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• PAMPAS Study : more power to the arm for transradial access
  Ian R Hall
  Published on: 17 September 2003

• Published on: 17 September 2003

  PAMPAS Study : more power to the arm for transradial access

  • Ian R Hall, Specialist Registrar Cardiology
  • Other Contributors:
    • James Nolan, Ted SN Lo

  Dear Editor

  We were interested to read the recent scientific letter from Pollard et al published in Heart.[1]

  The authors evaluated the safety of a protocol for earlier sit up and mobilisation after routine transfemoral cardiac catheterisation in contemporary practice. Patients were randomised to be mobilised after 2½ hours or 4½ hours bed rest. The authors report that a significant reduction in...

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  Dear Editor

  We were interested to read the recent scientific letter from Pollard et al published in Heart.[1]

  The authors evaluated the safety of a protocol for earlier sit up and mobilisation after routine transfemoral cardiac catheterisation in contemporary practice. Patients were randomised to be mobilised after 2½ hours or 4½ hours bed rest. The authors report that a significant reduction in the duration of bed rest was achieved in the early mobilisation protocol group with no adverse effect on vascular complications. They also report that early mobilisation was associated with a reduction in pain and discomfort, although this data is not presented. On this basis, the authors call into question the role of alternative arterial access sites for diagnostic cardiac catheterisation.

  The published data does not support this viewpoint. Firstly, the early mobilisation protocol still required 2½ hours of bed rest. There is extensive published evidence that bed rest after medical procedures has few benefits and a wide range of adverse effects.[2] The combination of back pain related to bed rest and groin pain related to femoral puncture and pressure haemostasis delays mobilisation and return to normal activity after discharge in at least one third of patients.[3] Secondly, despite studying only a selected low risk group of patients (only some elective patients with chest pain undergoing diagnostic angiography were eligible for the study. Patients with a difficult femoral puncture, those undergoing percutaneous revascularisation, receiving adjunctive antithrombotic therapy or with previously treated peripheral vascular disease were excluded) haematomas re-bleeding and vaso-vagal reactions were common. Indeed this study suggests that these problems occur in 15- 20% of these low risk patients. In contrast to this, we have recently reported on a series of 1000 consecutive transradial cases, in which a third of the study subjects had major risk factors for vascular complications.[4] Patients undergoing diagnostic angiography or percutaneous intervention were mobilised immediately, removing the potential for adverse effects from bed rest. Avoiding a groin puncture will facilitate a rapid return to normal activity after discharge. In this high risk population the incidence of both major and minor vascular complications was less than 1%. The data from the North Staffordshire series is entirely compatible with other published case series and randomised trials, which consistently show that use of the transradial access site is associated with short mobilisation and discharge times, a reduction in procedure costs and vascular complications, and a consistent improvement in patient quality of life when compared to the femoral access site.[5-7]

  In our view the data presented (a 2½ hour period of bed rest and 15- 20% incidence of access site problems) strengthens the case for selecting the radial artery (no bed rest and less than 1% incidence of access site problems) in the majority of patients undergoing routine diagnostic cardiac catheterisation.

  References

  (1) Pollard SD, Munks K, Wales C, Crossman DC, Cumberland DC, Oakley GDG, Gunn J. Position and mobilisation post-angiography study. (PAMAS): a comparison of 4.5 hours and 2.5 hours bed rest. Heart 2003;89:447-448.

  (2) Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999;354:1229-1233.

  (3) Foulger V. Patients’ views of day-case cardiac catheterisation. Professional Nurse 1997;12:478-480.

  (4) Eccleshall SC, Banks M, Carroll R, Jaumdally R, Fraser D, Nolan J. Implementation of a diagnostic and interventional transradial programme: resource and organisational implications. Heart 2003;89:561-562.

  (5) Eccleshall S, Muthusamy T, Nolan J. The transradial access site for cardiac procedures: a clinical perspective. Stent 1999;2(3):74-9.

  (6) Al-Allaf K, Eccleshall S, Kaba R, et al. Arterial access for cardiac procedures utilising the percutaneous transradial approach. Br J Cardiol 2000;7:548-52.

  (7) Kiemeneij F, Laarman GJ, Odekerken D et al. A randomised comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the Access study. J Am Coll Cardiol 1997;29(6):1269-75.

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  Conflict of Interest:
  None declared.

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