Elsevier

American Heart Journal

Volume 164, Issue 4, October 2012, Pages 462-467
American Heart Journal

Transradial Angiography and intervention
Transulnar approach as an alternative access site for coronary invasive procedures after transradial approach failure

https://doi.org/10.1016/j.ahj.2012.08.001Get rights and content

Background

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.

Methods

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.

Results

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.

Conclusions

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.

Section snippets

Methods

Patients who underwent coronary procedures through transulnar access were included in a prospective registry of effectiveness and safety. The effectiveness of the technique was evaluated by procedure success rate, defined as completion of coronary angiography and left ventriculography with adequate coronary opacification, and percutaneous coronary intervention obtaining residual lesion less than 20%, with no need of crossover. The procedure and fluoroscopy times were obtained starting from the

Results

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%), the last representing the analyzed sample. 387 patients were included, of whom 210 (54.3%) were women, the mean age was 61.2 ± 11.4 years, and 139 (35.9%) were diabetic. The baseline clinical characteristics of patients are shown in Table I.

Stable angina or silent ischemia

Discussion

In the present registry, we report the results of 410 coronary procedures performed using the transulnar approach. During 5 years, 387 patients, representing approximately 4% of the cases, were selected for the transulnar approach, when the radial approach proved to be unavailable or prone to technical failure, especially for a small caliber or weak pulse on physical examination, justifying the high percentage of women in our sample. We achieved a high success rate of the technique in our

Conclusions

Our registry adds data to the available evidence regarding the feasibility, efficacy, and safety of the transulnar approach for invasive coronary procedures. Since bleeding complications are associated with increased morbidity and mortality, the transulnar approach represents an elegant 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.

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