Rationale for Use of Radial vs. Femoral Access in Oncologic Embolization Procedures
Updated: Mar 11, 2019
For many interventional radiologists, the decision to go femoral or radial is often a matter of prior experience and comfort with the technique. In our recent podcast, Dr. Jason Iannuccilli, Dr. Chris Beck, and Dr. Michael Barraza provide rationale on their preferred access method in oncologic embolization procedures, covering the pros and cons of both approaches, and the distinct advantages that radial access may provide.
The BackTable Brief
Many interventional radiologists are more thoroughly trained and operationally equipped for femoral access by default, making the transition to radial access challenging.
A dedicated trans-radial cath lab configuration, staffing that’s proficient with radial access, and a little bit of trial and error can help you successfully integrate radial access into your practice.
Radial access has been shown to reduce operator radiation exposure compared to femoral access.
Some studies suggest that oncologic patients who have received both radial and femoral treatments prefer the radial approach when it comes to procedure comfort and recovery time.
Improved patient recovery time with radial access can translate into workflow efficiencies.
Pro Femoral Access: Comfort and Experience With Femoral Access
I almost always go femoral access….I have a high level of comfort with femoral access, I have a good feel for when the access is going right, when there's something wrong, and all the working catheters that I use or have access to - not that we couldn't get other ones….There are so many reverse curve catheters [that are] kind of just common practice for us to use. And so it ends up being femoral access. And I think that if I had to really get down to the base of it, it's probably just because I feel comfortable with that overall.
Pro Femoral Access: Ergonomics of Cath Lab Setup
...Some of the smaller reasons that I use femoral access, we have a couple of different cath labs that we work in, both at my main hospital and satellite hospital ... the rooms are built for femoral access, and so if I ever do a radial access case, and we can kind of get into the nuts and bolts and Jason may have some good tips to help facilitate it, but it seems like the ergonomics are very geared towards doing femoral access. I can lay everything across the patient, the monitors are directly in front of me, the back table is behind me, and it's just from that standpoint, everything like my hands and my line of sight, everything is directly in front of me at a 90 degree angle.
Pro Femoral: Shorter Catheter Working Lengths
I wouldn't say we do a lot of them, but for the intra-arterial cases that we do, Y-90 specifically, a lot of the catheters that we try and use are shorter working length catheters like if we're going to do a mapping. I was always taught to try and decrease the length of your catheters as much as possible. So if you can get a 65 centimeter SOS and then a shorter length Renegade that's 105 or 110, you get better injections for your mappings. And I have to admit, I'm a nut about my mapping procedures and I think that using some shorter working length catheters helps you get better injections and better pictures.
You have some special situations….I can think of a case where it included celiac and it was considering whether we were going to have to go via the SMA and pancreaticoduodenal arcade to get to this tumor versus what I ended up doing, was just pulling a Mickelsen catheter into the celiac, which was completely and chronically occluded. And basically what I do is I just take the Mickelsen, park it in the occlusion of the celiac, and then I just kind of chip away with the microcatheter system. And then, ultimately, you kind of treat it like a CTO case, you kind of bust through and then all of a sudden you have access into your hepatic arteries. I'm sure that you could do this if you were doing a radial access case but I have just such a higher level of comfort with the catheters and coming from a femoral approach.
Pro Femoral: Nurses and Techs Are More Comfortable with Managing Femoral Access
So I've made the switch to radial for fibroid embolization, but the only thing that's really keeping me from doing it in cancer therapy ... the barrier is really just having to train inexperienced nurses and techs who are just really very comfortable with managing femoral access patients. The place where I do the majority of my interventional oncology is just a really busy site and I can't waste half an hour having to set up an arm board and get everything set up a way that they're not used to.
I really don't even have that excuse because the cath lab that I work in, it's a cath lab mixed with cardiology and so the techs and nursing staff, everyone is very comfortable with a radial setup. And so for me, if I were to tell the techs, "Hey, let's set up for radial," they don't blink an eye, they'll set up for radial no sweat and they'll have the groins prepped in case of potential crossover. And we use radial access, it's just not my go-to access, especially when it comes to interventional oncology.
Pro Radial: Easier Catheter Access to Deeper Vessel Segments
...I find that my best contrast injections are obtained when I can actually park a catheter in the proper hepatic artery. So I usually try to use even a C2 although I don't like it as much because the tip kind of digs a little. And I'll advance that over a glide and sort of get it down deeper so that my contrast injection is primarily directed at the liver and I'm not getting contrast aversion to the spleen. So for that reason I found that it's almost easier and less traumatic to take some of these radial catheters in deeper inside the celiac access because of the angle that the catheter accesses the vessel. So that's where I think there might be a little bit food for thought and room for discussion.
Pro Radial: Superior Patient Comfort and Shorter Recovery Time
As far as other reasons why I prefer trans-radial, we have found in our practice that since we've transitioned over - about four years ago I think we made the transition - it was a learning experience but the patients that had been with us getting repeat treatments throughout that time markedly prefer the trans-radial approach in terms of comfort and duration of recovery over the femoral approach. So I think that that factor also considered has pushed us to try to use radial as much as possible.
Pro Radial: Improved Workflow Efficiency Secondary to Shorter Recovery Time
The one other thing I will mention since we're talking about limitations with facilities, at Brown at Rhode Island Hospital we have a common recovery area that we share with the diagnostic radiologists for all their biopsies and drainages so there's limited space when it comes to beds available for patient recovery. The faster we can get a patient sort of through the recovery period and discharge them onto the next phase of care the better off we are in terms of workflow efficiency. And we found that by using the trans-radial approach we've been able to cut our recovery times by as much as a third to a half. So we have markedly improved our efficiency just by switching over to the radial approach.
Pro Radial: Reduced Radiation Exposure for Operators
Interestingly, your observations, there's some recent data on it. There's a study at MUSC that was there in the January of February issue of JVIR comparing trans-radial versus trans-femoral access in liver cancer embolization. And so they took patients who had actually been treated from both radial access and femoral access, and they surveyed the patients and it showed radial was preferred by the patients and decreased operator radiation exposure actually and there were no differences in adverse events, procedure time, contrast usage, or patient radiation. So I thought that was interesting.
 A Technical Guide Describing the Use of Transradial Access Technique for Endovascular Interventions: https://www.techvir.com/article/S1089-2516(15)00022-0/fulltext
 Transradial Versus Transfemoral Arterial Access in Liver Cancer Embolization: Randomized Trial to Assess Patient Satisfaction: https://www.jvir.org/article/S1051-0443(17)30828-X/fulltext
Dr. Jason Iannuccilli is a practicing interventional radiologist with Rhode Island Medical Imaging.
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Dr. Michael Barraza is a practicing interventional radiologist with Radiology Alliance in Nashville.
Cite this podcast:
BackTable, LLC (Producer). (2018, April 4). Ep 26 – Radial vs. Femoral Access in IO Procedures [Audio podcast]. Retrieved from https://www.backtable.com/podcasts
The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable or its sponsors.
The podcast referenced in this article was sponsored by Surefire Medical.