Training Guidelines for Transradial Intervention

1. Training Guidelines For TRI
Mitchell W. Krucoff MD, FACC
Professor of Medicine / Cardiology
Duke University Medical Center
Director, Cardiovascular Devices Unit
Duke Clinical Research Institute
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2. Disclosures
 No equity or IP holdings
 All consulting and Duke/DCRI grants posted at:
https://www.dcri.org/about-us/conflict-of-interest/?searchterm=coi

3. Complete SCAI/ACC/AHA/ESC TRI Training Guidelines

4. ACC/SCAI Core Cardiology Training Symposium
(COCATS) Task Force 3
Jacobs AK et al. JACC 2008; 51: 355-61

5. Goals of a Cath Lab Training Program
1) requisite cognitive and technical knowledge of invasive
cardiology, including:
 indications and contraindications for the procedures
 pre- and post-procedure care
 management of complications
 analysis and interpretation of hemodynamic and angiographic
data.
2) core knowledge bases of cardiac anatomy, pathology,
physiology, and pathophysiology
3) training in the basic intravascular catheter insertion and
manipulation skills
Jacobs AK et al. JACC 2008; 51: 355-61

6. Program accreditation
 ACGME accredited program
 Dx cath:
Level 1 (noninvasive)
Level 2 (invasive diagnostic only)
 Interventional:
Level 3 (interventional)

7. Program structure
 Full time faculty: >150 caths/year
 Program director:
5 years practice
>1,000 PCIs
“recognized expert in catheterization”
 Key faculty: “The program faculty should include individuals with expertise in
the performance of myocardial biopsies, trans-septal catheterization, and the
interpretation and performance of intracoronary ultrasound and intracoronary
physiologic assessment (Doppler coronary flow and intracoronary pressure
measurement), although each member need not have expertise in every
area…. Ideally…the program should include faculty who possess skills in
advanced interventional cardiovascular techniques such as patent foramen
ovale and atrial septal defect closure, septal ablation for hypertrophic
obstructive cardiomyopathy, and balloon valvuloplasty…(and)…faculty with
expertise in peripheral vascular disease.”
 Associated faculty

8. Cath Lab Facilities & Environment
ADD ARMBOARD
HERE ?
 Equipped per ACC/SCAI consensus cath
lab standards*
 X-ray imaging
 Hemodynamic/physiologic monitoring
 Ancillary support
 Activity level & patient mix
*Bashore T et al. J Am Coll Cardiol 2001;37: 2170-7

9. Duration of Training & Case Volume
ADD TRI vs FA
 Level 1: CASE VOLUME
HERE ?
 minimum 4 months
 100 cases
 Level 2:
 min 8 months over 3 years
 300 Dx cases
 Level 3: WARNING:
 additional 4th year Does TRI volume
come at expense
 250 PCIs of FA competence?

10. Participation in Procedures ADD Allen’s Test
HERE ?
 Pre-procedure evaluation of pt
 Performance of procedure per skill level &
under supervision ADD Wrist band
and peace of mind
 Analysis of procedural data HERE ?
 Post-procedural management

11. Training Program Curriculum:
Cognitive Knowledge (Levels 1,2,3)
 Anatomy & principles of imaging
 Hemodynamics & principles of recording
 Indication(s) for cath
 Indications for interventions
 Optimal adjunctive therapies
 Complications & management
“19. Understand the indications for and complications of vascular
closure devices”

12. Training Program Curriculum:
Technical Skills ADD BASILIC VEIN
HERE ?
 Level 1:
 Vascular access
 Right heart cath, temp pacemaker
 Left heart ventriculography & coronary angiography
 Level 2-3:
 IABP
 Pericardiocentesis
 Trans-septal
 PCI
 Peripheral/Endo
 Other (PFO closure etc)

13. Training Program Curriculum:
Level 1, 2 & 3 Technical Skills ADD TRI HERE ?
Vascular Access:
 Level 1: Perform percutaneous vascular access
from the femoral artery and vein and subclavian
or internal jugular vein”
 Level 2 & 3: Perform vascular access from the
femoral, radial, or brachial route

14. TRI vs FA Technical Skills
 General principles of catheter materials, torque
and telescoping systems all apply
 FA principles of rote & self-intubating pre-
formed shapes do not apply
 FA: RCA vs LCA; TRI: also RRA vs LRA

15. Right Radial Route: 2-6 points of resistance…

16. Left Radial Route: 2-5 points of resistance

17. Radial Training Guidelines: Who Trains Who?
 Both Technically and State of mind:
 New fellows: open minded
 Old Dawgs learning new tricks
 Faculty training fellows or vice versa?
 From COCATS Training to Co-Training

18. Training Guidelines for TRI: Ancillary Questions
 Should catheter competence be
individualized to TRI vs. FA ? (No)
 Could simulator training be incorporated
into guidelines ? (Yes)
 Utility (requirement ?) for training courses?
(Maybe…)

19. Vascular Access Safety Training:
A VAST Addition to Training Guidelines
 Safety of the patient:
 Contrast
 Radiation
 Procedure duration
 Procedure success
 Procedure complications
 Safety of the operator:
 Radiation
 Quiet peaceful sleep at night

20. Basic Training Questions:
Vascular Access Safety Training (VAST)
 Access training definitions:
 From wrist to sinotubular junction
 From leg to sinotubular junction
 Who/when to train:
 Level 1, Level 2, Level 3 ?
 FA & TRI in parallel or in series?

21. Vascular Access Safety Training Matrix:
A VAST Addition to Training Guidelines
 Anatomy
 Indications:  Adjunctive meds:
 “TRI first”  RA spasm
 FA
 Bleeding
 Pt assessment:  RA patency
 Vascular risk factors
 BP management
 Vascular assessment

22. Vascular Access Safety Training Matrix:
A VAST Addition to Training Guidelines
 Arteriotomy
 Access technique  Complications:
 Access technology  Detection
 Access imaging  Management
 Sheaths & sheathless:  Arteriotomy site
 Technique follow up
 Technology
 Site closure:
BOTH TRI & FA
 Technique
 Technology

23. Conclusions
 Guidelines for TRI
 Conjoined with cath training guidelines
 Special emphases
 Level of first exposure to TRI (Level 1 vs 2)
 Preserving FA competence
 VAST focus
 Pt selection & prioritization of access technique (“radial
first”)
 Case volume (TRI & TFA) Level 2 & 3 for technical
competence
 Role of simulator training
 Requirements for faculty “trainers”

24. Training Guidelines For TRI
Mitchell W. Krucoff MD, FACC
Professor of Medicine / Cardiology
Duke University Medical Center
Director, Cardiovascular Devices Unit
Duke Clinical Research Institute
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