Radial Access Failure: When Should We Go Ulnar?

We had an interesting patient present to us 6 months after stenting with chest pain who needed repeat angiography and probable percutaneous coronary intervention (PCI). He was interesting, because we knew he had radial artery access failure on his prior study. Do we go radial first again? Perhaps the better question that was highlighted by this patient is, when do we go ulnar?

Here’s the case:  

Earlier in the year for his first admission, a 69-year-old man with coronary artery disease risk factors had typical angina with anterior ischemia on his stress test. He was brought to the cath lab for routine coronary angiography and possible PCI. The right radial artery had a good pulse and the oximetric Barbeau test was type A. Radial artery access was performed without difficulty inserting a 6 French (F) sheath. Over an .035-inch floppy guidewire, a 5F Jacky catheter (Terumo) would not advance beyond the elbow.  Angiography showed the problem, which was a radial loop that emptied into a larger ulnar artery (Figure 1). The diminutive radial artery continued up the arm, but was too small to permit catheter passage.  

What should be the operator’s next best access? Dr. Seto hypothesized that a small, tortuous radial artery might be associated with a larger ulnar artery, providing a straighter and more negotiable course for catheter passage. Ultrasound imaging of both radial and ulnar arteries showed the larger ulnar artery was suitable for cannulation, which was then performed successfully with ultrasound guidance (Figures 2-3). The 5F Jacky catheter was easily passed through the arm to the coronary arteries where the diagnostic angiography showed a focal left anterior descending coronary artery (LAD) 90% stenosis. Subsequent PCI with a 3.0 x 18 mm drug-eluting stent was successful. Hemostasis of the ulnar and radial artery puncture sites with two TR Bands (Terumo) was uncomplicated.  

Six months later, the patient returned with typical angina symptoms and electrocardiographic changes. Fortunately, the patient’s medical record reflected the use of the ulnar artery as his best access.  Knowing the problem of failed radial access on the prior procedure, we performed ultrasound-guided ulnar access again (Figure 4) without difficulty and treated the LAD restenosis with optical coherence tomography (OCT)-guided balloon expansion of the prior stent.

When Should We Go Ulnar?

This case is a good example for a discussion of when to use same-side ulnar access as opposed to femoral or contralateral radial/ulnar access.¹ Let’s start with what we know about ulnar access. From a number of studies comparing radial and ulnar access^1-3, we can say that 1) transulnar access is a reasonable alternative to transradial access; 2) transulnar procedural safety is as good as transradial procedures, but may be more difficult to successfully perform; and finally, 3) assessment of the ulnar artery by ultrasound will ensure adequate size (and improve safety).

Although radial access is successful in >90% of cases, some patients will have a small, collapsible, calcified, or mobile radial artery, or an anatomy associated with anomalies such as a radial loop, as in our patient. Transradial access has an access site crossover risk of 4-10%, especially in women with smaller arteries. Radial artery access failure typically then employs a crossover to a transfemoral or contralateral radial approach. The ulnar artery is rarely considered. The ulnar artery could be used as an access alternative after addressing a few caveats. The first consideration is the size of the ulnar artery. On average, the radial and ulnar arteries are about 2.5 mm in diameter. Secondly, the use of the ulnar artery is predicated on not being saved for a bypass graft or dialysis fistula. Lastly, the use of the ulnar artery should not compromise flow to the hand via the palmar arch in the setting of prior injury or occlusion of the radial artery. Be sure to consider the right size sheath for the vessel (Figure 5).

Given the low rates of forearm artery occlusion with patent hemostasis techniques, ipsilateral ulnar access after failed radial access appears to be safe. Dahal and colleagues⁴ compared outcomes of radial vs ulnar artery access with a meta-analysis of the five randomized, controlled trials. Among the 2744 patients (29% female), there was no difference in major adverse cardiac events (3.1% vs 3.5%, P=NS) or access-related complications (14.9% vs 15.4%, P=NS) including the individual events of arterial spasm, stenosis, occlusion, or bleeding. Only one case of nerve injury was noted in the ulnar artery arm, which resolved with conservative therapy. There was no difference in fluoroscopy parameters, time to access, or contrast volume, but the ulnar artery was consistently more difficult to access, with a larger number of punctures required and higher rate of access site crossover (14% vs 3.8%, P=0.003). These studies suggest that use of the ulnar artery is as safe as radial (given the cautionary notes). However, given a slight increase in difficulty, there is little reason to start with an ulnar approach for the typical patient, but ulnar catheterization is an excellent alternative for the difficult radial access, and almost certainly superior to femoral access.

Advances in our understanding of arm access technique come mainly from bedside ultrasound guidance studies.^5,6 With ultrasound imaging at the beginning of the procedure, the operator can see whether the radial artery: a) is small (i.e., <2.0 mm or smaller than the ulnar artery); b) has a high bifurcation or dual radial system; c) has a radial loop; d) is occluded or stenosed, situations which may occur in about 11% of cases.⁵ In such cases, we should consider going to an alternative access, like contralateral radial or ulnar. While not yet part of routine practice, an ultrasound forearm examination before attempts at radial puncture can minimize the risk of hand ischemia, particularly when the radial artery pulse is weak. One report notes a low 0.3% access site crossover rate in 1000 attempted forearm artery procedures with an ultrasound approach5, compared with typical crossover rates of 4-10%.   

The Bottom Line

While it has been said that “All [arterial] roads lead to Rome”, having more than one access route from the arm will likely improve our outcomes. Keep the ulnar artery in mind when the radial artery is too small, too tortuous, or too stubborn (spastic) to take the road more traveled.

References

1. Seto AH, Kern MJ. Transulnar catheterization: The road less traveled. Catheter Cardiovasc Interv. 2016 Apr; 87(5): 866-867.
2. Gokhroo R, Bisht D, Padmanabhan D, Gupta S, Kishor K, Ranwa B. Feasibility of ulnar artery intervention (Ajmer ulnar artery intervention group study: AJULAR). Presented at American College of Cardiology Annual Session 2015. Available at https://www.acc.org/education-and-meetings/image-and-slide-gallery/media-detail?id=108C7D837E47423685061D41FB7C5B80. Accessed October 19, 2016.
3. Baumann F, Roberts JS. Real time intraprocedural ultrasound measurements of the radial and ulnar arteries in 565 consecutive patients undergoing cardiac catheterization and/or percutaneous coronary intervention via the wrist: understanding anatomy and anomalies may improve access success. J Interv Cardiol. 2015 Dec; 28(6): 574-582.
4. Dahal K, Rijal J, Lee J, Korr KS, Azrin M. Transulnar versus transradial access for coronary angiography or percutaneous coronary intervention: a meta-analysis of randomized controlled trials. Catheter Cardiovasc Interv. 2016; In press.
5. Baumann F, Roberts JS. Evolving techniques to improve radial/ulnar artery access: crossover rate of 0.3% in 1,000 consecutive patients undergoing cardiac catheterization and/or percutaneous coronary intervention via the wrist. J Interv Cardiol. 2015 Aug; 28(4): 396-404.
6. Seto AH, Roberts JS, Abu-Fadel MS, et al. Real-time ultrasound guidance facilitates transradial access: RAUST (Radial Artery access with Ultrasound Trial). JACC Cardiovasc Interv. 2015 Feb; 8(2): 283-291.

Disclosure: Dr. Kern reports he is a consultant and speaker for St. Jude Medical and Philips Volcano, and a consultant for Opsens, ACIST Medical, Heartflow, and Merit Medical.  Dr. Arnold Seto reports no conflicts of interest regarding the content herein.

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