affirming for this.
So my friend, he comesout of the procedure,
any patient comes out ofa transradial procedure,
as you pointed out, they,they don't have to lay flat
(24:23):
for hours on end.
They can then go into whatwe call a transradial lounge.
- Yeah.
- And what a great concept.
- I tell you, it's, you know,if you go to a regular prep
and recovery roomafter a femoral heart catheterization,
it's like any under recovery room.
It looks like a post-anesthesia care unit.
(24:44):
There are beds, sometimesthey're individual rooms,
sometimes they're justseparated by curtains.
But nonetheless, it's designedfor patients to lay flat
and for hours.
But we took a different approachand we actually developed
what's called the radial lounge.
And there are eight bays in this lounge.
And there are actually nobeds in each of the bays.
(25:06):
Each of the bays has aarmchair that reclines,
because patients don't have to lay flatafter their procedure.
And so on one half of thislounge, you have these eight bays
and you're on a, a heart monitor,and there are nurses there monitoring you.
But in about an hour whenthat wristband comes off,
(25:26):
you can go to the secondhalf of this radio lounge
where there is a seatingarea and a large tv.
There's another areawhere you can sit and read
and charge your devices.
There is a small cafe wherepatients can get drinks
and some snacks in aself-serve atmosphere.
(25:47):
And then even a small room with a computerthat later on the doctors can come
and review your films with you.
So it's really transformedthe whole experience
of a heart catheterization andtaken a lot of the fear away.
And I often describethe radio lounge a lot,
like the waiting roomfor when you get your car serviced more
(26:09):
so than actually a traditional hospital- Or an airport.
An airport lounge. Exactly.
I've seen people sitting inthere watching tv. Right.
Or they're with their famultiple members of their family.
Right. And they're sitting in jeans,- Right.
- Reading or having a coffee.
Yeah, it's, it's very nice.
- It's a, it's really agreat experience for them.
- What's the recoverylike once they go home
(26:31):
and they resume their normal activity?
- Yeah, it really dependson what the indication
for the heart catheterization.
So for a heart attack patient,they may have to take it easy
for a few days.
When we say take it easy,we mean no heavy exertion,
but we don't mean sitaround and do nothing.
In general, the recoveryafter a radial heart
catheterization is no heavy liftingwith that wrist for a day or two.
(26:52):
Not a lot of flexion in an extension.
So no tennis, no golf,just no heavy lifting.
And I always tellpatients, I don't want you
to not move your wrist.
I don't want you to mobilize it,but just pretend like you
sprained it, you know?
And and trying to don't- Go easy. Go easy. Yeah,
- Go easy for a day or two.
But then after that it shouldbe totally back to normal.
(27:12):
- What if they have a stent?
- Same when they have the stent?
Again, the precautions we havefor the radio access is very similar.
But again, I would advisepatients to discuss
with their physiciansand there will be very clear
discharge instructions onwhat their activities can be,
depending on the indicationfor their heart catheterization.
(27:32):
- In an emergency case,what's the most, I guess,
dramatic case that you'vemanaged in the cardiac cath lab?
- Well, I mean- That you've treated trans radially.
- Yeah. I mean now we, we really do allof our STEMI patients
or heart attacks throughthe radial approach.
And I'm glad you broughtout that recommendation
(27:53):
by our societies that havereally recommended this.
But there's one area in particularwhere there's clear mortality benefit
to patients if we gofrom the radial approach,
and that's in these heart attack patients.
And the reason for thatis that during STEMIs
or heart attacks, when thevessel is a hundred percent
(28:13):
blocked and those emergent procedures,patients are very, very sick.
And the blood vesselsblocked a hundred percent
with a blood clot.
And in addition toopening it with a stent,
oftentimes we have to put patients on verypowerful blood thinners.
And as you can imagine, themore blood thinners you're on,
the greater your chance of bleeding,especially if you're going
(28:34):
from a femoral approach.
Right. So by going fromthe radial approach,
you've virtually eliminatedthat access site bleeding.
Not to say that patientsdon't have other causes
of bleeding from gastrointestinalcauses, et cetera,
but really the majorbleeding risk that occurs
with the heart catheterizationis from the access site.
(28:55):
So when we do heart attackpatients from the radial
approach, there have beenmany studies now that show
that those patients comparedto ones done from a
femoral approach die less.
Okay. It's a safer procedure for them.
Any heart attack patient,we really try our very best
to do from the radial approach.
- So I have to ask the question,who would not be a
(29:16):
candidate for a transradial?
And then you'd have to gothrough that femoral artery.
- Yeah, I mean that happens, right?
Because remember wesaid about 90% are done
through the wrist, so thatmeans there's 10% that aren't.
So the radio artery is oneof the two arteries in the
forearm that we can go into.
On the other side is the ulnar artery.
(29:39):
Most patients have twoarms, so four arteries
that we can try and put our catheters in.
So if you go into thesame artery multiple times
for multiple different procedures,sometimes it gets more challenging
to get into that artery.
And patients alsosometimes have a one artery
that's smaller than the other.
So in some patients,the ulnar artery is
(29:59):
larger than the radial,but in most patients, the radial artery's
larger than the ulnar.
So usually if we fail in oneradial artery on the right
arm, we will go to the left arm.
And if we fail in that, wecan try the ulnar arteries.
And if we fail in those,then we can go into the femoral artery.
(30:20):
Patients who've had their artery taken outfor open heart surgery
and had the radio artery usedas a conduit for a bypass.
Obviously we can't go inthose patients' radio arteries
and patients who havea fistula in their arm
that use that fistula for hemodialysis.
(30:41):
Those patients, of course, wealso don't go into their arms
to do the heart catheterizations.
When you take all of that into accountand patients with very,
very small radio arteriesor that have a lot of
problems with Ray Raynaudsor spasm in their
vasculature of their hands,and those patients, we
would try and avoid it.
(31:01):
But when you look at ournumbers, we're talking,
less than 10% are unable to bedone from the radio approach,
- Which - Is really remarkable.
- So what is your finaladvice for patients
or potential patientsor people who are taking care
of their parents and loved ones?
- I say be your, be your ownbest advocate and ask questions
(31:23):
and make sure that this isbeing offered at the place
where you decide to haveyour heart catheterization.
And one word of advice Ialways tell physicians,
learning about the radialapproach is that at the end
of the day, the ultimate goal isto have a successful procedure.
And so you never wanna letthe approach compromise
your final result.
(31:43):
If you are going from the radial approach,and it's very challenging, you cannot let
that cloud your decision whetheror not to actually fix a blockage or not,
and how to fix the blockage.
So like I said, what Isay to those physicians is
that the most important thing isto have a successful procedure.
And with the continued commitmentto the radial approach,
(32:04):
the success rate continues to improve,which is incredibly rewarding
and also benefits our patients the most- Perfectly said.
Thank you, Dr. Wang. Thanks, Debra.
Thank you for, for making thatcommitment 15 years ago. Of
- Course. Yeah. Thanks.
- We've been talking with Dr.
John Wang at MedStar UnionMemorial Hospital.
Thank you so much forsharing your expertise
with us here on DOC Talk.
(32:25):
For more information aboutinterventional cardiology at
MedStar Health, goto MedStar health.org/MHVI.
That's MedStar Heartand Vascular Institute.
If you would like tocomment on this podcast
or recommend a topic foranother episode of Doc Talk,
send an email to Doc talk@medstar.net.
- Comprehensive, relevant and insightful conversations about health
and medicine happen here.
When MedStar Health DocTalk,these are real conversations
with physician experts fromaround the largest
healthcare system in theMaryland DC region.
If you're looking for moreinformation on cardiac
(00:22):
catheterizations, this is your podcast.
Because these importantprocedures have evolved so much
through the years, andnot everyone is caught up
with the changes, whichis interesting when you
consider this fun fact.
In 1929, a young Germanphysician, Werner Forssmann,
performed the very firsthuman cardiac cath on himself.
(00:43):
He inserted a catheterinto a vein in his arm
and guided it into his heart under x-ray.
His supervisors werehorrified at the time,
but this bold act earned him a shareof the 1956 Nobel Prize in medicine.
Since then, cardiac catheterizationshave become a standard
(01:03):
procedure for physiciansto get a direct detailed look at the heart
and its blood vessels performedthrough the femoral artery in the groin.
But it seems Dr. Forssmann hadit right the first time.
Accessing the heart throughthe wrist has transformed
diagnostics and treatmentfor cardiac patients.
We're going to learn moreabout transradial cardiac
(01:25):
catheterizations with Dr. John Wang,who is truly a pioneer in
interventional cardiac proceduresperformed through the wrist.
He's the director of theCardiac catheterization labs at
MedStar Union Memorial Hospitaland MedStar Franklin Square
Medical Center in Baltimore.
I'm your host, Debra Schindler.
Welcome to Doc Talk Dr. Wang.
(01:46):
- Debra, thanks for having me.
- So when a patient comesto the cardiac cath lab,
is it usually an emergency situation?
Why does someone come in needof a cardiac catheterization?
- Well, it can be an emergency.
The most common emergency thatbrings people to the cath lab
that would require a heartcatheterization is a heart attack.
Sometimes you've heard peoplerefer to these as STEMIs,
(02:09):
and these are a type of heart attackwhere the blood vessel is acutely 100%
blocked with a blood clot.
People traditionally haveclassic symptoms like chest pain
and elephant sitting on their chestand are oftentimes quite sick.
- Some of the symptoms that youmight have people coming in,
let's go through the list.
(02:29):
- Sure. The classic one is chest painand that chest pain or pressure
or tightness can radiate to people's jaws.
They can also have neckpain or teeth pain,
and it can even radiate to the back.
But not everybody has chest pain.
You can also just haveshortness of breath,
(02:51):
and sometimes people only have nauseaand are what we call
diaphoretic, which is coldand clammy and sweaty.
So that's what makes heartattacks such a deadly disease is
that it doesn't alwayspresent with classic symptoms.
And this occurs morecommonly to not present
(03:12):
as classic symptoms in womenand in patients with diabetes.
- And not all of these casesthat come in are emergent cases.
Some of them are diagnosticor scheduled. Tell me about those.
- Right. Other than theemergent cases when people are
having heart attacks, the vast majorityof cases we do are elective
and those are scheduled cases.
(03:35):
And there are many differentreasons why people have heart
catheterizations.
So common ones include havingsome symptoms when they,
when they exert themselves,and you've heard of CT calcium scans,
and these are very commonscans now being ordered
by internist and cardiologists.
And when people have anabnormal calcium score,
(03:56):
that raises concernsbecause calcium in the wall
of the blood vessel is certainlyassociated with narrowing
of the coronary arteries.
Another common reason that brings peopleto the cath lab are positive stress tests.
Again, usually patients have symptomsor they have a strong family history
and they are being screenedwith a stress test.
(04:18):
And if the stress testshows a certain area,
the heart does not get enough blood flow.
They're oftentimes referredfor heart catheterization.
But then there's another whole hostof many different reasons,
including heart valve disease.
So in order to work up patientswith heart valve disease,
from aortic valves to mitral valves,and even the tricuspid valve,
patients are oftentimes sentfor a right
(04:41):
and a left heart catheterization,which is a catheterization
that looks to make sure theydon't have any blockages in the
blood vessels, but also onewhere they're measuring
the pressures in the heart.
And then of course,congestive heart failure.
And this is an ever-growingpopulation of patients.
And there are many patientsthat have difficulty breathing
(05:01):
and have been diagnosedwith heart failure.
And it comes in two broad categories,what's called preserved
ejection fraction heart failureor heart failure with
preserved ejection fractionwhere the heart is still
strong in beating normallyand it's actually too
strong and not able to relaxand fill properly.
And then there's somethingcalled heart failure
(05:23):
with reduced ejection fraction.
And that's when patientshave a cardiomyopathy,
which is just a fancy wayof saying the heart doesn't
beat well and it's not strong.
And because of that,they are having fluid
back up into their lungsand having heart failure symptoms,
and they can all sometimes get weight gainand swung in their legs as well.
- So sometimes your patientsmay get other tests done
(05:45):
elsewhere such as an echocardiogramor some other kind of
cardiac testing screenings,and then they come into the
cath lab for further diagnosis?
- Correct. And again, thetwo main reasons are to one,
to do a coronary angiogram,and that is to see if they
have any blockages in the bloodvessels that feed the heart.
And if they do in very severecases, those patients may need
(06:08):
to have open heart surgeryor bypass surgery to fix it.
However, the vast majority patientswith blockages in their
coronary arteries can be treatedwith these little metal
scaffold called stentsthat prop open the blood vessel.
It's all done through the wrist.
And then if the blockagesare not severe enough
and they're moderate orthey have no blockages,
(06:29):
then those patients wetreat with medications.
And those are really medicineslike cholesterol lowering
medicines and maybe baby aspirin.
And these are things to help ensurethat the blockages stay moderate
and don't progress to more severe ones.
- Do you take a baby aspirin every day?
- No. I think baby taking babyaspirin is something that,
(06:51):
believe it or not, isnot completely benign.
And it's definitely adiscussion that one should have
with their cardiologistbecause over a lifetime,
it really depends on yourrisk profile and whether
or not you have coronary disease.
And although it doesn'tseem like a big deal
to take a baby aspirin, ifyou think about the decades
that you would be on it, itcertainly is a small increase in
(07:13):
your bleeding risk.
So if you've had gastrointestinal bleedingor other types of bleeding,
it's not insignificant.
But that's something thatalthough most people
think is fairly benign,it's definitely worth the conversation
with your cardiologist andit's individualized based
on your risk profile.
- Good to know. Because if Ithought it was gonna keep me
outta your lab, I wouldtake one every day.
(07:34):
Okay. So first off, let's talk aboutwhat the standard treatment is.
As I mentioned in the introabout the femoral approach,
which has been the standardtreatment for decades, right?
Compared to this transradialor through the wrist approach.
- Right. So heart catheterizationstraditionally have been
done through the femoral artery,which is a large artery in the groin area,
(07:58):
and it's a very easy artery to access,and the procedure can usually be done very
safely from there.
This has some risks, though.
There is about a 1% chanceof a vascular complication.
1% doesn't sound like a lot,99% chance it's gonna go well.
But when it doesn't go well,it may not just be a bruise
(08:20):
or bleeding that requiresa blood transfusion,
but people have even died frombleeding complications when
it's done from the femoral approach.
When I was training up in Boston in 2003and 2004, we were doing
radial heart catheterizations.
However, the technologyin terms of the wristbands
that actually hold pressurewhen you're done as well
(08:41):
as the cathetersand the sheaths, that
technology hadn't really evolvedto the point where patients truly
benefited from that approach.
- Let let, let's back up a minutebecause I don't think everybody
hearing this will have acomplete and full understanding of even
what a cardiac catheterizationis or what happens.
So let's start with e femoral.
- Sure. - You do something.
(09:03):
Yes. You have a catheter.
- Go ahead. Yes. So what wedo is we numb up the skin
and we insert a smallneedle that allows us
to put a large IV that we call a sheath.
It's like the IV you get when you goto the hospital in your
arm, but it's larger.
And through this IVor sheath in the groin,
in the femoral artery,we're actually able to pass
(09:25):
catheters up into the heart.
And what we do is we actuallyinject dye into the left
coronary artery that lets ussee the two major branches
that come off of the left main artery,the left anterior dis he
artery and circumflex.
Then we use a different catheterto inject dye into the
right coronary artery sothat it comprises the three major blood
(09:50):
vessels that feed the heart.
Now of course, if you'vehad open heart surgery
and bypass surgery by a heart surgeon,we also have specific catheters
that look in those blood vessels too.
And what we do by injectingthe dye is we are looking
to see if there are anynarrowings in those blood vessels.
And if there are, those are the patientsthat have significant ones
(10:10):
that we treat with stentsthat prop open those blockages.
So again, the traditional procedures havebeen done through the groin.
And in 2010 we started really going fromthe radial approach.
And it was certainly a challengebecause the best analogy
(10:31):
for converting from femoralto radial approach is probably
much akin to what it's liketo have a patient who's had a
stroke that has to learn howto walk again, something walking
that we don't even think about.
For most of us, you just putone foot in front of the other
and you do it and literally effortlessly.
(10:51):
But if you watch patientsthat have had a stroke
and they have to learn how to walk again,and they have to be able to balance
and to think about their motionsand how much effort takes,
that's a very good analogy forwhat it's like for operators
that have done femoral casesfor years to convert
and learn how to do radialheart catheterizations.
(11:11):
It's much more challenging.
Getting the catheteror the sheath into the radial artery,
which is much smaller than thefemoral artery can take quite
a bit of learning curve.
Then putting those cathetersinto the left coronary artery
and the right coronary arteryis completely different in
how we do it from the armversus the femoral artery.
(11:32):
And finally, one has to learn howto insert stents into those
blood vessels safely fromthe radial approach.
So it's quite a commitmentfrom the physicians
that learn how to do this.
And there are still manyphysicians that decided not
to convert to the radial approach.
To give you an idea, when westarted this process, 2010,
(11:54):
less than 20 to 25%of the stent procedures in
America were done from theradial approach.
Now we're about 40 tomaybe 45% in America.
And to put this in perspective,at MedStar Union More
hospital, our PCI rate,or the percent of patients
that get a stent from the radialapproach is just about 90%.
(12:17):
So a quite a high number.
And it's not just doing it fromthe wrist versus the groin.
There's really verygood reasons to do this.
The first is it's about patient comfort.
So number one, when you talkto patients who've had a
heart catheterization from thegroin, and when we're done,
they have this sheath in the groinafter that's removed either
(12:39):
with a little collagen plugor a stitch, which would
be a closure device,or it's taken out
and someone has held pressureto make sure it stops bleeding.
Patients have to lay flatfor several hours afterwards.
And if you talk to patients,they say that's the worst part
of the whole procedurelaying flat afterwards.
Especially if you have backproblems, you can't sit up,
(13:01):
you can't eat, you can'tgo to the bathroom.
So these are,- And when you say several
hours we're talking- Yeah, three - Or four, maybe
- More.
Yeah. Sometimes if it bleeds,it could be four to six
and sometimes even longerdepending on the size
of the sheath that's in the groin.
Hmm. So patient comfort is a big deal.
So let's compare thatto the radial approach.
You have it from the wrist.
(13:22):
When we're done, we put what'scalled a transradial band on
there, which is a comfortable wristbandwith a little air diaphragm
that we blow up some airthat holds pressure
and patients are actually able to sit up.
They don't have to lay flat.
And not only can theysit up, they can stand up
and stand up and go to the bathroom.
(13:42):
Then they can also sit up andeat with their other hands.
So it's, it reallytransforms the whole hard
catheterization experience.
So we talked about patient comfort.
The next really important piece,probably more important
than even the comfortof the patient is the patient's safety.
So if you think about a 1%major complication rate from the
(14:05):
femoral approach, that numberfrom the radial approach is
essentially zero- Zero complications from
going in through the wrist.
- Nothing is exactly zero.
- Yeah.
- Yeah. But it's as closeto zero as possible.
- Okay. That's amazing. Compared to- 1%.
- 1%. - Okay. So when youthink about doing thousands
of procedures in a cathlab a year, all of a sudden
(14:27):
that's a big savingsand complication rates.
Right. Again,remember I mentioned earlier
on patients have even died froma heart catheterization.
Okay. Because of vascularcomplications. Why is it so safe?
It's so safe because theradio artery is so superficial
and it's so easy to control the bleedingthat even if patients
do have some bleedingor oozing from that area,
(14:51):
you can easily apply acouple fingers of pressure
and control that bleeding.
- You don't need to put astitch in the wrist to close it up.
- No, never. No, absolutely not.
And so it really is amuch safer procedure.
And when we review our complicationrates on a monthly basis
in our performance improvement meetings,our vascular complication rates
(15:13):
from these radial proceduresis routinely zero 0%.
And that is a numberwe've grown accustomed to
because so many of ourprocedures are from the radial
approach, like I said, over 90%.
And when we do have avascular complication,
it's no surprise it happensto be in one of those patients
where it was from the femoral approach.
- Oh, interesting.
- So yes, the second main benefitfor patients is really
(15:34):
the safety aspect of it.
- What about infection?
Is there a risk of infectionwith the femoral or the risk?
- There's always the, a small riskof infection anytime you break
the skin to do a procedure,even from getting an IV in.
But the infection rate is exceedingly,exceedingly low from a
heart catheterization.
(15:55):
The times that we have seeninfections from a heart
catheterization have been inpatients that have diabetes
and are somewhat obese.
And we put a closure devicein the femoral approach,
which is a little collagen plug,and sometimes that collagen
plug can get infected.
It is extremely rare,but that is the only time we
really have any infection froma heart catheterization.
(16:19):
Otherwise it's essentially non-issue.
- Does that stay there, thatcollagen collagen's closed?
- No, it gets absorbed bythe body within a few weeks.
Okay. And disappears. Yeah.
- Okay. So for the, the wrist approach,is the patient asleep?
- Yeah, it's a good question.
So the heart catheterizationshave really evolved from
a decade or two ago.
(16:40):
And when we do a radialheart catheterization,
patients get very, very light sedation.
It's a little tiny twilight,but they're able to talk
and they're able to take adeep breath if we need them to.
And we put a little bitof lidocaine into the radio artery right
before where we're gonnastick it with our needle,
a very small needle.
And it looks very much likethat wheel that's raised.
(17:04):
If you've ever had a PPDTB test under your skin,
it's a tiny little wheel oflidocaine and it numbs the skin.
And the procedure, believe itor not, to take pictures
of the blood vesselsand see how well the heart
squeezes if we don't do a stentprocedure, can take five to
six minutes and patients,- That's very quick.
(17:26):
- Yeah. Patients are always surprised.
They're like, that's it,that's all there is to it.
And I always joke with themthat, yeah, this is, you know,
easier than going to the dentistto get your teeth cleaned.
So you are opening certainly- Faster a vessel in six minutes?
- No, we're, we're able to putthe catheter into the wrist
and put our catheters up into the heartand take pictures of the blood vessels.
(17:47):
Okay. And make sure that thereare or are not any blockages.
If we have to insert a stent,it usually takes a few minutes longer.
And depending on thecomplexity of the procedure,
it can be another five, 10 minutes,or it could be a half an hour longer.
It really depends.
And it depends on how manyblockages we're fixing too.
- So inserting that stent is the sameas if you were inserting it
(18:11):
through the femoral artery? It's- Correct.
- Positioning it the- Same. Yep. It's the same.
And I think the biggest challengefor physicians when they
convert from the femoralto the radial approach is the
first challenge is becomingvery good at radial access in order
to get the radio artery again.
And remember I said it'sa much smaller artery.
The second challenge is being ableto understand the
(18:33):
differences in the anatomy.
So you can choose the right cathetersto get really good pictures of the heart,
and if need to put a stent in,in a very efficient manner.
And again, that just takes experience.
- It seems like a shorterdistance though, from the wrist
to the heart than thefemoral opening to the heart.
(18:54):
- Yeah, actually, you know what,not a significant shorter distance.
Okay. If you put your arm by your sidewhere your radio arteries is very close
and distance to whereyour femoral artery is.
So still a little ways away,but it, it's, it's got
other advantages beyond - That.
When you put it that way. Mine isprobably a longer distance.
I have very long arms.
- Yeah. - Does the patientfeel any pain when they're,
(19:15):
when you're sliding the catheter- Through the room?
No, you know, patientsare always surprised
by this heart catheterizationswhen we're actually putting
the catheters into the bodyand taking our pictures.
Patients don't feel it.
And I tryand explain to them that
there's no nerves on the insideof these blood vessels.
Imagine how distractingthat would be if you
could feel blood flowingthrough your blood vessels.
(19:39):
Oh, good point. Right.
And yes, we feel a little,maybe distention sometimes
with gas, with food goingthrough our GI system,
but you know, we don'tfeel food transiting
between our stomach toour small intestines,
to our large intestines.
So again, a lot of thisis the way we've evolved.
There are no nerves on, on theinside of these blood vessels.
(19:59):
And we use that to our advantage. Right.
So once we are in withour catheters, you know,
patients don't feel a thingand they're, they're surprised
and they constantly say atthe end of the procedure,
I didn't even realize you started yet.
I thought we were just talking.
And I said, no, no, no,we're done the procedure.
- Right. They're talkingthrough the procedure.
- Yeah, exactly.
- That's amazing.
Isn't that not distracting for you?
You've probably done it so many times.
(20:21):
- Yeah, no, it's not distracting.
It's actually quite nice.
And I think it really isgreat to put patients at ease.
- Now, a friend of minehad called me once.
He was very concerned abouthaving to go into a hospital
for a scheduled cardiac cath procedureto get some diagnostics done.
It was scheduled throughthe femoral artery.
But he was worried becausethat weekend his grandchild was due
(20:42):
and he wasn't gonna be able to travel.
And I was surprisedbecause as you said, we've
been doing it since 2010.
- Yeah.
- That they were still evenconsidering doing e femoral.
He wasn't high risk or anything.
- Patients should be their,they're their best advocate.
And when you go get a procedure,it's important to ask some questions.
And you know, I think one thatwould be important to ask is
(21:05):
that do the doctors at thisfacility, are they comfortable
with doing it from thewrist versus the groin?
It really is beneficial for patientsto have it done from the radial approach.
And the other advantage isthat when we put a stent
procedure in from the wrist,that patient about a third to
about half of those patients,if it's not a complicated procedure
(21:28):
and they didn't have a heart attackthat brought 'em into
the hospital emergently,those patients go home the same day.
And the advantage of thatis, you know, I don't have
to tell patients that theadvantages of being able
to go home and sleep inyour own bed versus having
to stay in the hospital overnight.
But if you have the proceduredone from the groin,
from the femoral artery,and you have a stent placed,
(21:51):
those patients we stillroutinely keep overnight.
And because rarely they can have bleedingcomplications at nighttime.
And so we keep them overnight.
So the radial approach hasallowed us to send home up
to about 50% of our stentprocedure patients the same day,
which has been a tremendouspatient pleaser to be able
(22:14):
to go home and sleep in your own bed.
- Well, it sure was forthis friend of mine,
because I told him aboutthe transradial approach.
He didn't know it existedand it wasn't offered to him.
I was just surprised by thatbecause I thought it was a
more widely used techniquefor cardiac catheterizations
and maybe not everywhere.
- Right. I think it's interestingbecause in a program like ours
(22:34):
where it really is the norm,I think people that have only
worked here just assume thisis the way it is at other
facilities, but really it's not.
And again, the nationalaverage for doing PCI
or stent procedures from thewrist is about 40 to 50%.
So to, to be up at 90% is really unique.
- What should patientsask for then, if they know
(22:55):
that they have to geta, a cardiac procedure?
Should, should they ask? Andhow would you want to be asked
- About this?
Yeah, I mean, I think I, Ithink if patients are gonna have
a heart catheterization procedure,they should find out a
little about their doctorand how many have they done,
how long have they done it for?
Do they have experiencefrom the radial approach?
And if there's publisheddata on the outcomes for
(23:18):
that particular hospital in termsof their complications
rate, these are all thingsthat patients could look into.
But most patients, I haveto tell you, Deb, they do
what their doctor recommends.
Right. I always saypatients should really be
their own advocates.
And when you're talking aboutAshley undergoing a procedure,
it's worth doing a little researchand find out, does this institution,
(23:41):
and particularly thedoctor you're going to,
do they do the radialheart catheterization?
Do they have a lot of experience?
What are their outcomes?
Et cetera. And those aregood questions to start with.
- I think too that it'simportant to mention,
don't just take our word for it.
Right. The American College of Cardiology,the American Heart Association,
and the Society forCardiovascular Angiography
(24:02):
and interventions explicitly recommend TRAor transradial access as the
preferred arterial accessfor coronary procedures.
So that's pretty affirming for this.
So my friend, he comesout of the procedure,
any patient comes out ofa transradial procedure,
as you pointed out, they,they don't have to lay flat
(24:23):
for hours on end.
They can then go into whatwe call a transradial lounge.
- Yeah.
- And what a great concept.
- I tell you, it's, you know,if you go to a regular prep
and recovery roomafter a femoral heart catheterization,
it's like any under recovery room.
It looks like a post-anesthesia care unit.
(24:44):
There are beds, sometimesthey're individual rooms,
sometimes they're justseparated by curtains.
But nonetheless, it's designedfor patients to lay flat
and for hours.
But we took a different approachand we actually developed
what's called the radial lounge.
And there are eight bays in this lounge.
And there are actually nobeds in each of the bays.
(25:06):
Each of the bays has aarmchair that reclines,
because patients don't have to lay flatafter their procedure.
And so on one half of thislounge, you have these eight bays
and you're on a, a heart monitor,and there are nurses there monitoring you.
But in about an hour whenthat wristband comes off,
(25:26):
you can go to the secondhalf of this radio lounge
where there is a seatingarea and a large tv.
There's another areawhere you can sit and read
and charge your devices.
There is a small cafe wherepatients can get drinks
and some snacks in aself-serve atmosphere.
(25:47):
And then even a small room with a computerthat later on the doctors can come
and review your films with you.
So it's really transformedthe whole experience
of a heart catheterization andtaken a lot of the fear away.
And I often describethe radio lounge a lot,
like the waiting roomfor when you get your car serviced more
(26:09):
so than actually a traditional hospital- Or an airport.
An airport lounge. Exactly.
I've seen people sitting inthere watching tv. Right.
Or they're with their famultiple members of their family.
Right. And they're sitting in jeans,- Right.
- Reading or having a coffee.
Yeah, it's, it's very nice.
- It's a, it's really agreat experience for them.
- What's the recoverylike once they go home
(26:31):
and they resume their normal activity?
- Yeah, it really dependson what the indication
for the heart catheterization.
So for a heart attack patient,they may have to take it easy
for a few days.
When we say take it easy,we mean no heavy exertion,
but we don't mean sitaround and do nothing.
In general, the recoveryafter a radial heart
catheterization is no heavy liftingwith that wrist for a day or two.
(26:52):
Not a lot of flexion in an extension.
So no tennis, no golf,just no heavy lifting.
And I always tellpatients, I don't want you
to not move your wrist.
I don't want you to mobilize it,but just pretend like you
sprained it, you know?
And and trying to don't- Go easy. Go easy. Yeah,
- Go easy for a day or two.
But then after that it shouldbe totally back to normal.
(27:12):
- What if they have a stent?
- Same when they have the stent?
Again, the precautions we havefor the radio access is very similar.
But again, I would advisepatients to discuss
with their physiciansand there will be very clear
discharge instructions onwhat their activities can be,
depending on the indicationfor their heart catheterization.
(27:32):
- In an emergency case,what's the most, I guess,
dramatic case that you'vemanaged in the cardiac cath lab?
- Well, I mean- That you've treated trans radially.
- Yeah. I mean now we, we really do allof our STEMI patients
or heart attacks throughthe radial approach.
And I'm glad you broughtout that recommendation
(27:53):
by our societies that havereally recommended this.
But there's one area in particularwhere there's clear mortality benefit
to patients if we gofrom the radial approach,
and that's in these heart attack patients.
And the reason for thatis that during STEMIs
or heart attacks, when thevessel is a hundred percent
(28:13):
blocked and those emergent procedures,patients are very, very sick.
And the blood vesselsblocked a hundred percent
with a blood clot.
And in addition toopening it with a stent,
oftentimes we have to put patients on verypowerful blood thinners.
And as you can imagine, themore blood thinners you're on,
the greater your chance of bleeding,especially if you're going
(28:34):
from a femoral approach.
Right. So by going fromthe radial approach,
you've virtually eliminatedthat access site bleeding.
Not to say that patientsdon't have other causes
of bleeding from gastrointestinalcauses, et cetera,
but really the majorbleeding risk that occurs
with the heart catheterizationis from the access site.
(28:55):
So when we do heart attackpatients from the radial
approach, there have beenmany studies now that show
that those patients comparedto ones done from a
femoral approach die less.
Okay. It's a safer procedure for them.
Any heart attack patient,we really try our very best
to do from the radial approach.
- So I have to ask the question,who would not be a
(29:16):
candidate for a transradial?
And then you'd have to gothrough that femoral artery.
- Yeah, I mean that happens, right?
Because remember wesaid about 90% are done
through the wrist, so thatmeans there's 10% that aren't.
So the radio artery is oneof the two arteries in the
forearm that we can go into.
On the other side is the ulnar artery.
(29:39):
Most patients have twoarms, so four arteries
that we can try and put our catheters in.
So if you go into thesame artery multiple times
for multiple different procedures,sometimes it gets more challenging
to get into that artery.
And patients alsosometimes have a one artery
that's smaller than the other.
So in some patients,the ulnar artery is
(29:59):
larger than the radial,but in most patients, the radial artery's
larger than the ulnar.
So usually if we fail in oneradial artery on the right
arm, we will go to the left arm.
And if we fail in that, wecan try the ulnar arteries.
And if we fail in those,then we can go into the femoral artery.
(30:20):
Patients who've had their artery taken outfor open heart surgery
and had the radio artery usedas a conduit for a bypass.
Obviously we can't go inthose patients' radio arteries
and patients who havea fistula in their arm
that use that fistula for hemodialysis.
(30:41):
Those patients, of course, wealso don't go into their arms
to do the heart catheterizations.
When you take all of that into accountand patients with very,
very small radio arteriesor that have a lot of
problems with Ray Raynaudsor spasm in their
vasculature of their hands,and those patients, we
would try and avoid it.
(31:01):
But when you look at ournumbers, we're talking,
less than 10% are unable to bedone from the radio approach,
- Which - Is really remarkable.
- So what is your finaladvice for patients
or potential patientsor people who are taking care
of their parents and loved ones?
- I say be your, be your ownbest advocate and ask questions
(31:23):
and make sure that this isbeing offered at the place
where you decide to haveyour heart catheterization.
And one word of advice Ialways tell physicians,
learning about the radialapproach is that at the end
of the day, the ultimate goal isto have a successful procedure.
And so you never wanna letthe approach compromise
your final result.
(31:43):
If you are going from the radial approach,and it's very challenging, you cannot let
that cloud your decision whetheror not to actually fix a blockage or not,
and how to fix the blockage.
So like I said, what Isay to those physicians is
that the most important thing isto have a successful procedure.
And with the continued commitmentto the radial approach,
(32:04):
the success rate continues to improve,which is incredibly rewarding
and also benefits our patients the most- Perfectly said.
Thank you, Dr. Wang. Thanks, Debra.
Thank you for, for making thatcommitment 15 years ago. Of
- Course. Yeah. Thanks.
- We've been talking with Dr.
John Wang at MedStar UnionMemorial Hospital.
Thank you so much forsharing your expertise
with us here on DOC Talk.
(32:25):
For more information aboutinterventional cardiology at
MedStar Health, goto MedStar health.org/MHVI.
That's MedStar Heartand Vascular Institute.
If you would like tocomment on this podcast
or recommend a topic foranother episode of Doc Talk,
send an email to Doc talk@medstar.net.
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