The Wrist As A Route To The Heart

About a million artery-clearing angioplasties are performed in the United States each year, and the usual route is to thread a tube to the heart through an artery in the groin.

But a major study this summer showed that going through the wrist instead can significantly lower the risk of bleeding, without the discomfort of lying flat for hours while the incision site seals up.

Just one-in-100 angioplasties in the United States is done via the wrist, and the approach isn't for everyone. But the study promises to spur more specialists to use the method.

"In experienced hands, it can be done more," said Dr. Sidney Smith, heart disease chief at the University of North Carolina at Chapel Hill and a past president of the American Heart Association, who wasn't part of the study. "This approach, when done by experienced operators, has advantages."

On The Early Show Wednesday, Dr. Howard Cohen, director of cardiac intervention at Lenox Hill Hospital in Manhattan, told co-author Julie Chen, "It's technically more difficult, and it's generally taught less in this country. So, it's more common in Europe and in Canada and the Far East."

Cohen performs many angioplasties through the wrist. He chatted with Cehn as part of the show's "HeartWatch" series.

Angioplasty is prized as a quick, minimally invasive way to restore blood flow in a clogged artery. A tiny balloon is inflated at the site of the blockage, pushing back the clog. Doctors often also insert a mesh tube called a stent to keep the artery propped open. It can be done during a heart attack, to alleviate worsening symptoms that signal a heart attack is imminent, or for non-emergency relief of recurring chest pain.

Who the best candidates are for an angioplasty as opposed to other treatments is hugely controversial. But the study addressed whether the through-the-wrist method works as well once the decision is made.

Cardiologists have preferred working through the femoral artery in the groin because it's a larger blood vessel than the wrist's radial artery, so it's easier to tug catheters through. When the procedure's over, heavy pressure -- often a sandbag -- is applied for several hours until the puncture site quits bleeding and essentially seals itself. But heavy bleeding and related complications are a risk, happening in anywhere from two percent to sometimes as many as 10 percent of patients.

Catheters have gradually gotten smaller and more flexible, and previous small studies had suggested the wrist approach could be safer because that puncture site can be bandaged. In one earlier study, the wrist method even trimmed hospital costs because patients were discharged sooner.

"We do about 8,000 procedures a year at Lenox Hill," Cohen told Chen. "Doing it this way is about $200 less per procedure. So, that's a savings for the hospital of about $1.6 million."

Duke University researchers turned to a national registry, analyzing more than half a million angioplasties performed at 600 U.S. hospitals between 2004 and 2007, to see how often wrist angioplasties are done, and the results.

One key caveat: These were first-time, non-emergency cases.

But just 1.3 percent of the angioplasties were done through the wrist. Both methods were equally effective at clearing heart arteries, lead researcher Dr. Sunil Rao reported in the Journal of the American College of Cardiology: Cardiovascular Interventions.

The wrist method cut the bleeding risk by nearly 60 percent: Nearly two percent of patients treated the usual way bled, compared with slightly fewer than 1 percent of those treated via the wrist.

The method may be gaining steam: In early 2007, the researchers measured a sudden jump, as the wrist method accounted for about 3.5 percent of angioplasties performed then.

Rao himself uses wrist angioplasty almost exclusively, but it takes extra training that many cardiologists haven't received.

Still, the heart association's Smith said training isn't difficult, and the need may be growing: Obesity can limit traditional access, plus more patients today have disease-damaged leg arteries.

"The procedure is not one that would be recommended for everybody," Smith cautioned. But, "there are definitely groups of patients where this can be done with the same results and fewer complications."

"Maybe one-in-ten patients, one-in-20 patients can't have it done through the wrist," Cohen explained to Chen, "because you need two arteries supplying the hand. Most patients have two arteries supplying the hand, but about one-in-ten to one-in-20 patients don't have two arteries, and they have to have it done from the leg."