Transulnar access
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This document discusses transulnar access (TUA) as an alternative vascular access approach for coronary procedures when transradial access fails or is not feasible. It provides information on the anatomy of the ulnar artery, techniques for TUA, studies comparing its safety and efficacy to transradial access, and potential complications. The largest studies found TUA to have similar success and adverse event rates as transradial access when performed by experienced operators, though transradial remains preferred due to the more superficial radial artery being easier to access. Real-time ultrasound guidance may improve outcomes for TUA.
Transulnar access
- 1. Transulnar Access Seek the help of immediate neighbour
- 2. Photo
- 3. Anatomy The ulnar artery arises from the brachial artery and terminates in the superficial palmar arch. The ulnar artery is the larger of the two terminal branches of the brachial artery, typically originates distal to the bend of the elbow in the cubital fossa and courses obliquely and distally and reaches the medial (ulnar) aspect of the forearm (midway between the elbow and the wrist) and subsequently courses along the ulnar nerve toward the medial aspect of the forearm and crosses the transverse carpal ligament on the radial side of the pisiform bone, and immediately beyond this bone divides into two branches, which enter into the formation of the superficial and deep volar arches……..
- 4. Anatomy • It is best palpable on the anterior and medial aspect of the proximal wrist crease. The ulnar nerve runs medial and parallel to the ulnar artery in the distal forearm and both are encased by the restrictive Guyton’s canal in the wrist. The ulnar artery varies in its origin and course in a significant proportion of cases. Typically, it branches from the brachial artery about 5 to 7 cm distal to the elbow or medial epicondyle. Occasionally, it may emerge directly from the axillary artery proximal to the elbow. Most anatomy reports suggest that the ulnar artery is usually larger in size than the radial artery…….
- 5. Anatomy Ultrasound-based studies observed no significant differences between the diameter of the two arteries: the radial artery was slightly larger than the ulnar artery in the PCVI-CUBA study (2.87 ± 0.6 mm vs 2.83 ± 0.9 mm, respectively; P=NS). Chugh et alreported considerably smaller diameters for both vessels (right ulnar artery size of 1.8 ± 0.3 mm and right radial artery size of 1.9 ± 1.1 mm; P=NS). Ulnar artery anatomical variations are rare, but can occur and are similar to those seen with the radial artery. Ulnar artery loop and high take-off of the ulnar artery have been described.
- 6. Pre test • A modified Allen’s test using pulse oximetry should be performed to confirm dual arterial flow in the hand
- 7. Access • The puncture is performed proximally to the pisiform bone, in the proximal wrists crease • 22-gauge needle • Modified Seldinger’s technique to avoid injury to the closely located ulnar nerve • 0.018˝, soft-tip Guidewire • A 4 or 5 Fr sheath • 5 or 6 Fr sheath is preferred for PCI • Larger sheaths can also be used • Cocktail to prevent spasm and thrombosis • Nitroglycerin (200-600 µg) +verapamil (2.5-5 mg) +40-70 U/kg UFH • Right TUA is preferred over left TUA •
- 8. Coronary angiography • Similar TRA • Watch guide wire tip • Feel the resistance • Listen to the patient
- 9. Post procedure • Immediate sheath removal • Graded compression with light pressure for short time • Commercial haemostatic devices used for TRA • Patency of the ulnar artery • Physical examination • Pulse oximetry • Doppler ultrasound
- 10. Efficacy and Safety of Transulnar Approach • Limited studies-21 studies till now • The reported procedural success ranges from 67%-98% in studies that included >100 patients. The sheath sizes used ranged from 4- 8 Fr. • So add to your experience
- 11. Kedev S, Zafirovska B, Dharma S, Petkoska D. Safety and feasibility of transulnar catheterization when ipsilateral radial access is not available. Catheter Cardiovasc Interv. 2014; 83: E51-E60. 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.
- 12. 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. 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.
- 13. 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. 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. 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.
- 14. Evidences 1. De Andrade PB, Tebet MA, Nogueira EF et al. Transulnar approach as an alternative access site for coronary invasive procedures after transradial approach failure. Am Heart J. 2012; 164: 462-467. 2. Aptecar E, Pernes JM, Chabane-Chaouch M et al. Transulnar versus transradial artery approach for coronary angioplasty: the PCVI- CUBA study. Catheter Cardiovasc Interv. 2006; 67: 711-720. 3. Hahalis G, Tsigkas G, Xanthopoulou I et al. Transulnar compared with transradial artery approach as a default strategy for coronary procedures: a randomized trial. The Transulnar or Transradial Instead of Coronary Transfemoral Angiographies Study (the AURA of ARTEMIS Study). Circ Cardiovasc Interv. 2013; 6: 252-261. 4. Gokhroo R, Kishor K, Ranwa B, Bisht D, Gupta Sj, Anantharaj A, Priti K. Feasibility of Ulnar Artery Intervention (AJmer ULnar AR tery Intervention Group Study: AJULAR): early results. J Am Coll Cardiol. 2015; 65(10_S):. doi:10.1016/S0735-1097(15)61684-9 5. 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; 8: 283-291. 6. Sattur S, Singh M, Kaluski E. Transulnar access for coronary angiography and percutaneous coronary intervention. J Invasive Cardiol. 2014; 26: 404-408.
- 15. Complications of TUA • Hematoma • Occlusion • Spasm • Rx with 2.5mg of verapamil or 200microgram of NTG
- 16. Innovation (1) Ultrasound or other non-invasive tools the preferred arterial wrist access based on diameter, flow, and tortuosity (2) The puncture of the deeper ulnar artery without injury to the ulnar nerve and adjacent structures (3) Specific devices for optimal hemostasis (4) Oversized ulnar sheath within the restrictive Guyton’s canal results in compression of the ulnar nerve
- 17. Thesis topic • Hypothesis • TUA is comparable to TRA for the purpose for diagnostic and intervention procedures in cardiology
- 18. After leaving THI, Dr. Norman stated in a letter to his former co-workers, “I do not believe everyone realized my true feelings towards the lab and the wonderful people there . . . they came to constitute my little world on which I became so dependent. My heart will always be in Houston. Think of me kindly, as I do of you.”