Crossover from Radial to Ipsilateral Ulnar Access: An Additional Strategy in the Armamentarium of the “Radialist”

The following case is part of a series of transradial-focused reports directed by section editor Dr. Samir Pancholy. This case series is supported by an educational grant from Medtronic.

The authors can be contacted via Dr. Mauricio Cohen at mgcohen@med.miami.edu.

Disclosures: Vikas Singh, MD, reports no conflicts of interest regarding the content herein. Mauricio G. Cohen, MD, reports he is a consultant for Terumo Medical, Merit Medical, Accumed Radial Systems, and Medtronic.

Transradial (TR) access for percutaneous coronary procedures improves clinical outcomes compared to the transfemoral approach by reducing vascular and bleeding complications. Despite several advantages, radial access is underutilized in the clinical practice in many countries including the United States.¹ This is primarily due to technical complexities related to the smaller caliber of the radial artery and more difficult catheter manipulations due to anatomical variants of the upper arm arterial axis from the wrist to the aorta. The TR approach may not be feasible in up to 5% of the patients due to inability to puncture the radial artery, radial artery spasm or dissection, hypoplastic or small radial artery, or a non-negotiable radio-ulnar loop.² Even amongst dedicated radialists, the crossover rate to an alternative access can reach up to 2%.³ In such situations, the transulnar approach (TU) represents a viable option with a rationale of sharing a similar safety and efficacy compared with the TR approach, especially when performed by operators familiar with the radial technique.⁴ Vascular access crossover to the contralateral radial artery or the femoral artery is classically recommended after TR access failure. However, in selected cases, access crossover to the ipsilateral ulnar artery may be considered. The following case describes a successful ipsilateral bailout by using a TU approach after a failed TR approach and a novel method for hemostasis.

Case description

A 65-year-old man with symptomatic severe aortic stenosis was brought to the cardiac catheterization laboratory for right and left heart catheterization. Right radial arterial access was obtained using a double-wall through-and-through puncture technique using a Teflon microcatheter and a 6 French (Fr) Slender Glidesheath (Terumo) was inserted. An .035-inch small J-tip wire (Merit Medical) supported by a Tiger catheter (Terumo) could not be advanced due to the presence of a 360-degree radio-ulnar loop (Figure 1). Subsequent efforts to advance the catheter over a .014-inch Balance Middle Weight (BMW) wire (Abbott Vascular) and .035-inch stiff shaft angled hydrophilic-coated wire were also unsuccessful, causing significant discomfort to the patient. Angiography of the forearm and hand demonstrated a well-developed interosseous branch and integrity of the palmar arch. Because the ulnar pulse was not easily palpable, we decided to obtain ultrasound-guided access in the ipsilateral ulnar artery (Figure 2). The remaining procedure was completed with no further difficulty. The hand was carefully observed during the procedure by pulse oximetry, which demonstrated an oxygen saturation of 92-93% throughout the case. At the conclusion of the procedure, we realized that most commonly used devices for radial hemostasis would not be able to provide effective compression in the radial and ulnar sites simultaneously. The Pulsera hemostatic band (Accumed Radial Systems) is an FDA-listed compression device constituted of two retention bands hinged at one end that fits around the wrist. The two bands are connected together by the operator by a Velcro strap once the device is placed at the desired location. Attached to the anterior section of the band is a movable and detachable compression balloon that is inflated with air using a standard syringe (Figure 3). In order to achieve simultaneous hemostasis at both radial and ulnar access sites, we attached a second compression balloon to a Pulsera device (Figure 4). Immediately after sheath removal, the balloons were partially deflated until bleeding could be noticed and then reinflated with 1cc of air. A patent hemostasis protocol was followed in the holding area. The radial pulse was 2+ before discharge 3 hours after the procedure was concluded.

Discussion

The TU route has been shown to be similar to TR route in terms of major access site complications and large hematomas in several prospective studies.^4,5 A randomized clinical trial comparing TR versus TU accesses, the PCVI-CUBA study consisting of 431 patients, showed safety and efficacy of TU access by achieving similar success and freedom from major adverse cardiovascular event rates (93.1% and 97.8% for the ulnar group, and 95.5% and 95.8% for the radial group).⁶ In selected cases, the TU approach also has the potential to spare injury to the radial artery in anticipation of its use as a coronary bypass conduit. Despite similar outcomes, TR is the preferred approach over TU because of the more superficial course of the radial artery, which makes it readily palpable and compressible. In addition, a large multicenter randomized trial of 902 patients (the AURA of ARTEMIS study) showed that the cannulation of the ulnar artery is associated with longer procedural and fluoroscopy times, and with more attempts and contrast medium use in comparison with the TR approach.⁷ The crossover rate with TU access was also significantly higher compared to TR access. These factors must be considered if ulnar access is chosen after failure of a TR approach, as it may be cumbersome for the patient and for the non-radial/ulnar trained operator.⁷ In the largest randomized study (2,556 patients) comparing TR versus TU access, operator experience (50 TU procedures) was found to be a significant predictor of improved outcomes, and showed similar major vascular complications and puncture time in the two groups. The study showed non-inferiority of TU over TR access when performed by experienced operators.⁸ Ultrasound access appears to be a sensible option and may provide further safety for puncturing the ulnar artery, which is located at a deeper level and adjacent to the ulnar nerve. Real-time ultrasound for TR access has been shown to shorten access time, decrease crossover, and improve first-pass success rates.⁹

The most commonly recommended crossover options after TR procedural failure include contralateral TR or transfemoral access. However, when the mechanism of failure is the radial artery per se, ipsilateral TU access may be considered. In our case, a radio-ulnar loop prevented advancement of catheters. In this situation, the ulnar artery has a less tortuous course and can be used as a bail-out access route without having to drape the contralateral arm or the groin. A major hypothetical concern is hand ischemia, as the lumens of the two major arteries supplying the hand are obstructed by the sheaths during the procedure. In a study of 240 patients with radial artery occlusion undergoing ipsilateral TU catheterization procedures, there were no occurrences of hand ischemia, most likely due to the rapid recruitment of collateral flow from the interosseous artery.⁴

A final challenge in our case was achieving simultaneous hemostasis in the radial and ulnar arteries. Placing two overlapping balloon-based compression devices would have been cumbersome and probably ineffective. Manual compression is obviously a feasible and safe approach. In our case, we used the Pulsera hemostatic device, which is a practical and novel solution, because of its design incorporating a movable and detachable balloon. Using two balloons aligned with the radial and ulnar arteries attached to the same device allowed for simultaneous patent hemostasis in both vessels.

Our case suggests that crossover to ipsilateral TU access after TR failure strictly due to anomalies of the radial artery (hypoplasia, loops) is feasible and simultaneous hemostasis can be achieved with a novel approach. However, this strategy should be used cautiously after angiographic confirmation of the integrity of the palmar arch and the presence of a generously sized interosseous branch capable of supplying collateral flow in case of occlusion of the ulnar or radial arteries. An astute radial interventionalist needs to be familiar with the TU approach, as it appears to be reasonably safe and an effective alternative to the TR approach.¹⁰ 

References

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