Harvard Heart Letter

Angioplasty and stenting through the arm

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Q. My friend recently got a heart stent with a procedure that involved going through his wrist instead of his upper leg. What are the pros and cons of these different techniques?

A. To deliver an artery-opening coronary stent, a doctor must gently guide a thin tube (catheter) and other instruments through a major blood vessel to reach the heart. This technique is known as angioplasty and stenting. Traditionally, the vessel of choice has been the femoral artery, the large vessel at the top of the thigh. One advantage of using this artery is that itís relatively large, which makes maneuvering the catheter a bit easier. Also, the vessel leads directly to the heart. In the United States, most doctors were trained in this so-called femoral approach.

However, there are some downsides. In people who are very overweight, the femoral artery can be buried under layers of fat, making it tricky to reach. And the inside of this vessel can be clogged with fatty deposits, creating obstructions for the catheter and other tools. To stop the bleeding after the procedure, people receive either a special closure device that helps seal the opening in the artery or 20 minutes or more of firm, manual pressure on the artery. They then have to lie still for several hours.

The alternative approach, which uses an artery in the wrist, gets around many of these problems. The radial artery is located in the forearm near the base of the thumb and sits just under the skin, making it somewhat easier to reach (even in people who are overweight). And compared with leg arteries, arm arteries are far less likely to develop fatty deposits.

Angioplasties done via the wrist are less likely to bleed, and any bleeding that does occur is easier to detect and stop. After the procedure, people can get up much sooner and therefore may be able to leave the hospital earlier. As a result, radial angioplasty and stenting tends to be less expensive for the health care system.

However, the radial artery is smaller and has more twists and turns. Maneuvering the catheter can be more challenging, so the procedure may take a little longer. Sometimes the doctor ends up needing to switch from the radial to the femoral artery to complete the procedure.

In parts of Europe and in Japan, most angioplasties and stent placements are done through the radial artery. Although the technique isnít yet as popular here in the United States, most major clinics and academic centers that provide heart procedures offer radial angioplasty and stenting. Because other factors might affect the choice, itís best to let the cardiologist decide which artery is most appropriate.

ó by Deepak L. Bhatt, M.D., M.P.H.
Editor in Chief, Harvard Heart Letter

Illustration by Scott Leighton

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