Coronary artery disease (CAD) is an enormous public health burden that kills more than 380,000 people annually, and 735,000 people suffer from myocardial infarctions each year.¹ Given this plight, it is the natural history of any budding interventional cardiologist to take a keen interest in CAD and the manor in which it is treated. The treatment of acute coronary syndrome evolved in the last half century with the advent of beta blockers, anti-platelet therapy, anti-lipid pharmacology, and, most notably, revascularization.

Percutaneous angiography and revascularization have become cornerstones of our approach to the patient with ST-segment elevation myocardial infarction (STEMI) and high-risk non-STEMI (NSTEMI). For the overwhelming majority of that time, diagnostic coronary angiography has been performed via access through the common femoral artery (CFA).² From 2010 through June of 2011, more than 90% of cardiac catheterization cases were performed transfemorally.³ The procedure does come with a fair share or risks, most of which are related to bleeding and vascular compromise. The radial artery has offered an attractive alternative to the CFA for diagnostic studies and interventions. Specifically, the radial artery approach dramatically reduces bleeding and access site complications and thus improves patient safety.²

The RIVAL (Radial Versus Femoral Access for Coronary Intervention),⁴ RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome),⁵ STEMI-Radial (ST Elevation Myocardial Infarction Treated by RADIAL or Femoral Approach),⁶ and MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox)⁷ studies have all demonstrated benefits of the radial artery approach. Radial artery access is associated with early sheath removal, improved patient comfort, and faster recovery.² Most notably, there is a demonstrated mortality benefit seen in these studies (though there is a fair amount of criticism regarding the anticoagulation techniques) that is driven primarily by a reduction in bleeding complications. Radial access has proven its superiority for straightforward cardiac catheterization.

What is to become of transfemoral access? Is it a relic of a bygone era? Perhaps not. Although cardiac catheterization and percutaneous intervention will have a large impact on the field of cardiology for the foreseeable future, advances in noninvasive therapy continue to make strides in primary and secondary prevention, meaning that catheterization numbers will continue to decline.

Enter femoral access. Population aging is an inevitability. And with aging comes opportunities for femoral access to once again prove its worth. Older patients with more comorbidities are generally poorer cardiovascular surgical candidates. There is no medical therapy for aortic stenosis, and transcatheter aortic valve replacement (TAVR) is clearly the rising star in this field. Eighty percent of TAVR procedures were transfemoral between PARTNER I and II (Placement of Aortic Transcatheter Valve) and US CoreValve Pivotal (Transcatheter Aortic-Valve Replacement with a Self-Expanding Prosthesis) trials. Complex left main/proximal left anterior descending interventions are now using percutaneous left ventricular support, again requiring femoral access. Critical care cardiology relies on transfemoral extracorporeal membrane oxygenation routinely. Transfemoral access is not going away. Rather, the size of access needed is increasing.

Femoral artery access and management should be a focus of the cardiologist's training rather than an afterthought. As interventions requiring large-bore access increase in frequency, it will become even more necessary to be an expert in femoral artery access. We cannot let this skill fall by the wayside.

Editorial Comment: Transfemoral Access—Patient Care and Issues of Fellow Training
by George W. Vetrovec, MD, MACC

Dr. Hansen has provided an interesting and somewhat provocative statement regarding the need for fellow training in techniques of transfemoral access.

I feel particularly qualified to discuss this issue as a "gray hair" who did his first 1000 or so "on-faculty" diagnostic coronary angiographic cases via brachial cut down using the traditional Sones technique.⁸ That was in the late 1970s. With the advent of percutaneous coronary intervention (PCI), I quickly saw that the field was changing and femoral was the way to go. Thus I retrained myself with the help of colleagues to perform the Judkins technique (the femoral approach).⁹ I was bolstered by the fact that brachial cases could still be done via a percutaneous approach and, if done from the left brachial artery, could be accomplished via Judkins catheters, albeit with a few modifications for the right coronary artery. If the right brachial was needed, alternative femoral catheters were feasible and had a femoral associated use in some complex anatomic cases, so they were not totally foreign. Overall, that was a reasonable conversion and one that really did not sacrifice fellow training.

Fast forward 30+ years to the current era. Internationally, but particularly in the United States, there has been a remarkable increase in the adoption of the transradial approach to coronary angiography and, in many cases, PCI. Furthermore, several studies^3,4 (as pointed out by Dr. Hansen) have demonstrated improved outcomes for radial that are ascribed to less bleeding and thus fewer late complications and better outcomes. Despite these benefits, however, there remains a potentially greater radiation exposure to patients and operators (greater for lower volume operators and particularly from the left radial) using the radial approach.¹⁰

That said, there remain patients who cannot be accessed from the radial approach because of vascular issues such as hemodialysis, and crossover to a femoral approach is necessary. Likewise, as mentioned by Dr. Hansen, large-bore catheters required for hemodynamic support require femoral insertion. Lastly, there is the growing use of transfemoral access for structural procedures such as TAVR. Thus, angiographers and interventionalists cannot be one-dimensional! To meet this need, training programs must continue to teach femoral as well as radial access to trainees. In addition, because the radial approach can be more challenging for successful coronary cannulation and because of the potential for greater radiation exposure for the operator, I fear that many times fellows have fewer opportunities to hone their skills at catheter manipulation during training.

How do training programs accomplish this without jeopardizing optimal patient care? First, it seems important to focus on optimal access techniques to avoid the major cause of differential bleeding outcomes. Femoral access via sonogram guidance with micropuncture techniques can improve the training and safety of access. Likewise, the use of simulation may also increase fellows' skills outside of patient care. It is also important to maintain nonphysician skills in groin management, including sheath removal. Lack of routine femoral use may well contribute to greater femoral complications when needed unless skills are maintained at all levels.

This issue will be a challenge going forward, but it is necessary to continue successful training and management of patients for necessary femoral access. To achieve the goal, programs will need to emphasize optimal training approaches including simulation, modern access techniques, and potentially specific patient assessment (e.g., thinner patients and dialysis patients) to appropriately select patients for femoral access. Training must include femoral access training, and trainees need to receive requisite coronary catheter experience and skills regardless of the access site.

References

1. Heart Disease Facts (Centers for Disease Control and Prevention website). Available at: http://www.cdc.gov/heartdisease/facts.htm. Accessed 08/01/2015.
2. Moscucci M. Grossman & Baim's Cardiac Catheterization, Angiography, and Intervention. 8th ed. Philadelphia, 2014:139-222.
3. Dehmer GJ, Weaver D, Roe MT, et al. A contemporary view of diagnostic cardiac catheterization and percutaneous coronary intervention in the United States: a report from the CathPCI Registry of the National Cardiovascular Data Registry, 2010 through June 2011. J Am Coll Cardiol 2012;60:2017-31.
4. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet 2011;377:1409-1420
5. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol 2012;60:2481-9.
6. Bernat I, Horak D, Stasek J, et al. ST-segment elevation myocardial infarction treated by radial or femoral approach in a multicenter randomized clinical trial: the STEMI-RADIAL trial. J Am Coll Cardiol 2014;63:964-72.
7. Valgimigli M, Gagnor A, Calabró P, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomized multicentre trial. Lancet 2015;385:2465-76.
8. Sones FM, Shirey EK. Cine coronary arteriography. Mod Concepts Cardiovasc Dis 1962;31:735-8.
9. Judkins MP. Selective coronary arteriography. I. A percutaneous transfemoral technic. Radiology 1967;89:815-24
10. Jolly SS, Cairns J, Niemela K, et al. Effect of radial versus femoral access on radiation dose and the importance of procedural volume: a substudy of the multicenter randomized RIVAL trial. JACC Cardiovasc Interv 2013;6:258-66.

Keywords: Acute Coronary Syndrome, Aortic Valve Stenosis, Blood Platelets, Brachial Artery, Cardiac Catheterization, Cardiac Catheters, Comorbidity, Coronary Angiography, Coronary Artery Disease, Critical Care, Extracorporeal Membrane Oxygenation, Femoral Artery, Hemodynamics, Lipids, Myocardial Infarction, Patient Care, Patient Safety, Percutaneous Coronary Intervention, Prednisone, Prostheses and Implants, Public Health, Punctures, Radial Artery, Renal Dialysis, Secondary Prevention, Transcatheter Aortic Valve Replacement

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