TRI and Same-Day Discharge Makes Sense Whenever Possible

In this month’s article, we turn to Dr. John Coppola from New York. Dr. Coppola has been a pioneer in the U.S., recognizing over a decade ago that femoral complications had consequences. As a result, he sought out the experience and tutelage of one of the world’s leading transradial experts, Dr. Tejas Patel. Through the years, Dr. Coppola has persisted in advancing the use of transradial through training programs for other physicians interested in learning the technique. Ten years later, the U.S. has interventional cardiologists located all over the nation who received their initial transradial exposure in Dr. Coppola’s lab. Recognizing the clinical and patient advantages that transradial access provides, Dr. Coppola and his lab utilize transradial access as their primary technique coupled with same-day discharge (SDD) whenever possible for their percutaneous coronary intervention (PCI) patients.

— Gary Clifton, Vice President, Terumo Business Edge

Dr. Coppola, perhaps you can take a minute to describe your practice and the type of patients you treat. 

I have been in practice 34 years and doing transradial intervention (TRI) for 15 years. I currently do about 500-600 cases a year between Bellvue and NYU Langone Cath Labs. My role is running the cath lab at a city hospital, but my most important function is helping to train cardiology fellows.

I know you are a very strong proponent of transradial access. Can you tell us when and why you decided to undertake transradial access as procedural technique? 

In 2002, after having seen many serious femoral complications leading to deaths, I had the honor of meeting Tejas Patel, a true leader in the worldwide radial movement, and was able to do cases with him.

You have been actively training cardiology fellows for years, but you also were heavily involved with training practicing physicians in the transradial technique for Terumo. Why was this important for you? 
I believe it was better for patient care, and by training fellows and physicians who will train other fellows, I felt this would have the greatest impact. Train a program director and he will train many fellows, so the effect is multiplied.

At what point in your practice did you begin to realize it was safe and effective to send PCI patients home same day? 

It was with the realization that bleeding complications were not an issue, and as data came out showing that cardiac complications occurred in the first 6 hours, I felt it was safe to discharge the same day. With Centers for Medicare & Medicaid (CMS) pressure to perform as outpatient procedures, the administration is on board. This also allows for freeing up a bed to accept a new patient and in a busy hospital this works out well for the bottom line.

What would you say to those physicians or administrators that still may be reluctant to utilize same-day discharge for PCI patients due to concerns about patient safety or complications? 

I believe that for patient care it is important to develop radial skills, and like anything that is worthwhile, it requires some work. The reward as a physician is to deliver better care to our patients. I have spent most of my professional life caring for patients and still have an active practice and continue with a fair volume, but at this point, I gain the greatest pleasure from teaching future cardiologists. I enjoy teaching fellows how to perform a radial procedure and how to care for patients. In addition, current data supports that same-day discharge is safe. Dr. Ian Gilchrist from Hershey Medical Center has a nice editoral1 in CCI: “no place like home”. But data over last several years suggests that if no cardiac complications are present by 8 hours, we will not see any over the next 16 hours.

What does your staff have to say about transradial? 

Nurses love it. The post procedure care is much easier and they feel it is more comfortable for patients and safer.

What is the expectation of fellows in training towards transradial? 

The fellows realize that it is an important skill to have, as it helps build practices. I have had multiple fellows tell me that having the radial skills has helped them gain referrals from the community.

Can you provide us your prospective on the various procedures and circumstances where the use of transradial has given you a procedural advantage? 

For renal procedures, it is much easier to engage the renal artery from a superior approach. For subclavians, it is much easier to work from the arm, and if doing iliac stenting, you don’t have to worry about the groin post procedure. It is easy from the left wrist to cannulate the left internal mammary artery (LIMA). I have been able to do patients who are anticoagulated and need a procedure without having to wait for their international normalized ratio (INR) to decrease.

Can you share how the use of radial access is viewed by your cath lab administrators? 

The cath lab administrators like the idea of decreased nursing resources to follow patient post procedure and early discharge. In addition, cost of delayed discharge due to bleeding complications is reduced.

As you know, our highest risk group of patients, the ST-elevation myocardial infarction (STEMI) population, sees the lowest utilization of transradial access. What would you say is important in driving to that goal? 

I believe the operator has to have confidence in his/her ability to perform radial procedures; so, if only used on occasion, fear of doing STEMI is real and justified. If you and lab are radial first, then STEMI is just any other case.

In your experience as an interventional cardiologist managing STEMI patients in the cath lab, will the use of transradial access make a difference in those programs where the Medicare AMI bundle is implemented?

I feel that the benefit in patient care, safety, and comfort is worth the effort to learn the procedure. I was doing transfemoral procedures for 20 years when I switched, so an old dog can learn a new trick and even teach young pups new tricks. 

Dr. Coppola is dedicated to furthering the efforts of any physician or cath lab wishing to learn more about transradial and SDD. He can be reached at john.coppola@nyumc.org or by cell at (917) 837-5699.  

Reference

1. Gilchrist IC. Walk in today, home tonight: who wants to spend the night after PCI? Catheter Cardiovasc Interv. 2013 Jan 1; 81(1): 14. doi: 10.1002/ccd.24743.