Transulnar Compared With Transradial Artery Approach as a Default Strategy for Coronary Procedures

Abstract

Ιnvestigations focusing on the ulnar artery as a workhorse tool for coronary procedures have shown either low Background-The ulnar artery is rarely selected for coronary angiography or percutaneous coronary intervention despite the expanding use of the transradial approach. We aimed to establish noninferiority of a default transulnar relative to transradial approach in terms of feasibility and safety. Methods and Results-This was a prospective, randomized, multicenter, parallel-group study involving 902 patients at 5 sites eligible to undergo diagnostic coronary angiography and percutaneous coronary intervention. Patients were randomized in a 1:1 ratio to either transradial approach (reference intervention) or transulnar approach (experimental intervention) regardless of the Allen test results. The primary end point was a composite of cross-over to another arterial access, major adverse cardiovascular events, and major vascular events of the arm at 60 days. The study was prematurely terminated after the first interim analysis because of inferiority of the transulnar approach. Although the difference in the primary end point became inconclusive after adjustment for operator clustering (24.30%; 99.99% confidence interval [CI], −7.98% to 56.58%; P=0.03 at α=0.0001), need for cross-over in the transulnar group remained inferior to transradial access site with a difference of 26.34% (95% CI, 11.96%-40.69%; P=0.004). Conclusions-As a result of higher cross-over rates, a first-line transulnar strategy was proven inferior to the transradial approach for coronary procedures. At present, the transulnar route should not be regarded as an acceptable alternative to the transradial access site. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01364532. (Circ Cardiovasc Interv.2013;6:252-261.)

Feasibility and Safety of Transulnar Catheterization in Ipsilateral Radial Artery Occlusion

“…Similar findings were reported by Hahalis, et al with mean arterial access times of 3 and 6 minutes in the TR and TU groups, respectively. 6) In their study, TU coronary catheterization also had longer procedural and fluoroscopy times, required more puncture attempts, and had an increased access cross-over rate. 6) Therefore, the ulnar artery was not recommended as an alternative route if the radial artery was feasible for cannulation.…”

“…6) In their study, TU coronary catheterization also had longer procedural and fluoroscopy times, required more puncture attempts, and had an increased access cross-over rate. 6) Therefore, the ulnar artery was not recommended as an alternative route if the radial artery was feasible for cannulation. However, TU catheterization would provide more safety and comfort to patients than would the transbrachial and transfemoral approaches.…”

“…[4][5][6][7] The TU approach has success rates for arterial puncture and coronary intervention similar to those of the TR approach without increasing entry site complications, including arterial occlusion. However, Hahalis, et al have reported not only the relative inferiority of the cross-over rate in the TU access route but also significantly higher puncture trials, longer puncture and fluoroscopy times, and higher amounts of contrast medium in TU patients than in TR patients.…”

“…However, Hahalis, et al have reported not only the relative inferiority of the cross-over rate in the TU access route but also significantly higher puncture trials, longer puncture and fluoroscopy times, and higher amounts of contrast medium in TU patients than in TR patients. 6) Thus, the ulnar artery is recommended as an alternative access site only if the radial arterial approach fails or is not feasible. In real world practice, radial artery occlusion is a major reason for choosing an alternate route for intervention.…”

Segurança e Factibilidade do Acesso Ulnar Após Falha do Acesso Radial Ipsilateral

“…A opção pela técnica ulnar sem avaliação prévia da anatomia e do pulso resultará em maior número de tentativas de punção, tempo para obtenção do acesso, duração do exame e taxa de insucesso próxima a 45%. 17,18 Dentre as limitações do nosso estudo, ressaltamos sua natureza não randômica, o tamanho amostral e, so bretudo, tratarse de uma casuística de um único cen tro, caracterizado por operadores familiarizados com o acesso radial e ulnar, utilizados em 95% dos pro cedimentos, bem como a disponibilidade de materiais de dicados a essas vias, como introdutores e cateteres hidrofílicos, e equipe multidisciplinar experiente e trei nada no manuseio de sua hemostasia.…”