“Do not be led by others, awaken your own mind, amass your own experience, and decide for yourself your own path….On this Earth, do I stand, unvanquished, unslain, unhurt” (Atharva Ved)
Having spent over 23,000 h in cath labs across the globe in pursuit of perfection and done 14,500 radials, here are my reflections on radials.
1. Background: the transradial bandwagon
August 2002: Returning to India from Royal Jubilee Hospital, Victoria, BC, a dedicated radial center was like traveling back in time. My colleagues in India considered transradial interventions (radial) difficult to do and hence unacceptable! One said ‘it was like driving in reverse gear’ and the other called it a gimmick!
I first learnt radials in Toulouse from Professors Jean Marco (Illustration A) and Jean Fajadet in 1997, where I went while I worked as a Cardiology Registrar in London, UK.
Illustration A.
The author, with Professor Jean Marco at the cath lab in Clinque Pasteur at Toulouse, France after a primary angioplasty on a Sunday in 1997.
I did my first radial in India in 2002 at Escorts Heart Institute (EHIRC), New Delhi; our first publication came from my work at Bikaner Medical College. In March 2003, we coined the term ‘walk-in-walk-out’ for transradial procedures. Relegated to the near-to-midnight-available-time-slot at EHIRC, no patient enjoyed ‘walking out’ of the catheterization laboratory or going home at that hour after a radial!
2. Where we were-
It needed guts to do radials in those days because it had to be better than a femoral; especially as we had no evidence to support what we were doing other than the only randomized study available at the time. We pursued radials because we were convinced about lower bleeding hazard as well as patient comfort, with attendant early mobilization.
Training nurses and other staff and setting up protocols were other big challenges because the staff did not feel obliged to comply as the boss did not do any radials! I empathized with Steve Jobs who also often had to go through similar frustrations in trying to bring in innovation, against resistance…; here I was not even the owner, but just a small fry!
3. ‘Fear was the key’ to innovation: necessity – the mother of invention
In those days, because we did radials, we were under the microscope and could not afford to fail/crossover (convert to alternate access to complete the procedure) or have a patient complaining of pain during a radial procedure.
The diameter of radial arteries in Indians is smaller compared to that of Caucasians on which I had trained! We only had femoral catheters then, mostly re-used; no TIG/Cordis radial catheter and so pain due to spasm on account of multiple catheter exchanges or test injections of dye into radial artery were a concern.
With this in mind, we started to do pre-procedural vascular Doppler of the arm arteries in our patients to know the Hand before Hand, to anticipate potential hurdles during radials (cubital loops or radial anomalies), thus minimizing trial and error to limit spasms, crossover, procedure failure, and fluoroscopy time. It also helped to find largest diameter arteries to minimize radial artery stretch and manipulation that initiates the vicious cycle of spasm and subsequent occlusion.
4. The journey to success
Using this, we created our innovative sheath sizing protocol and spasm grading which also helped us do the country's first transradial rotablation using a 7F sheath in 2003!
I was invited as faculty to talk at the Transradial Masterclass (TRM), UK in 2010 and at the Society of Cardiovascular Angiography and Interventions Conference and at Transcatheter Therapeutics, USA in 2011!! Our innovations soon found a place in international presentations and publications; and on invitation I even performed a successful live radial angioplasty to TRM, UK in 2011.
5. Where we are – the retribution
Data now supports our conviction of 18 years that radials serve patient interest best. Now it's easy to do radials on the strength of reported survival benefit with it. The learning curve of new operators has also improved with our efforts and those of other pioneers, with workshops, publications/books, and book chapters written by us. But back in 2003, it wasn’t so and I faced much unpleasantness in starting the country's first radial meeting!
As happens to anything new and different, whether it was Werner Frossman's first cardiac catheterization in humans or Copernicus’ theory that the sun was the center of the universe; radial too faced opposition and suppression for decades from those unable/unwilling to do radials who also starved our meetings of funds and institutional support.
Because institutional support was lacking until recently; for years, my two small children and wife volunteered to manually stick address labels and postage stamps on 10,000 invitations for ‘Radial Blitz’/‘Radial Live’ and we would post them at Delhi GPO! On one occasion, hundreds of our posted invitations were found lying beside railway tracks in Rewari, probably thrown away by a postman!
Transradial primary angioplasty is still under 1% and the country still does mostly angiograms (30–40%) transradially. Radial angioplasty is still only 10% at best!
6. Where are we going: the radial movement
‘It's not the strongest of the species that survive nor the most intelligent, but the ones most responsive to change’ (Charles Darwin)
Radial is now a movement in the country. It will take a decade for anyone starting now to become an expert and take on angioplasty in acute coronary syndromes, where most of the benefit is and which is most of our work in India!
After 4 French transradial angioplasty was introduced by me in India in 2013, India's first ‘slender club workshop’ concluded recently in eastern India. Slender techniques will enable angioplasty in smaller diameter radials with promise of less radial occlusions.
7. Reaping the benefits of radial
It is time to create a center of excellence, with “walk-in-walk-out’ radial centers across the country to take the benefit of radial to every patient who needs it and reduce the 40% increase in primary angioplasty mortality (most of which was done transfemorally) reported by National Intervention Council last year.
To connect and take the movement forward, email: contactus@waris.co.in or visit www.radial-live.com or www.waris.co.in. Together we can do more. Much more. The time is NOW.
Conflicts of interest
The author has none to declare. The above manuscript is solely the opinion of the author and the Editorial Board of Indian Heart Journal in no way subscribe to the above views.