Catheterization and Cardiovascular Interventions 83:367–368 (2014)
Editorial Comment At Least It Is Safe When Done Via A Transradial Approach Ian C. Gilchrist,* MD, FSCAI Pennsylvania State University, Heart and Vascular Institute, Milton S. Hershey Medical Center, Hershey, Pennsylvania
Working between the interface of solid organ transplantation and cardiology often is an exercise in contrasts between evidence-based guidelines stemming from the cardiovascular literature and empiric protocols from the surgical fields. One example that is familiar to those who work in liver transplant centers is the need for certain transplant surgeons to know what the heart catheterization shows. Results of non-invasive evaluation do not satisfy their need to see the arteries and measure the pulmonary pressures. The threat of delisting the patient for transplant is often the coup d’ etat that forces the cardiologist into the catheterization laboratory. Jacobs et al. [1] in this issue provide several points of discussion related to this topic of cardiac catheterization and risk abatement. The first issue relates to whether we can safely perform cardiac catheterization of patients in hepatic failure. Prior work had suggested these procedures are feasible from the femoral vasculature, but at a cost of access site bleeding [2]. By utilizing an transradial approach for arterial access and forearm for the venous catheterization [3], Jacobs et al. have taken advantage of the unlikely transradial complication of access site bleeding and used it advantageously in their work ups of pre-liver transplant patients. The results speak for themselves as they successfully performed complete cardiac catheterizations in this naturally anticoagulated patient group with bleeding complications well below the historical reports. Performing a procedure safely satisfies the desire to do no harm, but is it really helpful or just another loop to jump through? Some further insight is provided by the analysis of whether the procedure influenced the liver transplantation procedure. The coronary angiography may have been helpful to define high-grade coronary disease that can co-exist in the liver failure patient. After all, the ability to adequately exercise for a stress test or whether the vasoactive state of end stage liver C 2014 Wiley Periodicals, Inc. V
failure can allow accurate pharmacologic stress testing could be argued. Pulmonary hypertension from hepatopulmonary syndromes likewise can complicate liver patients and is a reason to preclude transplantation. Estimates of pulmonary pressures are reliably obtained by non-invasive techniques such as echocardiography. In fact, none of the routine right heart catheterizations in the present series provided data that altered the decision making about transplantation. While right heart catheterization is feasible from the forearm, its need can rarely be defined as routine in the presence of adequate non-invasive techniques. There are situations that clear confirmation of the data is needed and proficiency at the safest approaches to the heart will prevent harm. Even at the best centers, the true status of the right heart pressures may be ambiguous due to patient characteristics or technical difficulties obtaining data by non-invasive means. A right heart catheterization from the forearm can rapidly define the central pulmonary pressures and evaluate for pulmonary hypertension that can significantly alter the therapy for the end-stage liver patient. Clotting profiles such as the International Normalized Ratio [4] are not particularly helpful in defining those at risk for bleeding. Prophylactic infusion of fresh frozen plasma and other products have been suggested prior to procedures from the femoral vessels to lessen bleeding. These added risks can all be avoided using a forearm approach, while the net risk/benefit maximized by reserving procedures for situations where there is a true question to be answered. Beyond the question of liver disease and the role of cardiac catheterization in the triage for transplantation, the application of transradial techniques points to an area that is often overlooked in arguments about the merits of this approach over femoral. With transradial, one can perform procedures in situations that otherwise are contraindicated via the transfemoral approach. The Conflict of interest: Nothing to report. *Correspondence to: Ian C. Gilchrist, MD, FSCAI, Penn State Heart and Vascular Institute, Pennsylvania State University, 500 University Drive, Hershey, PA 17033. E-mail: [email protected] Received 2 December 2013; Revision accepted 4 December 2013 DOI: 10.1002/ccd.25343 Published online 4 February 2014 in Wiley Online Library (wiley onlinelibrary.com)
368
Gilchrist
present study exemplifies coagulopathy induced by liver failure, but highly anticoagulated patients from any etiology can be approached transradially, be it an arterial or venous procedure, with little concern about access site bleeding. In my own experience at a cardiac and solid organ transplant center, patients are usually followed non-invasively for their right pressures. Routine monitoring of right heart pressures is not condoned, but there are times when inotropes are not working or mechanical support devices are not making sense and knowing for sure the actual heart pressures can be very helpful. Recognizing that now a small right heart catheter can be slipped up a peripheral vein and provide that information without having to reverse anticoagulants or add blood products has been very valuable in the management of complicated hemodynamic cases and gives the providers a snap-shot of the hemodynamics to correlate with their non-invasive impressions. Transradial is not substituting for transfemoral but rather extending to a broader range of indications to add utility to invasive cardiac procedures. Safety is important and using the right tool for the procedure can go a long way toward doing no harm. Containment of unneeded testing should also be a goal as just because we can do it safely does not mean we
should; clearly there is a need to have a guideline-based dialog with some of our professional surgical societies, perhaps even gather some outcomes data, to define rational approaches to pre-organ transplant screening. On the other hand, having the ability to invasively evaluate cardiac pathology using lower risk transradial/forearm approaches does provide a potential new tool to integrate into the modern diagnostic toolbox to help manage complex patients such as those with end-stage liver failure. REFERENCES 1. Jacobs E, Singh V, Damluji A, Shah NR, Warsch JL, Ghanta R, Martin P, Alfonso CE, Martinez CA, Moscucci M, Cohen MG. Safety of transradial cardiac catheterization in patients with endstage liver disease. Catheter Cardiovasc Interv 2014;83:360–366. 2. Sharma M, Yong C, Majure D, Zellner C, Roberts JP, Bass NM, Ports TA, Yeghiazarians Y, Gregoratos G, Boyle AJ. Safety of cardiac catheterization in patients with end-stage liver disease awaiting liver transplantation. Am J Cardiol 2009;103:742–746. 3. Gilchrist IC, Moyer CD, Gascho JA. Trans-radial right and left heart catheterizations: A comparison to traditional femoral approach. Catheter Cardiovasc Interv 2006;67:585–588. 4. Townsend JC, Heard R, Powers ER, Reuben A. Usefulness of international normalized ratio to predict bleeding complications in patients with end-stage liver disease who undergo cardiac catheterization. Am J Cardiol 2012;110:1062–1065.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Editorial Comment At Least It Is Safe When Done Via A Transradial Approach Ian C. Gilchrist,* MD, FSCAI Pennsylvania State University, Heart and Vascular Institute, Milton S. Hershey Medical Center, Hershey, Pennsylvania
Working between the interface of solid organ transplantation and cardiology often is an exercise in contrasts between evidence-based guidelines stemming from the cardiovascular literature and empiric protocols from the surgical fields. One example that is familiar to those who work in liver transplant centers is the need for certain transplant surgeons to know what the heart catheterization shows. Results of non-invasive evaluation do not satisfy their need to see the arteries and measure the pulmonary pressures. The threat of delisting the patient for transplant is often the coup d’ etat that forces the cardiologist into the catheterization laboratory. Jacobs et al. [1] in this issue provide several points of discussion related to this topic of cardiac catheterization and risk abatement. The first issue relates to whether we can safely perform cardiac catheterization of patients in hepatic failure. Prior work had suggested these procedures are feasible from the femoral vasculature, but at a cost of access site bleeding [2]. By utilizing an transradial approach for arterial access and forearm for the venous catheterization [3], Jacobs et al. have taken advantage of the unlikely transradial complication of access site bleeding and used it advantageously in their work ups of pre-liver transplant patients. The results speak for themselves as they successfully performed complete cardiac catheterizations in this naturally anticoagulated patient group with bleeding complications well below the historical reports. Performing a procedure safely satisfies the desire to do no harm, but is it really helpful or just another loop to jump through? Some further insight is provided by the analysis of whether the procedure influenced the liver transplantation procedure. The coronary angiography may have been helpful to define high-grade coronary disease that can co-exist in the liver failure patient. After all, the ability to adequately exercise for a stress test or whether the vasoactive state of end stage liver C 2014 Wiley Periodicals, Inc. V
failure can allow accurate pharmacologic stress testing could be argued. Pulmonary hypertension from hepatopulmonary syndromes likewise can complicate liver patients and is a reason to preclude transplantation. Estimates of pulmonary pressures are reliably obtained by non-invasive techniques such as echocardiography. In fact, none of the routine right heart catheterizations in the present series provided data that altered the decision making about transplantation. While right heart catheterization is feasible from the forearm, its need can rarely be defined as routine in the presence of adequate non-invasive techniques. There are situations that clear confirmation of the data is needed and proficiency at the safest approaches to the heart will prevent harm. Even at the best centers, the true status of the right heart pressures may be ambiguous due to patient characteristics or technical difficulties obtaining data by non-invasive means. A right heart catheterization from the forearm can rapidly define the central pulmonary pressures and evaluate for pulmonary hypertension that can significantly alter the therapy for the end-stage liver patient. Clotting profiles such as the International Normalized Ratio [4] are not particularly helpful in defining those at risk for bleeding. Prophylactic infusion of fresh frozen plasma and other products have been suggested prior to procedures from the femoral vessels to lessen bleeding. These added risks can all be avoided using a forearm approach, while the net risk/benefit maximized by reserving procedures for situations where there is a true question to be answered. Beyond the question of liver disease and the role of cardiac catheterization in the triage for transplantation, the application of transradial techniques points to an area that is often overlooked in arguments about the merits of this approach over femoral. With transradial, one can perform procedures in situations that otherwise are contraindicated via the transfemoral approach. The Conflict of interest: Nothing to report. *Correspondence to: Ian C. Gilchrist, MD, FSCAI, Penn State Heart and Vascular Institute, Pennsylvania State University, 500 University Drive, Hershey, PA 17033. E-mail: [email protected] Received 2 December 2013; Revision accepted 4 December 2013 DOI: 10.1002/ccd.25343 Published online 4 February 2014 in Wiley Online Library (wiley onlinelibrary.com)
368
Gilchrist
present study exemplifies coagulopathy induced by liver failure, but highly anticoagulated patients from any etiology can be approached transradially, be it an arterial or venous procedure, with little concern about access site bleeding. In my own experience at a cardiac and solid organ transplant center, patients are usually followed non-invasively for their right pressures. Routine monitoring of right heart pressures is not condoned, but there are times when inotropes are not working or mechanical support devices are not making sense and knowing for sure the actual heart pressures can be very helpful. Recognizing that now a small right heart catheter can be slipped up a peripheral vein and provide that information without having to reverse anticoagulants or add blood products has been very valuable in the management of complicated hemodynamic cases and gives the providers a snap-shot of the hemodynamics to correlate with their non-invasive impressions. Transradial is not substituting for transfemoral but rather extending to a broader range of indications to add utility to invasive cardiac procedures. Safety is important and using the right tool for the procedure can go a long way toward doing no harm. Containment of unneeded testing should also be a goal as just because we can do it safely does not mean we
should; clearly there is a need to have a guideline-based dialog with some of our professional surgical societies, perhaps even gather some outcomes data, to define rational approaches to pre-organ transplant screening. On the other hand, having the ability to invasively evaluate cardiac pathology using lower risk transradial/forearm approaches does provide a potential new tool to integrate into the modern diagnostic toolbox to help manage complex patients such as those with end-stage liver failure. REFERENCES 1. Jacobs E, Singh V, Damluji A, Shah NR, Warsch JL, Ghanta R, Martin P, Alfonso CE, Martinez CA, Moscucci M, Cohen MG. Safety of transradial cardiac catheterization in patients with endstage liver disease. Catheter Cardiovasc Interv 2014;83:360–366. 2. Sharma M, Yong C, Majure D, Zellner C, Roberts JP, Bass NM, Ports TA, Yeghiazarians Y, Gregoratos G, Boyle AJ. Safety of cardiac catheterization in patients with end-stage liver disease awaiting liver transplantation. Am J Cardiol 2009;103:742–746. 3. Gilchrist IC, Moyer CD, Gascho JA. Trans-radial right and left heart catheterizations: A comparison to traditional femoral approach. Catheter Cardiovasc Interv 2006;67:585–588. 4. Townsend JC, Heard R, Powers ER, Reuben A. Usefulness of international normalized ratio to predict bleeding complications in patients with end-stage liver disease who undergo cardiac catheterization. Am J Cardiol 2012;110:1062–1065.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
