Cost-Effectiveness of the Radial versus Femoral Artery Approach to Diagnostic Cardiac Catheterization
- Volume 19 - Issue 8 - August, 2007
- Posted on: 8/1/08
- 1 Comments
- 14704 reads
The radial artery approach to diagnostic cardiac catheterization has emerged as an attractive alternative to the femoral artery approach in recent years, especially in Canada and Europe, due to more familiarity and training.1,2 In experienced hands, the radial approach has been shown to minimize patient discomfort, achieve early ambulation and discharge,3,4 with a reduced incidence of bleeding and other vascular complications compared with the femoral approach.5–8
Cost comparisons have been made between the radial and femoral approaches to diagnostic cardiac catheterization, demonstrating reduced cost with the radial approach.3,9–11 However, previous studies did not include patients who received femoral puncture closure devices.
Therefore, we sought to determine the cost effectiveness of the radial artery approach to diagnostic cardiac catheterization compared with the femoral artery approach in two groups, one with and one without the utilization of closure devices.
Patient population. Patients who underwent diagnostic cardiac catheterization between October 2004 and December 2005 at Salem Veterans Affairs Medical Center were identified for cost analysis. Patients were excluded if they required additional adjunct procedures such as coronary intervention, peripheral angiography or intervention, right heart catheterization, cardiac biopsy, intra-aortic balloon pumping or coronary artery bypass graft cannulation.
Catheterization approaches. The femoral approach was performed through the right or left femoral artery based on femoral pulse strength, patient anatomy and operator discretion using 18 gauge, 70 mm long Cook needles (Cook, Inc., Bloomington, Indiana), and 5 or 6 Fr Cordis sheaths (Cordis Corp., Miami, Florida) and Judkins catheters. At the end of the procedure, the femoral sheath was removed and hemostasis was achieved either manually, with a mechanical device, or using a closure device — the Angio-Seal™ (St. Jude Medical, St. Paul, Minnesota) or Perclose® (Abbott Vascular, Abbott Park, Illinois).
The radial approach was performed only in patients who had a normal Allen’s test, preferentially through the right radial artery. Access into the radial artery was achieved using a 21 gauge, 25 mm long Cook needle. This was followed by the introduction of a 5 Fr Cook Flexor Check-Flo Performer Introducer set with hydrophilic coating. Then a “cocktail” of nitroglycerin (50 mcg), heparin (2,000 U), lidocaine 1% (10 mg), verapamil (1.25 mg) and 0.9% normal saline (3.5 cc) was injected intra-arterially through the radial introducer. A 5 Fr multipurpose MPA 2 Cordis catheter was the initial choice in all patients. At the end of the procedure, hemostasis was achieved with manual compression and a D-Stat Radial band (Vascular Solutions, Inc., Minneapolis, Minnesota).
Our catheterization laboratory policies for recovery times were concordant with the 2001 ACC/SCAI Catheterization Standards recovery times of 2–6 hours for the femoral approach and 1–2 hours for the radial approach. All femoral and radial procedures were performed by the same operator.
Data collection. Patient demographics and catheterization data were obtained through the Veterans Administration computerized electronic medical record (CPRS), the Witt monitoring system and the catheterization laboratory and recovery area nursing notes and quality management data.
Cost analysis. Hospital cost was obtained from the Veterans Administration accounting office. This included the cost for needles, sheaths, wires, catheters, closure devices, medicationsand nurse/technician utilization recovery cost.
Statistical analysis. Variables of interest were analyzed to determine normality of distribution. Pair-wise comparisons between the three groups were performed using the two-tailed unpaired t-test.
Patient population and demographics. Between October 2004 and May 2006, a total of 181 patients who underwent diagnostic cardiac catheterization at Salem Veterans Affairs Medical Center were selected for the cost analysis. Seventy patients were in the Radial Group (R), 62 patients in the Femoral Group without the closure device (F) and 49 patients in the Femoral Group with the closure device (F ± C). The mean age was 63 ± 9 years in Group R versus 66 ± 10 in Group F and 61 ± 11 in Group F ± C. The majority of patients were white males. There were no significant differences between the three groups in the prevalence of hypertension, diabetes mellitus, congestive heart failure, chronic renal failure, cerebrovascular disease, peripheral vascular disease or previous myocardial infarction, as indicated in Table 1. During the same period, 334 patients were excluded for analysis because they had concurrent procedures such as right heart catheterization, coronary graft cannulation, peripheral angiograms or interventions, or use of intra-aortic balloon pumping. Three patients in the Radial Group had an unsuccessful procedure, and the femoral approach was subsequently adopted.
Catheterization results. There were no significant differences in the number of patients with one-vessel, two-vessel, three-vessel or multivessel disease among the three groups, as shown in Table 2. The mean left ventricular ejection fractions, as determined by cardiac catheterization, were also similar.
Contrast, catheters and closure devices. As shown in Table 3, while the amount of contrast used was not significantly different between the three groups, more catheters were utilized in both femoral groups compared to the radial group. Sixteen out of the 70 radial patients had a D-Stat radial band, while 49 closure devices (Angio-Seal or Perclose) were used in 49 patients.
Time comparisons. As shown in Table 4, fluoroscopy time was longer in the Radial Group, at 7.4 ± 6.5 minutes, compared to the Femoral Group without closure device use, at 4.5 ± 3.3 minutes (p < 0.01), and was not significantly increased compared to the Femoral Group with closure device use, at 5.9 ± 5.1 minutes. At the same time, procedural duration was nearly identical in all three groups: R = 20.8 ± 12.5 minutes, F = 20.5 ± 9.4 minutes and F ± C = 20.2 ± 11.4 minutes. However, recovery time in the Radial Group, at 126 ± 36 minutes, was nearly half that of the Femoral Group without closure device use, at 240 ± 42 minutes (p < 0.001), and was also significantly shorter than the Femoral Group with closure device use, at 150 ± 48 minutes (p < 0.04).
Cost comparisons. Table 5 depicts access cost, catheter cost, contrast cost, closure device cost and recovery cost for all three groups (R, F and F ± C). The results demonstrate the following:
• Access cost was significantly higher in the Radial Group, at $93.95, compared with either Femoral Groups, at $40.5 (p < 0.001).
• Catheter cost was significantly lower in the Radial Group, at $19.7 ± $12.7, compared with the Femoral Group without closure device use, at $31.1 ± $9.3 and $30.9 ± $9.6 in the Femoral Group with closure device use (both p < 0.001).
• Contrast cost was significantly lower in the Radial Group, at $26.9 ± $17.0, compared with Group F ± C, at $42.9 ± $25.0 (p < 0.001), as well as higher contrast cost in Group F ± C compared with Group F, $32.6 ± $18.9 (p < 0.001).
• Closure device cost was significantly higher in the Radial Group compared with the Femoral Group without closuredevice use, at $61.4 ± $12.9 versus $36.4 ± $24.9 (p < 0.001), but was significantly lower in than the F ± C Group, at $245.0 ± $0 (p < 0.001).
• Recovery cost was significantly lower in the Radial Group compared with the Femoral Group without closure device use, at $185.2 ± $52.7 versus $337.5 ± $59.0 (p < 0.001), and was also lower than the F ± C Group, at $208.0 ± $70.4 (p < 0.05). Total procedural costs including access, catheters, contrast, closure device and recovery costs were significantly lower in the Radial Group, at $369.5 ± $74.6, compared with the Femoral Group without closure device use, at $446.9 ± $60.2, and Group F ± C, at $553.4 ± $81.0 (both p < 0.001).
Procedural complications. No patient in any of the three groups developed a postprocedural complication. It is noteworthy that no patient in the Radial Group developed radial artery spasm or other vascular complications.
Seventeen years after the introduction of the radial artery approach to diagnostic cardiac catheterization by Campeau,1 the femoral approach remains much more commonly used in the United States because it is technically easier and allows the use of larger catheters. However, in Canada and Europe, the radial approach has gained greater acceptance due to more familiarity, while the cardiovascular training programs in the United States have not emphasized the importance of learning this technique.12,13 In experienced hands, the radial approach to diagnostic cardiac catheterization has a number of advantages that need to be emphasized in order to bring greater acceptance of this procedure in the U.S.: (1) The radial artery, unlike the femoral or brachial artery, is not an end-artery. Therefore, even with its possible occlusion, adequate ulnar artery collaterals can salvage the hand from ischemia; (2) the radial artery is more superficial than the femoral artery, therefore it is easily compressible and sheath removal results in diminished risk of bleeding and other vascular complications. A meta-analysis by Agostoni et al5 of 3,244 patients who underwent radial or femoral artery catheterization showed that the former had less entry site complications (0.3% versus 2.8%; p < 0.0001) with similar MACE of 2.2% and 2.4%, respectively; (3) the radial approach carries less risk of nerve injury since there is no adjacent nerve; (4) the radial approach overcomes the limitations and risks of the femoral approach in aorto-iliac vascular disease8 and obese patients; (5) the radial approach allows for reduced postprocedural recovery time, earlier ambulation and earlier discharge, resulting in higher patient satisfaction scores as demonstrated by a number of randomized and nonrandomized clinical trials.3,4 Cooper et al3 showed in a randomized clinical trial comparing 101 patients who underwent the radial technique to 99 patients who underwent the femoral technique, that measures of bodily pain, back pain and walking ability 1 day and 1 week after the procedure both favored the radial approach, which was associated with a mean reduction of length of stay of 6.8 hours. Accordingly, there was a strong patient preference for the radial approach (p < 0.0001).