Safety and feasibility of transulnar catheterization when ipsilateral radial access is not available

Kedev, Sashko; Zafirovska, Biljana; Dharma, Surya; Petkoska, Danica

doi:10.1002/ccd.25123

Cited by 80 publications

(54 citation statements)

References 21 publications

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“…Larger studies have further confirmed the safety and effectiveness of TUA as an alternative wrist approach to TRA for coronary interventions. 16,53 The procedural success, advantages and complication rates for transulnar interventions appear similar to those from the TRA. 15,53 Adding the ulnar artery access expertise could further reduce the crossover rate to TFA and lower the intrinsic risk of bleeding and vascular complications associated with the TFA.…”

Section: Ulnar Artery Accessmentioning

confidence: 75%

The Role of the Transradial Approach for Complex Coronary Interventions in Patients with Acute Coronary Syndrome

Kedev

2013

Interventional Cardiology Review

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An invasive strategy including percutaneous coronary intervention (PCI) improves clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and in high-risk patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). 1,2The femoral approach (TFA) is the preferred and most widely used percutaneous access site in most cardiac catheterisation laboratories worldwide. However, being a relatively deep and terminal vessel, the femoral artery may expose the patient to frequent bleeding and vascular complications, 3,4 especially in the setting of acute coronary syndrome (ACS) where potent antithrombotic drugs are frequently used. 5,6 Since its initial description as a safe and feasible access route for cardiac catheterisation, 7,8 the transradial access (TRA) has increasingly been used for PCI. The main advantage over the TFA is a reduced risk of access site bleeding and major vascular complications, particularly in the presence of multiple and more powerful antiplatelet and antithrombotic agents.9 This is mainly ascribed to the more favourable anatomy of the radial artery that runs superficially, separated from major neurovascular structures, thus allowing shorter times to haemostasis and ambulation as compared with the TFA. 10More recently, the radial approach has been shown to confer mortality benefits for STEMI patients and a reduction in mortality, myocardial infarction (MI) and stroke for patients undergoing the procedure at high-volume radial centres. 11-13Reported access failure for radial procedures in primary PCI (PPCI) is low with an access crossover rate between 3.8 % 14 and 9.6 % 13 with negligible time delay by expert operators. There are several reasons leading to failure -inability to cannulate, severe radial artery spasm (RAS) and anatomical variations. In some of these difficult transradial cases, ulnar artery cannulation has been proposed as a reasonable and useful alternative to the TRA if performed by an experienced radial operator, before crossover to the TFA. 15,16 Bleeding Complications in Acute Coronary SyndromePeri-PCI procedural bleeding complications have been consistently associated with worse outcomes and increased short-and longterm mortality. 6,17 Access site-related bleeding, accounting for as many as 30-50 % of all causes of bleeding in patients with ACS, has repeatedly been found to be the major contributor for bleeding events. 9,[18][19][20] Due to the firm link between bleeding, ischaemic events and mortality, more attention has recently been focused on bleeding avoidance strategies.21 Despite the development of new more potent, selective and safe antithrombotics, the use of TRA remains likely the best way to significantly influence access site-related bleeding risk. [22][23][24][25] Recently, the REgistro regionale AngiopLastiche dell'Emilia-Romagna (REAL) Registry of 11,068 STEMI patients undergoing PPCI, showed that TRA was associated with a decreased two-year mortality rate compared with the traditional TFA (8.8 versus 11.4 %, hazard ratio ...

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Section: Ulnar Artery Accessmentioning

confidence: 75%

The Role of the Transradial Approach for Complex Coronary Interventions in Patients with Acute Coronary Syndrome

Kedev

2013

Interventional Cardiology Review

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“…27,28 This concept is supported clearly by studies that show the safety of using the homolateral ulnar artery for access in patients with occluded or unavailable radial artery access. 29,30 Finally, no substantial numbers of isch emic complications were reported in our study or in other RCTs that evaluated transradial access. 2,12,31 Thus, although the practice of assessment of dual circulation is prevalent and rooted in the †Values of p were generated using a generalized estimating equation model for the randomization arm parameter (i.e., modified Allen test versus heart rate-monitoring application) with binomial distribution using a logit link where the outcome was a correct test result.…”

Section: Discussionmentioning

confidence: 58%

Photoplethysmography using a smartphone application for assessment of ulnar artery patency: a randomized clinical trial

Santo¹,

Harnett²,

Simard³

et al. 2018

CMAJ

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“…[3][4][5][6][7][8][9] In transulnar catheterization, investigators in a small single-center prospective study showed a low incidence of vascular sequelae, in which 2 patients (0.4%) had developed major forearm hematomas that resolved without clinical consequences. 10 In a large prospective study of more than 10,000 patients, the overall vascular sequela rate in transradial percutaneous coronary procedures was 0.5%, and there were 2 cases of compartment syndrome. 11 In a larger retrospective review 5 of more than 50,000 cases, the incidence of forearm compartment syndrome necessitating surgery was 0.004%: two patients with low body surface area and low creatinine clearance had received excess anticoagulation.…”

Section: Discussionmentioning

confidence: 99%

Compartment Syndrome of the Hand: A Rare Sequela of Transradial Cardiac Catheterization

Jue¹,

Karam²,

Mejía³

et al. 2017

Texas Heart Institute Journal

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T he transradial approach to percutaneous coronary intervention (PCI) has lower rates of bleeding and vascular sequelae than does the femoral approach. Compartment syndrome of the forearm is a rare vascular sequela associated with radial access. We describe an unusual case of compartment syndrome of the hand without involvement of the forearm. Case ReportIn September 2015, a 64-year-old, right-handed man with a medical history of hypertension and end-stage renal disease (on hemodialysis) presented for elective outpatient cardiac catheterization. He had a systolic blood pressure (BP) of 190 mmHg. The patient's body mass index was 17.6 kg/m 2 (weight, 52 kg; height, 1.7 m). He had fair cardiac functional capacity and normal left ventricular function (ejection fraction, 0.55) on echocardiography.The patient's preprocedural laboratory values included an international normalized ratio of 1.0, a prothrombin time of 10.9 s, a baseline hemoglobin level of 9.1 g/dL, and a platelet count of 202,000/µL. He was given 325 mg of aspirin on the morning of the procedure.We attained, on the second attempt, right radial artery access with use of the frontwall (bare-needle) technique, and we inserted a 5F hydrophilic sheath 10 cm in length. Intra-arterial verapamil (5 mg) and intravenous unfractionated heparin (UFH) (5,000 U) were given at this point. Diagnostic cardiac catheterization revealed a mild stenosis involving the distal left main coronary artery (LMCA). The first obtuse marginal branch of the left circumflex coronary artery was a moderate-caliber vessel with a 90% eccentric stenosis. The sheath was upsized to 6F, and a 6F extra-backup guiding catheter engaged the LMCA without incident. The patient was given an additional 7,000 U of UFH, which resulted in an activated clotting time of 413 s. We successfully performed PCI of the obtuse marginal branch, using 2 drug-eluting stents. There was a good angiographic result-Thrombolysis in Myocardial Infarction-3 flow and no evidence of dissection. After the procedure, we gave the patient a 600-mg loading dose of clopidogrel.Upon completion of the procedure, we removed the right radial arterial sheath and placed an air-filled, transradial vascular hemostasis band over the access site. A small hematoma was noted proximal to the wristband, so a second vascular band was placed over that area. Pre-and postprocedural Barbeau tests with use of combined plethysmography and pulse oximetry recordings revealed normal findings consistent with patent radial and ulnar arteries. The patient was admitted to the inpatient medical service for post-PCI monitoring.Two hours later, nurses reported substantial bleeding upon initial deflation of 3 cc of air from the wristband, which was immediately reinflated per protocol. How-

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Safety and feasibility of transulnar catheterization when ipsilateral radial access is not available

Abstract: Transulnar approach is safe and feasible alternative wrist access when performed by experienced radial operators, providing high success rate and low incidence of vascular complications.

Cited by 80 publications

References 21 publications

The Role of the Transradial Approach for Complex Coronary Interventions in Patients with Acute Coronary Syndrome

The Role of the Transradial Approach for Complex Coronary Interventions in Patients with Acute Coronary Syndrome

Photoplethysmography using a smartphone application for assessment of ulnar artery patency: a randomized clinical trial

Compartment Syndrome of the Hand: A Rare Sequela of Transradial Cardiac Catheterization

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