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FOREWORD |
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YVES LOUVARD
THE STENT REVOLUTION, THE EVOLUTION OF STENT DESIGN, AND ASSOCIATED BIOTECHNOLOGY have
significantly improved the results of coronary angioplasty. Angioplasty is being used in more
and more situations once reserved for open surgery.
Questions about the skills of interventional cardiologists are at the forefront as the
number and complexity of coronary interventions increase.
The well-known vascular complications associated with the Transfemoral approach remain
a significant concern. Today’s patients expect procedures to be safe, simple, and preferably
ambulatory; hospitals expect high success rates, low costs, less demanding post-procedure
care, and efficient patient turnover.
The Transradial approach virtually eliminates major vascular complications while
increasing the numerous benefits that operators, their staffs, hospitals, and patients demand.
While the radial approach does have a learning curve, it is surmountable. The purpose of
this Atlas is to help operators in this regard.
Authored by Tejas Patel, the charismatic leader of one of the very best interventional
centers in India, the Atlas is a treasure trove of experience. You will find detailed explanations
about how to overcome the challenges of the Transradial approach, including those produced
by congenital and acquired anatomic variations, frequent and rare. Classic and new solutions
to every basic challenge are outlined.
The most important advice Dr. Patel offers is to select your first cases carefully, to be patient,
to persevere, to be gentle, and to use angiography to identify all problems.
Patel’s Atlas of Transradial Intervention: The Basics contains over 55 close-up photos,
over 160 helpful (and beautiful) drawings, and over 275 angiograms that have been handselected
from over 20,000 diagnostic and interventional cases. It is an essential book for
those who wish to begin or to improve a Transradial program.
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Yves Louvard, MD |
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Department of Interventional Cardiology,
Institut Hospitalier Jacques Cartier—ICPS
Massy, France
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JEFFREY POPMA
I LEARNED TRANSRADIAL CATHETERIZATION BY NECESSITY. My former partners at the Brigham and
Women’s Hospital, Dan Simon and Campbell Rogers, brought the Transradial technique to us
several years ago, and it was soon clear that to be a “respected” interventional cardiologist at
the Brigham, one needed to master this approach.
Cases were selectively referred to those of us who “did radials.” By trial and error we learned
the basics of Transradial catheterization and together experienced the challenges and
complications of the Transradial approach in complex cases.
We often asked for each other’s help (or, at least, I did) and we sought advice from our national
and international friends and colleagues who were experts in Transradial access and
intervention. Further, we learned from the lectures and experience of the radial pioneers
Ferdinand Kiemeneij, Shigeru Saito, and Gerald Barbeau.
What was not available to us before now was this Atlas. I am sure this Atlas would have shortened
our learning curve significantly. Even with five years of Transradial experience behind me, I have
found many pearls, tips, and tricks here that will help me with my next radial cases.
The thorough and thoughtful approach to the major issues of Transradial catheterization
addressed by this Atlas have culminated in the definitive teaching source for our Fellows on
the Transradial approach. The Atlas’s side-by-side angiograms and illustrations are unique
to interventional textbooks. They provide the visual reinforcement that will help
interventionalists truly understand the anatomy and find solutions for challenging cases.
Why is this Atlas so valuable and unique? The reasons begin with Tejas Patel’s exquisite
attention to the basics of Transradial catheterization. He is an international expert in the field
and has trained scores of interventionalists around the world. The Atlas also has detailed
discussions of the complex anatomy that is sometimes faced when negotiating the radial,
brachial, subclavian, and aortic vasculature. As a result, this Atlas has all of the components
of a single-source teaching tool for radial access and catheterization. After studying this text,
all that is needed for a successful Transradial program is an engaged physician, a motivated
support staff, and willing patients who are excited about having a safer, less complicated, and
more convenient coronary procedure.
Let me review some specifics in this Atlas that I found most useful. A fundamental first step is
selecting the right patient for learning the Transradial technique. A clear delineation of the
basic criteria for radial catheterization is found in Chapter 1 (Patient Selection & Exclusion)
and its understanding is essential for surmounting the early learning curve. Initial procedures
that focus on the “basics” with low-risk patients are the surest way to gain confidence with
this technique. Mastering the fundamental maneuvers in straightforward cases renders the
more complex cases less problematic.
Our nurses and technologists are the most enthusiastic supporters of the Transradial
technique. Chapter 2 (Cath Lab Set Up & Patient Preparation), Chapter 3 (Puncture Technique),
and Chapter 4 (Post-Procedure Management) are critical chapters for the catheterization
laboratory staff. We have often found that it is their enthusiasm that determines the success
of the radial program. The photos and the illustrations in this Atlas will support the
catheterization laboratory team.
Even if an operator is highly skilled, minor procedural complications sometimes occur and
Chapter 5 (Complications) is likely the most important chapter in this Atlas. When the radial
procedure goes well, it is a real joy to perform. When it does not go well, the procedure can be
challenging and lengthy. Success is based on whether complications can be avoided or
managed appropriately. Clearly those most stimulating meetings are those in which we
discuss the management of our complications. My favorite adage, attributable to a number
of skilled interventionalists, including David Holmes, is: “Good judgment comes from
experience, and experience comes from bad judgment.” This Atlas goes a long way in helping
us make good judgments, without having to pass through the bad judgments first.
Patience is key in performing the Transradial approach. Chapters 6 and 7 (Radial Region)
discuss the anatomic variations and complexities of the radial artery, and Chapter 8 (Patel’s
Algorithm) and Chapters 9 and 10 (Brachial to Subclavian Region and Innominate-Arch
Junction) provide valuable information relating to common challenges to attaining access
to the ascending aorta. Knowing how to proceed when the guidewire does not pass easily
into the central circulation is one of the keys to success with the Transradial approach.
I have been amazed at how similar the radial approach can be to the femoral approach once
a few techniques are mastered, particularly from the left radial artery. Chapter 12 (Cannulation
of the Coronary Ostia) and Chapter 13 (Right or Left Radial Artery) address the issues of size
and shape of the diagnostic and guiding catheters from the right and left radial approaches.
Deep-seating techniques, particularly with smaller-diameter guiding catheters during
coronary intervention, are invaluable in getting stents and balloons to the distal vessels
through tortuous proximal anatomy.
It takes courage to start a radial program, especially when other physicians are very
comfortable in their Transfemoral ways. Two US interventionalists give their reasons for taking
on the Transradial approach in Chapter 14 (How & Why I Started My Transradial Program). In
Chapter 15 (Transradial Intervention: Today and Tomorrow), Tejas Patel gives us his perspective
about “What’s Next” for Transradial intervention.
Patel’s Atlas of Transradial Intervention: The Basics is a “must have” for all interventional
cardiologists. It will be on my shelf for ready access and we will use it as our teaching guide for
our interventional Fellows.
Whether you are a beginner who is considering becoming a radialist or an experienced
radialist who wishes to fine-tune your skills, you will find this Atlas an important part of your
interventional library. |
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Jeffrey J. Popma, MD |
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Director, Interventional Cardiology
Brigham and Women’s Hospital;
Associate Professor of Medicine
Harvard Medical School
Boston, Massachusetts, USA |
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