Transulnar Access Research Articles

AJMER ULNAR ARTERY ACCESS IN ELDERLY (AJULAR IN ELDERLY): A SINGLE CENTER PROSPECTIVE RANDOMIZED CONTROL STUDY

Upper arm access use for percutaneous coronary procedures is default site over femoral route in view of periprocedural complications and better results. Trans radial access (TRA) is almost established entity now while trans ulnar access is being increasingly used by experienced operators. Elderly

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To assess the crossover rate from primarily chosen transradial access (TRA) in a high volume transradial center.All consecutive 30,848 patients, that underwent diagnostic angiography and/or intervention in the period from 2010 until 2015 were examined. Preprocedural radial artery angiography was performed in all patients since 2011. Clinical and procedure characteristics, reason for crossover and its direction were analyzed. Primary end-point of the study was the occurrence of TRA failure and need to crossover to another approach to finish the procedure.Procedural success of primarily chosen TRA was 94% (n = 28,988). Crossover to other access sites was 6% (n = 1860). Most common reason for crossover was inability to puncture the right radial artery in 4,1%, presence of radial artery anomalies (0,3%), high grade spasm (0,1%), or radial artery occlusion (1,2%). Crossover direction was primarily through the ipsilateral transulnar access (TUA) 3,8%, left radial access (LRA) 1,5% and in only 0,6% (n = 189) of patients to transfemoral access (TFA). Access site bleeding complications were present in 5,1% (n 1579).Total wrist access is feasible and safe with low rate of access site complications and crossovers, especially when performed in experienced high volume transradial center.

All Roads Lead to the Heart: A Case of Transulnar Approach for Coronary Catheterization in a Patient with Limited Access Routes

Introduction: In a time of increasing use of forearm arterial access in cardiac catheterization, the reported use of the ulnar artery remains low. However, in the patient population with heavy cardiovascular disease burden, it is not uncommon to have patients requiring either multiple catheterizations, future coronary bypass, or other additional procedures which may compromise arterial anatomy. Previously thought to require longer access time, several large meta analyses have shown comparable access time and failure rates to radial access. Case presentation: We present a case of a 51-year-old male who underwent successful transulnar access for cardiac catheterization in the post-bypass setting with limited arterial access points. Presenting with an eight-month history of angina and positive stress test, he was found to have multivessel disease on initial catheterization. He underwent four vessel bypass using LIMA, RIMA, left radial artery, and left great saphenous vein. On post-op day two, he went into cardiac arrest requiring CPR and multiple vasopressors. He was subsequently placed on venoarterial ECMO with arterial access at his right femoral artery after failed access on his left femoral artery. With a new drop in ejection fraction, he returned to the lab for right and left catheterization. With recent failed L femoral access, ongoing use of R femoral artery for ECMO, harvest of L radial for bypass, and a failed Allen’s test on his R radial, the decision was made to use the R ulnar artery. Arterial access was successful, and PCI was performed on a severely stenotic lesion of the distal RCA. Ejection fraction returned to 55-60%, and he was weaned off ECMO. Discussion: This case demonstrates opportunity for transulnar catheterization and reviews literature demonstrating comparable outcomes to radial access.

Total wrist access for angiography and interventions: Procedural success and access site crossover in a high volume transradial center.

Abstract Objective To assess the crossover rate from primarily chosen transradial access (TRA) in a high volume transradial center. Methods All consecutive 30,848 patients, that underwent diagnostic angiography and/or intervention in the period from 2010 until 2015 were examined. Preprocedural radial artery angiography was performed in all patients since 2011. Clinical and procedure characteristics, reason for crossover and its direction were analyzed. Primary end-point of the study was the occurrence of TRA failure and need to crossover to another approach to finish the procedure. Results Procedural success of primarily chosen TRA was 94% (n = 28,988). Crossover to other access sites was 6% (n = 1860). Most common reason for crossover was inability to puncture the right radial artery in 4,1%, presence of radial artery anomalies (0,3%), high grade spasm (0,1%), or radial artery occlusion (1,2%). Crossover direction was primarily through the ipsilateral transulnar access (TUA) 3,8%, left radial access (LRA) 1,5% and in only 0,6% (n = 189) of patients to transfemoral access (TFA). Access site bleeding complications were present in 5,1% (n 1579). Conclusion Total wrist access is feasible and safe with low rate of access site complications and crossovers, especially when performed in experienced high volume transradial center.

Trans-ulnar catheterization and coronary interventions: From technique to outcomes.

The ulnar artery is similar in size to the radial artery, however it is more difficult to palpate and access. For those physicians who mastered trans-ulnar access (TUA) this access site serves as an alternative to trans radial access (TRA) when the radial artery access is rendered suboptimal (by palpation, ultrasound examination or previous procedural records) or when encountering TRA difficulties or failure. The manuscript describes the anatomy, suggested technique, procedural success and complications associated with TUA. Data from single center registries and randomized studies show that TUA has a lower and more variable success rate than TRA, however these 2 approaches carry similar safety profile and complications rates. The authors suggest that interventionalists should consider, learn and master TUA to maintain higher success rate of wrist based interventions while avoiding the potential complications, discomfort and costs of trans-femoral approach.

Primary Percutaneous Coronary Intervention through Right Trans-Ulnar Access in a Case of Arteria Lusoria: Feasibility Stamped

We report a case of primary coronary angioplasty of left coronary artery through right upper ulnar access with acute lusoria angle due to aberrant right subclavian artery. Although it is very tedious and challenging job to deploy stent in left coronary artery by upper arm access in Arteria lusoria. Hence we propose that PCI is feasible in a case of arteria lusoria by upper right arm access if done with great experience and skill.

Transradial and transulnar access for iliac artery interventions using sheathless guiding systems: A feasibility study.

PurposeOur aim was to evaluate the acute success and complication rates of the transradial and transulnar access for iliac artery stenting using sheathless guiding systems.MethodsClinical and angiographic data from 156 consecutive patients with symptomatic iliac artery stenosis who were treated with transradial or transulnar access were evaluated. All patients underwent Duplex ultrasound before and after the intervention. The primary endpoints were the procedural success rate, major adverse events, and access site complication rates. The secondary endpoints were the angiographic result of the iliac artery intervention, fluoroscopy time, X‐ray dose, procedure length, crossover rate to another puncture site and hospitalization duration. The impact of the learning curve was also investigated, along with right or left radial access.ResultsThe indication for the intervention was intermittent claudication in 109 patients (69.9%), critical limb ischemia in 44 (28.2%) subjects and acute limb ischemia in three individuals (1.9%). Technical success was achieved in 155 patients (99.4%), with a crossover rate of 3.8%. Radial and ulnar artery access was used in 151 (96.8%) and 7 (4.5%) patients, respectively. The Ankle‐brachial index increased from 0.69 [0.65–0.72] to 0.91 [0.88–0.95] as a result of the procedures (P < 0.001). The cumulative incidence of major adverse events was 3.8% at the 2‐month follow‐up (0% in patients with intermittent claudication and 13.8% in patients with critical limb ischemia). Radial artery access site complications were encountered in eight patients (5.1%). We documented decreased X‐ray doses (1742.0 [783.9–2701] vs. 1435 [991.1–1879] vs. 692.8 [275.3–1110] Gy cm−2 P < 0.05) over time; however, the fluoroscopy time, procedure time, and contrast consumption were not significantly different. Left hand access was not associated with significantly better results than right radial artery access.ConclusionsIliac artery stenting can be safely and effectively performed using radial or ulnar artery access and sheathless guiding catheters, with acceptable complication rates and high levels of technical success. The physician learning curve plays an important role in decreasing the X‐ray dose. © 2016 The Authors. Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.

Transulnar versus transradial access as a default strategy for percutaneous coronary intervention: AJULAR cohort

Transulnar versus transradial access as a default strategy for percutaneous coronary intervention: AJULAR cohort

Transulnar versus transradial access for coronary angiography or percutaneous coronary intervention: A meta-analysis of randomized controlled trials.

Although transfemoral access (TFA) remains the standard of care for patients undergoing coronary angiography (CA) or percutaneous coronary intervention (PCI) in the USA, TRA is being increasingly used over TFA due to lower bleeding and mortality rates on the basis of meta-analyses and recently published MATRIX trial. In patients with unsuccessful ipsilateral radial access, TUA has been used as an alternative approach. The randomized controlled trials (RCTs) comparing TUA and TRA have reached mixed conclusions regarding the use of transulnar approach for coronary procedures. To systematically review and perform a meta-analysis of published RCTs comparing the safety and efficacy of transulnar access (TUA) vs. transradial access (TRA) in patients undergoing CA or PCI. PubMed, EMBASE, and CENTRAL databases were searched for RCTs since inception through December, 2014. Meta-analysis was performed using random-effects model. Five RCTs involving 2,744 total patients were included in the meta-analysis. TUA compared with TRA had similar risks of MACE [risk ratio (RR): 0.87; 95% confidence interval (CI): 0.56-1.36; P = 0.54] and access-related complications [RR: 0.92 (0.67-1.27); P = 0.62]. Higher rates of access cross-over [RR: 2.31 (1.07-4.98); P = 0.003] and number of punctures [1.57 vs. 1.4; mean difference (MD): 0.17; 95% CI: 0.08-0.26; P = 0.0002] were noted with TUA. There was no difference in arterial access time [12.8 vs. 10.9 min; MD: 1.86 (-1.35-5.7); P = 0.26], fluoroscopy time [7.6 vs. 7.2 min; MD: 0.37 (-0.39 - 1.13); P = 0.34] and contrast volume [151 vs. 153.7 ml; MD: -2.74 (-17.21 - 11.73); P = 0.71]. For patients requiring CA or PCI, TUA compared with TRA has similar efficacy and safety except for higher puncture rates and access cross-over.

A Technical Guide Describing the Use of Transradial Access Technique for Endovascular Interventions

Transradial arterial access (TRA) has been employed for transcatheter coronary procedures for more than 25 years, with numerous studies demonstrating improved patient safety as compared with transfemoral arterial access. However, TRA remains underused by the interventional radiology and vascular surgery communities. Advantages of TRA over transfemoral arterial access include easier accomplishment of postprocedure hemostasis, decreased risk of hemorrhagic complications, shorter patient recovery leading to immediate ambulation and decreased procedure-related costs, and increased patient satisfaction. In particular, TRA may be advantageous in the population of patients with obesity. The primary patient selection factor to consider before attempting TRA is whether the patient has adequate collateral perfusion to the hand; this is assessed using the Barbeau test. Limitations of TRA may include operator unfamiliarity or learning curve and unavailability of adequate length catheters. The most common complication, although still rare, is localized access site hematoma, which is often asymptomatic. Radial artery occlusion is rare and rarely symptomatic owing to collateral perfusion to the hand. Theoretical increased risk of cerebral embolism during TRA may be minimized by preferentially accessing the left wrist during below-diaphragm procedures, which limits transcatheter manipulation of the aortic arch. Transulnar artery access is under investigation for use in patients who cannot undergo TRA. Providing patients the option of TRA can lead to improved outcomes, potentially increasing safety and patient satisfaction while decreasing procedure costs.

FEASIBILITY OF ULNAR ARTERY INTERVENTION (AJMER ULNAR ARTERY INTERVENTION GROUP STUDY: AJULAR): EARLY

Although diagnostic catheterization and percutaneous coronary intervention via transulnar access (TUA) is a safe alternative to transradial access (TRA), ulnar artery is rarely utilized for this purpose. The present study attempted to assess the feasibility and safety of TUA. In a high volume

Feasibility of ulnar artery for cardiac catheterization: AJmer ULnar ARtery (AJULAR) catheterization study.

The ulnar artery is rarely selected for cardiac catheterization despite the expanding use of the transradial access (TRA). We tried to compare default transulnar access (TUA) with TRA in terms of feasibility and safety. This was a prospective, open label, single center, observational study. We analyzed a total of 410 patients with normal Allen's test, who were then scheduled for coronary angiography through TUA with ad hoc PCI if necessary. Procedures were performed by a single operator who had an adequate transradial experience (≥150 transradial coronary procedures per year) but not trained in transulnar procedures. We analyzed observed findings with a retrospective cohort of patients undergoing TRA angiography under a previous study done at our center. We also performed selective ulnar arteriography of 200 patients, through radial route, to predict the bottlenecks of TUA. There is no statistically significant difference among the number of attempts made till the successful puncture, the total procedure time and the total fluoroscopy time for either radial or ulnar access angiography by an experienced operator (P > 0.05). However, the time taken in arterial access is statistically significant in the initial learning curve for the same (P < 0.05). On the contrary, the arterial access time, the total procedure time, and the total fluoroscopy time, all are statistically significant for the inexperienced operator (P < 0.05). There is a negligible incidence of nonmaneuverable anatomic obstruction in the real-world scenario in TUA, and so fear of the same should not impede the use of this route. Vasospasm in the use of this route is also not different from the radial route, with the experience of the operator. For an experienced operator, TUA is a safe and also an effective alternative to TRA in terms of feasibility and safety.

A comparative study of transulnar and transradial artery access for percutaneous coronary intervention in patients with acute coronary syndrome.

Transradial access has become commonly used for elective evaluation of patients with coronary artery disease, but it has some disadvantages and has had limited use in the acute coronary syndrome (ACS). Because the diameter of the ulnar artery is usually larger than that of the radial artery, we hypothesized that the ulnar artery could be used as an access for percutaneous coronary intervention (PCI). The present study compares the feasibility, safety, and outcome of transulnar artery and transradial artery access for PCI in patients with ACS. We reviewed 636 patients who had PCI for ACS from May 2006 to May 2009. The patients were randomly assigned to transulnar intervention (TUI; 317) or transradial intervention (TRI; 319). Several outcomes were similar in the TUI and TRI groups: success rate of first puncture, duration of guiding catheter engagement, puncture-to-balloon inflation time, final thrombolysis in myocardial grade 3 flow, complications at the vascular access site, and postprocedure complications. The incidence of severe arterial spasm and forearm hematoma in the TUI groups was significantly less than that in the TRI group. At 1-year follow-up, the level of blood oxygen saturation at the middle finger and Doppler ultrasonographic characteristics of the ulnar artery did not significantly change from pre-PCI values for these criteria in either group. The TUI approach has results and access complications similar to the TRI approach and is a safe and feasible alternative for ACS patients.

Bilateral Trans-radial/ulnar Access for Percutaneous Recanalization of a Chronic Total Coronary Artery Occlusion using Antegrade Dissection and Re-entry

Percutaneous Coronary Intervention (PCI) for Chronic Total Occlusions (CTOs) necessitates dual arterial access to allow visualisation of the vessel both proximal and distal to the occlusion as well as the course of interventional collaterals. Potential access sites include bilateral femoral, combination of femoral and radial and bilateral radial arteries. Trans-ulnar access has been shown to be safe and feasible in patients with weak radial pulses and this is a further option. The advantages of radial/ulnar access relate to reduction in access site bleeding complications, which is particularly pertinent in CTO PCI where 7-8Fr guiding catheters are usually required. We describe a case of a patient undergoing repeat attempt at PCI of a Right Coronary Artery (RCA) CTO, the first attempt having been complicated by a life threatening retroperitoneal haemorrhage secondary to 8Fr femoral arterial access. Access was gained via the right ulnar artery and the left radial artery, a 7Fr JR4 guide catheter was used to intubate the RCA with a 5Fr EBU3.5 catheter in the left coronary artery providing contrast visualisation of the distal RCA. The CTO was successfully recanalized using antegrade dissection and re-entry technique with the Stingray™ catheter system without any access site complications. This case highlights the safety and feasibility of CTO PCI via bilateral trans-radial/ulnar access and this maybe the combination of choice in patients at high risk of access site bleeding.

Efficacy and safety of transulnar coronary angiography and interventions—A single center experience

To evaluate the efficacy and long-term safety of transulnar approach in complex coronary interventions. The success rate of transulnar approach in complex coronary interventions and its long-term safety remains to be proven. We conducted a retrospective chart review of patients undergoing transulnar coronary angiography and interventions at our institution from January 2004 through July 2009. Primary endpoint of the study was the success rate of the procedure. Secondary endpoints were major bleeding, local vascular and neurological complications, cerebrovascular accident (CVA)/transient ischemic attack (TIA), myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE) rate that was a composite of MI, CVA/TIA, and all-cause mortality. Of 81 patients undergoing transulnar approach, 41 (50.6%) patients underwent intervention on 65 lesions. Twelve percent of the interventions were performed on coronary bypass grafts and 9.2% on the left main coronary artery. Success rates for transulnar access, coronary angiography, and coronary/bypass graft interventions were 93.8%, 100%, and 92.6%, respectively. Follow-up data was available on 71 patients at short term (30 days) and 58 patients at long term (1 year). At 30-day follow-up, vascular complication rate was 2.8 %. At 1-year follow-up, there were no residual deficits from vascular or neurological complications associated with the index procedure and the overall MACE rate was 3.4%. In this first study evaluating long-term safety and feasibility of transulnar coronary angiography and complex coronary interventions, we conclude that transulnar approach appears to be safe and effective.

Transulnar carotid artery stent placement

Carotid artery stenting (CAS) has increased in popularity as an alternative to carotid artery endarterectomy for the treatment of significant carotid artery stenosis. The access site is predominantly the femoral artery, with radial or brachial access used less often. Here, we describe a case of CAS after failure of brachial access. Transulnar CAS was performed successfully without complications. Transulnar access represents an additional option in a patient undergoing CAS when conventional femoral, brachial, and radial arteries are not applicable.

Transulnar approach as an alternative access site for coronary invasive procedures after transradial approach failure

Unsuccessful radial artery puncture, inability to advance the guide catheter to the ascending aorta, and inadequate guide catheter support represent mechanisms of transradial approach failure. With the rationale of sharing the same efficacy and safety promoted by radial access, the transulnar approach represents an alternative access site for percutaneous coronary procedures. Between May 2007 and May 2012, 11,059 coronary invasive procedures were performed in a single institution: 10,108 by transradial approach (91.4%), 541 by transfemoral approach (4.9%), and 410 by transulnar approach (3.7%). Patients who underwent coronary procedures through transulnar access were included in a prospective registry of effectiveness and safety. Diagnostic procedures accounted for 71.8% of cases, and the right ulnar access was the most common route (88.9%). Procedure success was high (98.5%), with a crossover rate of 1.5% (6 cases), of which 5 were achieved through the contralateral radial access and 1 through femoral approach. Complications related to access site were low (3.9%), consisting mostly of minor bleeding due to subcutaneous hematomas. There were no cases of major bleeding, nerve injury, pseudoaneurysm, arteriovenous fistula, or necessity of vascular surgical repair. The transulnar approach represents an alternative to the transradial approach in selected cases when performed by radial-trained operators, sharing a high success rate and extremely low incidence of access-site complications.

First Case of Transulnar Approach for Angiogram (Coronary and Peripheral) in BSMMU

Transfemoral approach is mostly used for coronary and peripheral angiography and intervention. Transradial coronary angiography and intervention has become a popular technique due to reduced local and bleeding complications, easier post-procedural care and patient preference. In certain patients, transradial access may not be possible due to various anatomical reasons and usually, the transfemoral route is used for these patients. In a minority of patients, such as those with significant peripheral arterial disease or obesity, the transfemoral approach is challenging and is associated with an increased risk of local complications or bleeding. Transulnar arterial access, however, has recently been shown to be feasible and safe for both coronary angiography and intervention. The procedural success, advantages and complication rates for this procedure appear similar to those for the transradial approach. This is a case of transulnar artery percutaneous coronary and peripheral intervention in a patient of chronic stable angina and peripheral vascular disease. DOI: http://dx.doi.org/10.3329/uhj.v8i1.11672 University Heart Journal Vol. 8, No. 1, January 2012

Transradial and transulnar access for percutaneous coronary interventions

Periprocedural bleeding and vascular complications after percutaneous coronary intervention (PCI) are associated with worse clinical outcomes and increased short- and long-term mortality. Vascular access-related bleeding accounts for more than 80% of all major bleeding events in PCI performed by the transfemoral approach. Transradial approach (TRA), on the other hand, virtually eliminates access site bleeding and vascular complications. Although clinical trials have mostly evaluated different pharmacological strategies for reducing bleeding risk, adoption of a radial rather than a femoral access may allow greater reductions in bleeding complications than pharmacological strategies alone. High-risk patients such as those with acute coronary syndrome and ST-segment elevation myocardial infarction, women, obese patients, and elderly subjects who are at increased risk for vascular complications and bleeding might particularly benefit from the radial approach. Besides increased patient safety, the TRA is associated with improved patient satisfaction, reduced cost, and length of hospital stay, thus allowing outpatient performance of uncomplicated PCI.

Intra-arterial lidocaine versus saline to reduce peri-procedural discomfort in patients undergoing percutaneous trans-radial or trans-ulnar coronary procedures

Objective Trans-radial and trans-ulnar access is increasingly used for percutaneous coronary procedures, but spasm or pain may limit comfort and compliance. Intra-arterial lidocaine administration could provide a local anaesthetic eff ect, but its risk-benefi t ratio is unclear. We aimed to compare intraarterial lidocaine versus saline to reduce peri-procedural discomfort during percutaneous trans-radial or trans-ulnar procedures.Methods and results Patients undergoing percutaneous trans-radial or trans-ulnar coronary procedures were single-blinded randomly assigned to intra-arterial treatment with 20 mg lidocaine or saline. The primary end-point of the study was local pain, measured on a 10-point scale.A total of 101 patients were enrolled (50 allocated to lidocaine and 51 to saline). Trans-radial access was employed in 48 (96%) and 47 (92%), respectively, trans-ulnar access in 2 (4%) and 4 (8%), and coronary intervention was performed in 18 (36%) and 11 (22%). Severity of local pain was equivalent in both groups (2.3 ± 2.3 vs. 3.0 ± 2.5, P = 0.167). Similar results for both groups were found also for local spasm, local access success, procedural success, and net clinical adverse events (all P > 0.05). No sustained cardiac arrhythmia or neurologic symptom developed in any patient.Conclusions Current approaches and techniques for percutaneous trans-radial or trans-ulnar coronary procedures are associated with few local or systemic complications. Local forearm/wrist pain is relatively frequent in this setting, and is not signifi cantly prevented by intra-arterial lidocaine.