Procedural and clinical utility of transulnar approach for coronary procedures following failure of radial route: Single centre experience

Abstract

Objectives: To assess the feasibility and safety of transulnar approach whenever transradial access fails.

Background: Radial access for coronary procedures has gained sound recognition. However, the method is not always successful.

Methods: Between January 2010 and June 2013, diagnostic with or without percutaneous coronary intervention (PCI) was attempted in 2804 patients via the radial approach. Transradial approach was unsuccessful in 173 patients (6.2%) requiring crossover to either femoral (128 patients, 4.6%) or ulnar approach (45 patients, 1.6%). Patients who had undergone ulnar approach constituted our study population. Selective forearm angiography was performed after ulnar sheath placement. We documented procedural characteristics and major adverse cardio-cerebrovascular events.

Results: Radial artery spasm was the most common cause of crossover to the ulnar approach (64.4%) followed by failure to puncture the radial artery (33.4%). Out of 45 patients (82.2%), 37 underwent successful ulnar approach. The eight failed cases (17.8%) were mainly due to absent or weak ulnar pulse (75%). PCI was performed in 17 cases (37.8%), of which 8 patients underwent emergency interventions. Complications included transient numbness, non-significant hematoma, ulnar artery perforation, and minor stroke in 15.5%, 13.3%, 2.2% and 2.2%, respectively. No major cardiac-cerebrovascular events or hand ischemia were noted.

Conclusion: Ulnar approach for coronary diagnostic or intervention procedures is a feasible alternative whenever radial route fails. It circumvents crossover to the femoral approach. Our study confirms satisfactory success rate of ulnar access in the presence of adequate ulnar pulse intensity and within acceptable rates of complications.

Keywords: Alternative; Coronary procedures; Feasible; Femoral approach; MACCE; Radial; Ulnar.

Figure 1

Radial artery spasm. Intense focal (a) and diffuse (b) radial artery spasm at the puncture site (2 dashed arrows). Note that radial artery spasm persisted until we crossed over to the ulnar artery and forearm angiography was performed via the side port of the ulnar sheath (continuous arrow).

Figure 2

Rare anatomical variation of the radial artery. Unique anatomical variation of the radial artery trifurcating into three smaller branches a few centimeters proximal to the styloid process of the radius (dashed arrows) making access to the main radial artery via any of these branches extremely difficult. Ulnar artery sheath in place (continuous arrow).

Figure 3

Radial loop. Complete radial artery loop resulted in crossover to ulnar approach. Radial loop (dashed arrows), ulnar artery (continuous arrow) and brachial artery (curved arrow).

Figure 4

Ulnar artery spasm. Intense focal ulnar artery spasm few millimeters from its origin (continuous arrow) that was treated with an extra dose of the vasodilatory cocktail 100 mcg of glyceryl trinitrate and 2.5 mg of verapamil through the side arm of the ulnar sheath. Note that the radial artery (dashed arrow) is small in size, most likely due to diffuse spasm. Brachial artery (curved arrow) is normal.

Figure 5

Ulnar artery perforation and superficial hematoma. localized ulnar artery perforation (a) and consequent superficial hematoma (b). The perforation was managed conservatively and the superficial hematoma healed few weeks later.

Figure 6

Duplex scan after ulnar artery perforation: (a): Gray scale ultrasound image of right wrist demonstrating diffuse subcutaneous hypo echoic hemorrhage (white arrow). (b): Longitudinal color Doppler image of the right wrist demonstrating normal antegrade flow in ulnar artery with no stenosis or pseudoaneurysm.