September 23, 2022 by John Fernandez
How Accessing Arteries has Evolved from Femoral (Groin Area) to the Wrist
The femoral artery — referring to the main blood vessel supplying blood to the lower body near the groin — had been the most common entry point for percutaneous coronary intervention (PCI) to open up blood vessels in the heart — or for accessing the brain to treat aneurysms and strokes.
But more than two decades ago, interventionalists started considering and testing a safer alternative: using the artery in the wrist, known as “radial artery access,” as an alternative. That’s mainly because femoral access near the groin can be a cause of serious access site complications during interventions to treat blood vessels in the heart or brain.
“Traditionally, if you need to deal with issues in the arteries, you get access in the femoral artery, which is near the groin,” explains Brian Snelling, M.D., chief of cerebrovascular and endovascular neurosurgery and the director of the Stroke Program at Marcus Neuroscience Institute at Boca Raton Regional Hospital. “And then from there, you can get anywhere else. You can go up to the brain to treat aneurysms or strokes. If you’re a cardiologist, you can go to the arteries of the heart and perform coronary interventions. That’s really how endovascular therapy is done.”
Dr. Snelling recently co-authored an article in Endovascular Today on medications to reduce any potential risks during procedures via radial artery access.
Guilherme Dabus, M.D., co-director of interventional neuroradiology and vice-chief of the department of neuroscience at Miami Neuroscience Institute, also part of Baptist Health, has helped pioneer radial artery access using it for several years for both diagnostic and some interventional cases.
“Over the last few years, the number of cases that have been performed via radial artery access has increased, particularly in the diagnostic angiography cases,” said Dr. Dabus. “One of the main advantages of the radial artery access for outpatient procedures, such as for diagnostic cerebral angiography, is that the patient needs to recover only for a few hours. And the patient is more comfortable with no significant limitations afterward.”
A diagnostic angiography requires a catheter (a thin flexible tube), x-ray imaging guidance and an injection of contrast material to examine blood vessels in key areas of the body. PCI refers to non-surgical procedures that uses a catheter to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup. The femoral artery can also use for coronary angiograms, a procedure that uses X-ray imaging to see your heart’s blood vessels.
‘Mountain of Evidence’ in Favor of Wrist Access
Dr. Snelling points out that the shift toward radial artery access in the wrist started in the 1990s.
“About 20 to 25 years ago, the field of interventional cardiology started looking at using the artery in the wrist, the radial artery, as an alternative to the femoral artery,” Dr. Snelling said. “And they’ve built a real mountain of evidence — prospective data and randomized trials with tens of thousands of patients in total — showing that when you use the artery in the wrist, it’s safer and patients have a better outcome, compared to using the artery in the leg.”
Primarily, the risk of access site complications, such as bleeding, is reduced substantially, he adds. Neurosurgeons at Marcus Neuroscience Institute and Miami Neuroscience Institute have made much progress in implementing radial artery access, or using an entry point in the wrist, as a standard of practice for patients being treated for aneurysms or strokes.
Neurointerventional surgeons have lagged behind cardiovascular specialists in widely adopting radial artery access over femoral access.
“There are hundreds of thousands of interventional cardiology procedures done per year,” explains Dr. Snelling. “There’s probably one-tenth of those being done for stroke-based procedures. We’re a smaller field, and as such, we lag behind cardiology in terms of technology development.”
When Femoral Access is Still Best Option
Neurointerventional surgeons have steadily shifted toward the wrist entry point, but in some cases the femoral artery is still the best option, as in a life-saving thrombectomy, a procedure during which a catheter is threaded into an artery and up through the neck until it reaches the blood clot causing the stroke.
“It is important to consider that there are still several cases performed via femoral access, particularly stroke intervention where very large bore catheters are needed,” said Dr. Dabus. “It is also important for patients to understand that both femoral and radial access are extremely safe.”
Adds Dr. Snelling: “A majority of the portfolio of procedures that we offer endovascularly we can do from the wrist. There’s a few that I still do from the groin, and that’s mostly stroke thrombectomies. That’s when we may need bigger catheter, or we’re worried about speed — then that’s usually the time we’ll go femoral.”
Otherwise, the safer entry point of using an artery in the wrist will continue to be used for most procedures where the size of the catheter, treatment urgency or patient-specific factors are not issues.
Patient Safety and Comfort
While patient safety, in terms of preventing bleeding complications, is the primary reason behind the shift toward the wrist, comfort and ease of recovery for the patient are also considerations.
“If you have an aneurysm that’s treated, or you have a brain AVM, or even if you have a coronary lesion, you’re likely to need repeated catheter-based diagnostic or treatment procedures,” said Dr. Snelling. “When a patient will need to undergo multiple procedures, patient comfort starts to become paramount. So, patients prefer radial (wrist) access because it’s more comfortable. They don’t have to lie flat after the procedure. They can sit in a chair, eat and drink, and walk much more quickly.. Some of my patients are texting family members 20 minutes after a procedure using the same hand where the procedure was performed.”