This assignment was a 1500 to 2100 word paper (approximately 5 to 7 pages). Literature papers are usually 25 to 50 pages long and aim to synthesize a body of research and summarize large bodies of research to report on a topic of interest in a scientific field. This paper was to include five to seven or more citations on a topic of interest. Using models discussed in class, this paper served as preparation for the final research paper yet to come.

Self-Reflection

The lit review paper sounded easy enough since it was simply a summary of papers and research that was already done. Thus preparing for it was manageable. After choosing a topic, I used databases such as PubMed and Medline. Although my initial topic and final paper are worlds apart, this paper taught me to be more specific when choosing a topic. I also learned to be careful not to write a review paper on a review paper, instead, finding a review paper close to your topic and following the references is a way to find authentic studies and research that would help you in your paper. Even though it may sound like an easy paper to write, it was challenging since most scientific topics have multiple components depending on what topic you have. For instance my topic related to Cardiovascular complication and intervention. The hardest part about researching this topic was finding very many different types of information that would get overwhelming since Cardiological studies are very detailed. In fact, it helped to write my research paper before my literature review since I would focus on one topic and had a clear perspective on what topic I wanted to write about and why it was important to my audience. Charging to 1600 words… Clear!

Percutaneous Coronary Intervention: Comparing Transradial versus Transfemoral Approaches

Percutaneous Coronary Intervention (PCI) also known as Coronary Angioplasty, is a minimally invasive nonsurgical procedure that is used to improve blood flow to the heart during cardiovascular complications. As defined by the National Heart, Lung, and Blood Institute (NIH), it is a procedure performed by injecting contrast dye, followed by feeding a thin tube into coronary arteries either transradially or transfemorally during heart attacks or cardiac to clear any arterial blockage that may constrict blood flow to the heart. According to the American Heart Association, this nonsurgical procedure is an out-patient procedure with a less than one percent mortality rate within the first thirty days in which the rate reduces after the first thirty days (Cutlip). The transfemoral approach takes place when the tube is passed through an artery in the leg versus the transradial approach which is passed through an artery in the arm, as stated by Johns Hopkins Medicine website. Although PCIs have one of the lower mortality rates compared to similar procedures both surgical and nonsurgical, there is debate as to which approach is safer or better. This review will include research studies from Pubmed and MEDLINE to provide a general understanding of what both approaches entail as well as their pros and cons, in order to relay the recommended approach.

A study with a total of 1997 consecutive patients were enrolled to receive either procedure. 1076 (54%) patients received the transradial, while 921(46%) patients received the transfemoral approach. The results concluded the transradial approach was better since it contained lower post-procedural complications (Sinha). In comparing both procedures, it was found that although vascular bleeding is a major complication in both approaches, and the leading cause of death after the procedure itself. This complication was more potent in the transfemoral approach since the femoral artery is larger than the transradial artery (Anjum). Other complications included hematoma formation, vascular spasm in the transradial approach, shunt or fistula complications, clot formation and Pseudoaneurysms. These complications primarily mean different types of bleeding and clotting of blood that would cause the procedure to fail or the patient to expire. Because the femoral artery is larger in diameter and the only source of blood to the leg, the risk would be elevated and the cost for the procedure as well as recovery time would much longer. The pros on the other hand would be the diameter of the artery, since it is larger than the radial, the margin of error is lower since it is easier for the surgeon to pass the tube throughout the artery without risk of tearing the artery. Another favoring factor is the success rate, since the transfemoral approach is known as the traditional approach (since 1977) it is heavily practiced by Physicians (Anjum).

Another study containing a total of four hundred patients, concluded the transradial approach is better than the transfemoral approach (Bhat). The patients were divided fifty-fifty and monitored over a period of two years. The results were categorized by gender as well as body mass, location, age and smoking history. The study concluded that the transradial had a higher access time, meaning it took longer to gain access to the blocked area of the artery and thus a longer procedure time, as well as access failure. This meant that even after performing the transradial approach, there was higher risk the surgeon could not access the blockage to clear it up and had to stop the procedure and start another procedure to gain access, [most likely the transfemoral approach] (Bhat). Although these were the risks of the transradial approach, the study also concluded the transfemoral approach yielded much greater post-procedural complications. Thus, ruling in favor of the transradial approach. Since the transradial approach has various procedural complications but a lower mortality rate as well as post-procedural complications, it is heavily favored as the safer or recommended approach in the Cardiological field. Although it needs further study and experimentation, studies published to online resources such as PubMed and Medline heavily advocate for a transradial approach versus the classical transfemoral approach.

The transradial approach is also known as the modern approach, it was first practices in 1989, twelve years after the established transfemoral way (Anjum).  In the same study, it was found that the approach yielded less vascular complications post-procedure and an overall lower morbidity rate in patients. The cons did however include, smaller artery diameter which led to longer time under anesthesia and higher risk of a severe vascular spasm leading to sudden cardiac death (UChicago). Although the radial artery is not the only blood supply to the arm, it is smaller and more delicate than the femoral artery, after the procedure a vascular spasm is caused when the artery suddenly tightens briefly or completely constricting blood flowing to the heart (Anjum). As a result, the modern approach is more difficult to perform and carries slightly higher risk since vascular spasms can cause sudden cardiac death. Thus, although both approaches yield success, they both have varying consequences that would both lead to more vascular complications post-procedure. Factors such as age, gender, surgical history, genetics, etc. are factors that affect the outcome of either procedure. There are also time frames, outcomes before and after thirty days post-procedure, since a procedure is considered “successful” if the patient does not die within the first thirty days (Lansky).

Percutaneous Coronary Intervention is one of many procedures’ cardiologists use to restore blood flow and functionality to the heart. Compared to other procedures it has one of the lowest morbidity rates and lesser vascular complications post-procedure as well as lower health delivery costs making it affordable (Tewari). The study of PCIs and comparing the different approaches is increasingly controversial since the leading cause of death in the United States continues to be Heart Diseases for over twenty-one years (CDC). Thus, although the current studies point to transradial as being favorable, more research needs to be done in consideration of age, gender and weight. It should also further examine whether access through left or right arteries make a significant difference and compare PCIs to other Coronary procedures such as Coronary Artery Bypass Grafting whereby the doctor would clear the blocked artery by grafting or creating a new artery using healthy artery or vein tissues from the patient’s body (NIH). And the success in transition from transfemoral to transradial and vice versa during procedural complications. Studies showing how often a surgeon has difficulty in accessing either a radial or femoral artery would advocate for which procedure is better, since it would provide the sample size, age and gender in which transradial or transfemoral PCIs would no longer benefit the patient. One of the limiters in the literature of these studies lies in comparing the two approaches, although the studies state which approach has ‘more’ or ‘less’ of an impact, they fail to specify general time in days or hours. This may be a limiter in further comparing PCIs to other Coronary Interventional procedures. Another factor that should be further researched and published is the rate of occurrence. According to the NIH, PCIs are performed to clear arterial blockage that is built up of atherosclerotic plaque made of fat, cholesterol, calcium and other substances found in blood. After a PCI, an ideal assumption would be no recurrence of plaque in a patient with respect to healthy living, but what about practicality? Research should paint a realistic picture of the rate of recurrence in both men and women, followed by success rate in procedure and recommendation of what additional or transitional procedures would be necessary after the first PCI. Simply put, PCIs can be performed multiple times on a patient but may not always be successful; with respect to circumstance, doctors should indicate what additional risks or procedures may be required when multiple PCIs fail.

Additionally, with the emerging of PCIs becoming the forefront of Coronary Intervention, most of the studies included patients who had already undergone a prior procedure to restore blood flow to the heart, by studying first time patients, the research would validate the mortality rate for the general population and increase the sample pool of patients who may or may not be able to receive this procedure. Women have a much greater risk to contract vascular complications that are undetected by doctors, when comparing data women show much greater risk for complications due to their smaller surface area, profile and older age (Lasky). With these risks, in an annual total of approximately 1.2 million PCIs performed, only 33% are performed in females. A study done by the Northern New England PCI Registry sought to compare the rates of complication in women and men in order to predict what caused the complications and how they impacted each gender specifically (Ahmed). With a sample size of 13, 653 female patients and 32, 334 males, the results concluded although women have a much higher risk profile, the decline in vascular complications was 50% within a six-year period and a 45% decrease in males. When attempting to predict why there was a decrease, the study implicitly declared there needs to be more research done since the cause is unknown.

Bibliography

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Cutlip, D. E., & Fischman, D. L. (2018). Mortality After Percutaneous Coronary Intervention. Circulation: Cardiovascular Interventions,11(7), 1-3. doi:10.1161/circinterventions.118.007008

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and endorsed by the American College of Cardiology Foundation

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Tewari, S., Sharma, N., Kapoor, A., Syal, S. K., Kumar, S., Garg, N., & Goel, P. K. (2013, July 12). Comparison of transradial and transfemoral artery approach for percutaneous coronary angiography and angioplasty: A retrospective seven-year experience from a north Indian center. Retrieved May 20, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/23992998

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