The Transulnar Approach for Coronary Intervention: A Safe Alternative to Transradial Approach in Selected Patients

The transradial artery approach (TRA) for coronary interventions is now well accepted as a safe and cost-effective alternative to the traditional transfemoral approach (TFA).^1,2 In our center, more than 90% of coronary interventions are performed today by TRA. However, in some cases, this approach cannot be used. As an alternative to TRA, we have evaluated the transulnar artery approach (TUA) in 122 consecutive cases. Methods From June 2001 to April 2003, 117 patients underwent 122 TUA coronary diagnostic or interventional catheterizations, representing 1.31% of the total number of procedures. Patients referred for catheterization were selected for possible TUA at the discretion of the interventional cardiologist. Reasons for possible TUA were due either to homolateral radial artery approach failure in a previous procedure (group 1), or the operator’s preference when clinical examination demonstrated a larger ulnar artery pulse than radial artery pulse (group 2). Palmar arch patency was assessed by oxymetry-plethysmography as previously described.3 Briefly, radial and ulnar arteries were successively compressed and oxymetry curves were observed with the detector placed over the thumb. Curves A (no dampening), B (dampening), and C (curve loss with recovery within 2 minutes) indicated that the palmar arch was permeable, whereas curve D (loss of pulse tracing without recovery) indicated insufficient vascular collateralization, therefore prohibiting safe use. Patients were prepared in the same manner as for the TRA approach. The arm was abducted at 70° with the wrist hyperextended over a gauze roll. The skin was infiltrated with 2% subcutaneous lidocaine in front of the ulnar artery pulse at 2 cm proximal to the pisiform bone. The ulnar artery was punctured with a 19 gauge open needle to obtain a pulsatile blood flow and the artery was cannulated with a 45 cm, 0.019 inch straight wire. A short (15 cm) 4 to 7 Fr sheath was then inserted. Our routine pharmacological cocktail involved verapamil 2.5 mg via the side-hole of the introducer and intravenous heparin 70 UI/Kg body weight. When angioplasty was performed, glycoprotein IIb/IIIa inhibitor use and heparin dosage was left to the operator’s discretion. At the completion of the procedure, the sheath was immediately withdrawn and pressure was applied over the puncture site with a gauze roll and tourniquet for approximately one hour. The puncture site was then checked every 15 minutes and the device was withdrawn after hemostasis was achieved. The patient was allowed to ambulate and to be discharged either the same day (after diagnostic angiography) or the following day (after angioplasty). The ulnar pulse and puncture site were controlled before discharge. An ultrasound exam was performed only when a complication was suspected. Results Between June 1, 2001 and April 30, 2003, we performed 122 coronary interventions by the TUA in 117 patients. There were 80 males (68%), aged 62 ± 13 years (mean ± SD). The patients’ height was 1.67 ± 0.9 meters, and weight was 79 ± 19 Kg. The TUA was selected either because of prior TRA failure (30 cases; 25%; group 1), or due to the operator’s preference (92 cases; 75 %; group 2). We performed 88 successful right punctures of the right ulnar artery and 17 of the left ulnar artery. Five patients underwent a second TUA during this period and all were successful. Overall, the success rate for the TUA was 85.2% (104/122 cases). The success rate was slightly lower following prior TRA failure (76.6% in group 1 versus 88% in group 2, p = 0.75 by Fisher’s exact test). The reasons for failure included puncture failure (9 patients), inability to insert the wire or spasm (8 patients), and suboptimal left main guiding catheter cannulation (1 patient). None of these patients experienced local complications, and all had successful procedures using an alternative route during the same procedure (two-thirds with the contralateral TRA and one-third with the TFA). Fifty-three procedures (51%) were diagnostic and 51 (49%) were therapeutic. Among the types of procedures performed were 5 brachytherapy for in-stent restenosis and 19 IVUS procedures. Small-sheath diameters were usually employed (Table 1). For coronary angiography, most catheters (40/53, 75%) were 5 Fr or smaller. In terms of angioplasty procedures, 39% were performed with 5 Fr catheters and 53% with 6 Fr catheters. The Judkins and Multipurpose catheters were more frequently used to perform coronary angiography. The right coronary artery (RCA) was preferentially cannulated by the Judkins Right and the Multipurpose catheters (63% and 25%, respectively), whereas the left coronary artery (LCA) was preferentially cannulated by the Judkins Left and the Multipurpose catheters (68% and 20%, respectively). Furthermore, both coronary arteries were able to be injected with the same catheter in 28% of the diagnostic procedures using the Multipurpose, Barbeau and Amplatz catheters. In terms of PCI, the catheter curves most frequently used were the Amplatz and the Barbeau for the RCA (37% for each), and the Extra Back Up or the Amplatz for the LCA (76% and 14%, respectively). Overall, 72.5% of the patients had 1 vessel treated, 21.5% had 2 vessels treatd, and 4% of the patients had 3 vessels treated. The left anterior descending artery was the target vessel in 35% of the patients, the circumflex artery in 23%, and the RCA in 33%. However, procedures were also performed on the left main stem (n = 2), vein graft (n = 2), and internal mammary arteries (n = 2). Stents were deployed in 41/51 (80%) of the patients (1.4 ± 1.1 stent per patient). A total of 59% of the treated patients received glycoprotein IIb/IIIa inhibitors. One TUA angioplasty failed due to a lack of back-up support of the guiding catheter in the left main stem; the procedure was then successfully performed by the TFA. Local complications were noted in 7 (5.7%) patients. Five patients developed local hematomas (4 were localized in the distal part of the forearm and one extended to the elbow), one patient developed a local hematoma associated with a false aneurysm, and one patient had an extended hematoma from the arm to the pectoral muscle (suggesting a wire-induced vascular injury). All 7 complications were controlled by prolonged compression, with no need for surgical repair or blood transfusion. No ulnar pulse loss was noted. One 87-year-old patient died of pneumopathy and acute renal failure 23 days after the angioplasty procedure. All other patients were asymptomatic at discharge. Discussion This study reports our preliminary experience with TUA coronary interventions. To date, it represents the largest cohort of patients reported. We show that this approach is feasible and is associated with a high success rate and a low rate of access site complications. Since 1994, after considering the advantages of the TRA over the TFA, our catheterization laboratory has progressively adopted the TRA as the preferred technique.^4–6 During the study period, 3,826 PCIs were performed, 85% of which used the TRA. With the use of oxymetry-plethysmography as a screening tool for a permeable palmar arch before catheterization, the number of inadequate palmar arch patencies appears very low.³ In a few cases, an alternative route to the TRA appears to be necessary (low radial pulse) or easier (ulnar pulse > radial pulse). The ulnar artery has been described as the larger terminal branch of the brachial artery.⁷ However, in a recent post-mortem study, the ulnar artery was found to be larger or equal to the radial artery in only 17% of right arms and 29% of left arms.⁸ Recently, small studies using the TUA approach have reported high success rates and no complications. Therashima et al reported 7/9 successful TUA approaches for coronary angiography, and Dashkoff et al had 5/5 successful TUA approaches, including two angioplasty cases.^7,9 In both series, no complications were observed. More recently, Talwar et al reported their experience with 30 consecutive cases.¹⁰ Access was obtained in 29/30 patients (97%). Potential cases were selected based on a positive reverse Allen’s test and an easily palpable ulnar artery. They noticed two transient spasms but no access site bleeding. In our preliminary series including the learning curve and less stringent inclusion criteria, we safely performed procedures with a high success rate (85.2%) and a low complication rate (5.7%), in spite of glycoprotein IIb/IIIa inhibitor use in 59% of the cases. Similar to our experience and that of others with regard to the TRA, the rate of local complications was very low.¹¹ We observed 1 pseudoaneurysm in a hypertensive patient who was kept on heparin after his diagnostic catheterization while waiting for coronary bypass surgery. Recent large series involving the TFA reported a significant rate of vascular complications (2.9–12.8%), including retroperitoneal bleeding (0.1–2.6%), need for transfusion (0.8–2.6%), and surgical repair (0.2–2.6%).12–16 Furthermore, the real benefits of closure devices after the TFA and glycoprotein IIb-IIIa use are still discussed.^12,15–17 In contrast, series comparing the TRA with the TFA using glycoprotein IIb/IIIa inhibitors showed only a few local complications following the TRA.^18–20 It was therefore our intent to find a safe alternative to the TRA without reverting to the TFA. Limitations. We did not use systematic Doppler control after ulnar catheterization, thus we cannot comment on the possible thrombosis rate. However, all patients who left the hospital had a palpable ulnar artery and in cases of clinical doubt, a Doppler examination was performed. Conclusion. As an alternative to the TRA, the TUA is an elegant technique for coronary catheterization in select cases, as it offers a high success rate and a low incidence of access site complications.

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