DETROIT, MI (Ivanhoe Newswire) - They are clogs that kill. Arteries hardened with plaque can lead to deadly heart attacks. Every year, one million Americans undergo a potentially life-saving procedure to reopen clogged arteries. Now, there's a new technique with some great benefits for patients.
Shooting buckets with his son, Brian Bennett knows the key to a good jumper is all in the wrist. The key to saving his life may have started at his wrist too.
"I was a walking time bomb," Brian Bennett told Ivanhoe. "My LAD, they call it the widow-maker, was 90 percent blocked."
A stress test uncovered coronary heart disease. Several of Brian's arteries around his heart were clogged with plaque. Doctors performed a coronary angioplasty, inflating tiny balloons in the arteries to break up the blockages. But instead of the traditional approach of threading a catheter through Brian's leg to reach those arteries, doctors went through his wrist!
"Because the artery in your wrist is right on the surface, it's easily visible. It's right next to a bone. You can easily stop any bleeding," Adam Greenbaum, M.D, director of the cardiac catheterization laboratory at Henry Ford Hospital, said.
Doctors said bleeding from the leg is a risk after surgery and one of the main reasons angioplasty patients are often kept overnight for observation. When surgeons enter at the wrist, patients need a shorter observation period making it possible for them to go home the same day. Brian was back home just six hours after surgery.
"I took my kids to school the next day, went to a wedding a day later, back to work on Monday," Brian said.
Doctors said with the wrist procedure, patients can sit up to recover. With an approach through the leg, patients must remain flat during recovery, which can slow recovery time for those with back problems.
RESEARCH SUMMARY
BACKGROUND: Coronary heart disease (CHD) is a narrowing of the small blood vessels. CHD is also called coronary artery disease (CAD). It is a condition in which plaque (plak) builds up inside the coronary arteries. These arteries supply oxygen-rich blood to the heart muscle. CHD is the number one killer in the U.S., killing more than 13 million American men and women a year. (SOURCE: www.ncbi.nlm.nih.gov/pubmedhealth, www.webmd.com, www.nhlbi.nih.gov)
Coronary heart disease (CHD) starts when certain factors damage the inner layers of the coronary arteries. These factors include: smoking, high blood pressure; having high levels of certain fats and cholesterol in the blood; or high levels of sugar in the blood due to insulin resistance or diabetes. When damage occurs, your body starts a healing process. The healing may cause plaque to build up where the arteries are damaged. Eventually, an area of plaque can rupture. If this happens, blood cell fragments called platelets will stick to the site of the injury and may clump together to form blood clots. Blood clots narrow the coronary arteries even more and worsen angina or cause a heart attack. (SOURCE: www.nhlbi.nih.gov)
SYMPTOMS: A common symptom of coronary heart disease (CHD) is angina. Angina is chest pain or discomfort that occurs if an area of your heart muscle doesn't get enough oxygen-rich blood. Angina may feel like pressure or squeezing in your chest. You also may feel it in your shoulders, arms, neck, jaw, or back. Angina pain may even feel like indigestion. The pain tends to get worse with activity and go away with rest. Emotional stress also can trigger the pain. Other symptoms of CHD may include shortness of breath and fatigue. (SOURCE: www.nhlbi.nih.gov)
PREVENTION: The best way to prevent CHD is by maintaining a healthy lifestyle. Don't smoke, get plenty of exercise – at least 30 minutes a day, keep the weight off, and choose a diet rich in fruits, vegetables, and whole grains. Also, eat meats lean in protein such as chicken, fish, beans, and legumes, and avoid sodium (salt) and fats found in fried foods, processed foods, and baked goods. You should eat low-fat dairy products, such as 1% milk and low-fat yogurt. Finally, read labels, and stay away from "saturated fat" and anything that contains "partially-hydrogenated" or "hydrogenated" fats. SOURCE: (www.ncbi.nlm.nih.gov/pubmedhealth)
HANDS ON: Clearing a clogged or blocked heart artery once required open-heart surgery, followed by a weeks-long recovery period. Coronary angioplasty is a procedure used to open narrow or blocked coronary arteries. The procedure restores blood flow to the heart muscle. Usually a small tube called a catheter is inserted into an artery in the groin. However, doctors have found going through the wrist to clear up clogged arteries is a lot easier and it cuts recovery time significantly. The radial artery is found in the wrist and it supplies the hand with blood. This artery offers ready access to the heart and is sometimes easier to get at. Doing angioplasty through the wrist also tends to cause less bleeding around the puncture after the procedure is over than the groin approach. (SOURCE: http://www.health.harvard.edu, www.nhlbi.nih.gov)
INTERVIEW
Adam Greenbaum, M.D., director of the Cardiac Catheterization Lab at Henry Ford Hospital in Detroit, Michigan talks about angioplasty procedures.
For starters, I want to talk a little bit about angioplasty. For our viewers again who are not familiar, what is the goal?
Dr. Greenbaum: The definition of angioplasty is widening, or opening, of an artery. When we talk about heart procedures that usually means clearing a blockage in one of the arteries on the surface of the heart, which supplies the heart muscle with blood. That involves inserting a balloon inside the artery and inflating it, opening the artery, then deflating and removing the balloon.
When that procedure is done now, just roughly, if you could describe how that is done.
Dr. Greenbaum: Any heart procedure that we do involves threading catheters through the blood vessels to the heart, to either take pictures of certain structures of the heart, or to perform a procedure like angioplasty and place a stent. That involves gaining access to the blood vessels and threading the catheters to the heart.
For the patient, this is an inpatient procedure and one that requires some hospital stay?
Dr. Greenbaum: Traditionally, the procedure is either performed as an inpatient procedure on someone in the hospital, who came in with symptoms such as chest pain or a heart attack; or it can be outpatient, meaning the person came in for a diagnostic procedure. Maybe there was chest pain or an abnormal stress test, but typically when an angioplasty is performed, an overnight stay for observation is usually required.
Why is that? Why is there the need?
Dr. Greenbaum: The procedure carries some risk. We are going into the heart and working on arteries that supply blood to the heart muscle, and there are some risks to that. But over time, those risks have become very predictable and have decreased. The unknown related to angioplasty and these procedures has always been the chance of a serious bleeding complication. That typically comes from gaining access through the leg to blood vessels that guide the catheters to the heart.
I want to talk a little bit about the transradial. If you could explain what that is first of all.
Dr. Greenbaum: Historically, when this procedure first started, it was actually done from the arm via a minor surgical procedure called a cut down, in the crease above the elbow. In the mid ‘80s, the dominant mode of gaining access to the blood vessels to the heart transitioned to the femoral artery in the leg, and that remained the dominant mode for many years. However, as equipment got better and smaller, doctors realized that the radial artery in the wrist could be used as an alternative.
What is the benefit of going through the arm as opposed to the leg?
Dr. Greenbaum: Going through the wrist has three major benefits. The first is that there are two blood vessels which bring blood to the hand, one on each side of the wrist. The femoral artery is the sole blood supply to the leg. So, if there were damage to the blood vessel during the procedure, there could be danger to the leg. Since there are two vessels to bring blood to the hand, if there was damage to one artery, there would be much less chance of injury to the hand.
Second, there is a nerve that runs next to the femoral artery that brings feeling and sensation to the leg. So, if during the procedure there is a little bit of bleeding outside of the femoral artery, it could result in nerve damage to the leg. In the wrist, there is no nerve next to the artery. There happens to be a median nerve which runs in the middle, but not on the side, so there is less chance of nerve damage to the hand.
The third major advantage to using the wrist - and probably the most important - is the femoral artery is deep in the leg. At the end of the procedure, we need to remove the catheters and control the bleeding. We need to press down hard to achieve adequate control of bleeding. Since the artery in the wrist is right on the surface, it is easily visible, smaller, and right next to a bone, we can easily stop bleeding. So, we have virtually eliminated the chance of a bleeding complication.
Sounds like a silly question, but what is the benefit to the patient? What are you seeing from making the transition in a certain number of patients, certain amount of patients from leg to wrist?
Dr. Greenbaum: With those distinct advantages, at Henry Ford we have embraced using the radial artery, or the wrist, as the mode of access to the blood vessels to the heart - not as an alternative to when we cannot use the leg, but as the preferred mode. And there are additional advantages after the procedure. Typically if you use the leg artery, the patient has to lie flat for a few hours after the procedure to allow the leg a chance to heal and to decrease the chance of a bleeding complication. For patients with significant back discomfort, low back pain, neck discomfort or patients that are short of breath when lying flat, that becomes very uncomfortable for them. If the procedure is done through the wrist, the patient can sit up right away and recover in a sitting position. Another big advantage is that it allows us to discharge some patients to recover at home the same day after their angioplasty.
Why is that?
Dr. Greenbaum: While there are risks to the procedure, they are pretty predictable and occur soon after the procedure. So, with a period of about six hours of observation in the hospital after the procedure, we know that those complications are not likely to occur. The remaining unknown is the serious risk of a bleeding complication, which can occur hours after the procedure. Once we moved to using the wrist as the main access to the blood vessels and virtually eliminated the bleeding risk, some patients can now go home after the observation period, the same day as their procedure, to recover in the comfort of their own homes.
And again, it sounds like a silly question, but why is it important when you have a procedure like this to be able to get them? It is not like you are just kicking them out, but why is it important to be able to discharge them as soon as you can, as soon as the doctors are comfortable that they can go home?
Dr. Greenbaum: Most patients prefer to recover at home. There may be comfort issues related to a hospital bed versus their own beds. There may be financial issues, in child care, time off from work, and maybe other responsibilities that their loved ones have around the house. So, there may be distinct advantages to patients and their families to recover at home. From a healthcare standpoint, it costs money to care for those patients overnight, so with a procedure that is done hundreds of thousands of times per year in the U.S. alone, it could result in significant savings.
Who would not be a good candidate for the transradial? Are there some patients where going through the femoral artery would be the preferred way to do the angioplasty?
Dr. Greenbaum: For the majority of patients, the preferred access to the blood vessels should be the radial artery. However, there are still a few patients that, due to anatomical reasons, may not be good candidates for access through their wrists. There may also be some patients that - depending on the complexity of their procedure, the size of the catheters that we need to use, and various anatomical features of their arteries - their procedure may still be performed best through the leg. However, we feel that that should be a small amount of patients.
What is the bottom line message then? Will it take a while before this idea of going through the wrist catches on? What do you think needs to happen before that becomes the gold standard?
Dr. Greenbaum: Using the radial artery in the wrist has been the dominant mode of access in Europe for many years. The uptake has been slow in this country; most likely because of U.S. physicians are trained to use the procedure through the leg. Since Henry Ford was an early adopter of this approach and has been doing it for some time now, we are one of a very few training centers in the U.S. Physicians come to Henry Ford Hospital in Detroit to learn how to do cardiac catheterization through the wrist. In fact, we are one of the rare centers to allow hands-on training, where not only will cardiologists come watch us do the procedure, but they will actually perform the procedure themselves, which has become a very attractive option for physicians.
You had mentioned better equipment or smaller equipment. Is there an investment in equipment then that needs to happen or is this pretty much standard?
Dr. Greenbaum: The improvement in equipment, and the decrease in its size, came as technology improved. It is about an increase in confidence and being able to perform the procedure, understanding the intricacies of performing it through the wrist, as opposed to the leg. And as time goes on, I think we will see a large increase in the use of the wrist access in the U.S.
At Henry Ford, is that now the standard way to do angioplasty?
Dr. Greenbaum: At Henry Ford, we have made the transition to use the wrist and would have to look for a reason why we could not do it.
Is there anything I did not ask you, a bottom line or anything I did not ask you that you want to make sure people know?
Dr. Greenbaum: I want people to know that not everybody is a candidate to be discharged the same day after an angioplasty. We have a very strict protocol and set of criteria: you have to have someone who can stay with you, you have to be within a certain number of miles to a hospital, the procedure has to go well, and there can be no problems during the six hours of observation. But, if your procedure was done through the wrist and you meet all those criteria, we feel that it is completely safe and may be more comfortable for you to go home the day of the procedure and enjoy the comforts of your own home.
When you hear from a patient, I felt fine, I was dancing at my cousin's wedding 3 days later, and does that surprise you?
Dr. Greenbaum: That does not surprise me, if they had their procedure done through the wrist. It makes us very happy to know that these patients are getting back to their daily lives much quicker.
Had this patient had to have access through the leg, would that have been the case? Would there have been dancing 3 days later?
Dr. Greenbaum: Typically not. They are usually sore for two or three days after the procedure. We ask them not to lift heavy objects or perform aggressive exercise for a few days, to allow the artery a chance to heal. So, I would say that dancing at a wedding two days after a heart catheterization through the leg would be much less likely.
It does not hurt as much to go through the wrist. It takes much less numbing medicine because it is such a small space.
The procedure is done through the radial artery, where a pulse can be felt, and it is located on the side of the wrist. There is another pulse on the other side of the wrist, at the ulnar artery. And so, in the unfortunate circumstance of any damage to the blood vessel during the procedure, there is still an adequate blood supply to the hand. So, there is virtually no risk of nerve damage, lack of blood flow to the hand, or bleeding, since pressure can be applied at the wrist.
Pull your sleeve up a little bit. Just show me with your other finger, kind of like draw a line where the catheter would go.
Dr. Greenbaum: The catheter would point in this direction, aiming up the radial artery, and we thread the catheter all the way up the arm, all the way around the shoulder, into the heart.
I got a close up on your wrist, like what you just showed. So, I am going to get a medium shot. Show me again how you went up your arm because I was close up on your wrist and I missed all the rest of it.
Dr. Greenbaum: The catheter that we use to gain access is about 13 cm, and is placed in the wrist, pointing in this direction. The catheters are threaded up the arm, around the shoulder, and down to the heart. If you put your wrist next to your leg, the actual distance for using either route is almost identical. So, many doctors use the same catheters for either the wrist or leg.
You can see the wrist, and a lot of these people cannot see their legs. First off all, they are under a sheet.
If you are flat on your back?
Dr. Greenbaum: You cannot see it. They have to feel the bleeding, and usually by then, there is a pool of blood.
FOR MORE INFORMATION, PLEASE CONTACT:
Sally Ann Brown
Sr. Public Relations Specialist
Henry Ford Health System
(313) 874-6280
sbrown2@hfhs.org
