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Worldwide radial artery approach has been accepted as a default technique for coronary access because of obvious safety advantages over femoral access. However, the transradial (TR) approach may not be feasible in up to 5% of the patients due to inability to puncture the radial artery, radial artery spasm or dissection, hypoplastic or small radial artery, or a non-negotiable radioulnar loop.
Vascular access cross over to the contralateral radial artery or the femoral artery is classically recommended after transradial access failure. However, in selected cases, access crossover to the ipsilateral ulnar artery may be considered. The following study describes the usefulness of an ipsilateral bailout by using a transulnar approach after a failed TR approach due to extreme complex anatomy.
The objective of the study: To study the safety and feasibility of crossover from transradial to ipsilateral transulnar access in difficult radial artery anatomy.
This is a prospective observational study which included failed transradial access due to complex radial artery anatomy. Between October 2013 to September 2016 totally 50,667 patients underwent coronary angiography. Out of them, 8,443 (16.6%) patients underwent transradial interventions. Four hundred and thirty-nine patients had failed transradial artery approach due to various reasons. Four hundred and twenty-one patients were crossed over to either contralateral radial (18) or femoral artery approach (403). Eighteen patients underwent ipsilateral transulnar coronary interventions. These 18 patients were included in the study.
Challenging radial artery anatomy: Uncrossable radial artery loop was noted in 8 patients. Six patients had high taken off (2 from subclavian artery, 4 from a brachial artery) of radial artery with thin calibre vessel. Remaining 4 patients had diffuse small calibre radial artery.
Procedure: When the catheter (TIG) or wire advancement was failed from difficult anatomy the anatomy of radial, ulnar and brachial artery were studied using injection through a radial sheath (Figure 2 and 3). In all 18 cases, ulnar artery anatomy was found normal and ulnar artery diameter was larger than a corresponding radial artery. The radial sheath (6F Terumo) was left in situ and Ulnar artery access (Figure-1A) was obtained using routine Seldinger’s technique and sheath (6F Terumo) was inserted. The diagnostic coronary angiography was done successfully in all cases using 5F Optitorque (TIG) catheter. Six cases underwent ad-hoc angioplasty. After the procedure, both transradial and transulnar sheaths were removed one after the other achieving proper haemostasis using routine pressure application as shown in Figure-1B.
In all 18 cases, a transulnar procedure was successful and there was no procedure related complications like bleeding, forearm haematoma, ischemia or gangrene. At discharge, after 24 hours 13 patients had both radial and ulnar pulses palpable and 3 patients had an impalpable radial pulse but preserved ulnar pulse.
Crossover to ipsilateral transulnar access after transradial failure strictly due to anomalies of the radial artery (hypoplasia, loops) is feasible and safe. A radial interventionalist needs to be familiar with the TU approach, as it appears to be reasonably safe and an effective alternative to the contralateral transradial or transfemoral approach.