Transulnar AccessTransulnar Access

Ugo LimbrunoUgo Limbruno

Cardiovascular Department, ASL 6 Livorno, ItalyCardiovascular Department, ASL 6 Livorno, Italy

Why Transulnar?Why Transulnar?

Limitations of transradial access: rate

• Insufficient collateral circulation 5-10%

• Anatomic variations (radial loop, high take-off) 8-10%

• Technical failures 2-3%

• Radial artery occlusion 3-5%

• Radial artery as a graft conduit… -

Limitations of transradial access: rate

• Insufficient collateral circulation 5-10%

• Anatomic variations (radial loop, high take-off) 8-10%

• Technical failures 2-3%

• Radial artery occlusion 3-5%

• Radial artery as a graft conduit… -

Diffuse narrowing of radial artery after repeat procedures

Diffuse narrowing of radial artery after repeat procedures

Yoo et al, Catheter Cardiovasc Interv 2003;58:301

Would you use it as a graft?Would you use it as a graft?

Transulnar: a Medline scanTransulnar: a Medline scan

Keywords: “transulnar” & “coronary”

• Terashima et alCatheter Cardiovasc Interv 2001;53:410-4

• Dashkoff et al Catheter Cardiovasc Interv 2002;55:93-6

• Limbruno et alCatheter Cardiovasc Interv 2004;61:56-9

• Lanspa et alCatheter Cardiovasc Interv 2004;61:211-3

Keywords: “transulnar” & “coronary”

• Terashima et alCatheter Cardiovasc Interv 2001;53:410-4

• Dashkoff et al Catheter Cardiovasc Interv 2002;55:93-6

• Limbruno et alCatheter Cardiovasc Interv 2004;61:56-9

• Lanspa et alCatheter Cardiovasc Interv 2004;61:211-3

9 coro

3 coro, 2 PCI

13 primary PCI

1 coro

9 coro

3 coro, 2 PCI

13 primary PCI

1 coro

Transulnar safety-feasibility:

a single-center prospective study

Transulnar safety-feasibility:

a single-center prospective study

• Site: Cardiovascular Dpt, Livorno, Italy.

• Population: 307 consecutive pts (224 M, 69±8 yrs) referred for elective coronary

angiography and/or PCI (April ’04 - Aug ‘04).

• Screening: 1) Modified Allen’s Test, bilateral2) Ulnar artery palpability, bilateral3) Reverse Modified Allen’s Test.

• Site: Cardiovascular Dpt, Livorno, Italy.

• Population: 307 consecutive pts (224 M, 69±8 yrs) referred for elective coronary

angiography and/or PCI (April ’04 - Aug ‘04).

• Screening: 1) Modified Allen’s Test, bilateral2) Ulnar artery palpability, bilateral3) Reverse Modified Allen’s Test.

Submitted

Transulnar feasibility: different strategies

Transulnar feasibility: different strategies

1. “1st CHOICE” STRATEGY: Transulnar in all patients with palpable ulnar artery and neg. reverse Allen test, regardless of the radial artery availability.

2. “2nd CHOICE” STRATEGY: Transulnar in patients with pos. Allen test, palpable ulnar artery and neg. reverse Allen test.

3. “CROSS-OVER” STRATEGY: Transulnar in case of transradial failure.

1. “1st CHOICE” STRATEGY: Transulnar in all patients with palpable ulnar artery and neg. reverse Allen test, regardless of the radial artery availability.

2. “2nd CHOICE” STRATEGY: Transulnar in patients with pos. Allen test, palpable ulnar artery and neg. reverse Allen test.

3. “CROSS-OVER” STRATEGY: Transulnar in case of transradial failure.

Transulnar feasibility: a prospective study

Transulnar feasibility: a prospective study

Two different strategies: Two different strategies:

• “1st choice” strategy (applied)

• “2nd choice” strategy (retrospective)

+ _

307 pts307 pts

Allen test(cut-off 7sec)Allen test(cut-off 7sec)

+ _

Ulnarpalpability

Ulnarpalpability

RadialRadialFemoralFemoral

ReverseAllen testReverse

Allen test_ +

UlnarUlnar

“2nd choice” strategy (retrospective)“2nd choice” strategy (retrospective)

12%12% 88%88%

5%5% 7%7%

5%5% 0%0%

_

307 pts307 pts

Ulnar palpableUlnar

palpable

+ _

ReverseAllen testReverse

Allen test

RadialRadialFemoral(radial control.)

Femoral(radial control.)

Ulnar accesssuccessful

Ulnar accesssuccessful

+ _

UlnarUlnar

60%60% 40%40%

59%59% 1%1%

48%48%

Allen test(cut-off 7sec)Allen test(cut-off 7sec)

+

_+ 36%36%16%16%

“1st choice” strategy (applied)“1st choice” strategy (applied)

Ulnar(n=181)

Radial(n=110)

6F/7F 141/6 97/4

Artery access rate 81% 98%

Aortic access 81% 95%

PCI 37% 39%

PCI procedural success 98% 98%

Transulnar feasibility: “1st choice” strategy

Transulnar feasibility: “1st choice” strategy

P<0.05 vs radial

* *

* *

0

2

4

6

8

10

12

14

Tim

e (

min

)

Sheathinsertion

Coronarycannulation

Fluoroscopy

Ulnar Radial

p<0.05p<0.05

Transulnar feasibility: time consumption

Transulnar feasibility: time consumption

Ulnar(n=181)

Radial(n=110)

AV fistulae/pseudoaneurism - -Nerve injury - -Hand ischemia - -Artery occlusion / flow reduction

11 (6%) 4(4%)

Severe hematoma 1(0,6%) -

Slight hematoma 10(5%) 3(3%)

Transulnar safetyTransulnar safety

Transulnar: technical issuesTransulnar: technical issues

• CORDIS Radial Kit (6F, 11cm) orTerumo Radifocus II

• Bare needle 21G (very mobile/deep artery!)

• 0.021 metal wire, in case of failure 0.014 “J-ed” coronary guidewire.

• Cocktail: verapamil 2,5 mg + heparin 5000 UI.

• CORDIS Radial Kit (6F, 11cm) orTerumo Radifocus II

• Bare needle 21G (very mobile/deep artery!)

• 0.021 metal wire, in case of failure 0.014 “J-ed” coronary guidewire.

• Cocktail: verapamil 2,5 mg + heparin 5000 UI.

81%success81%success

98%success

98%success

Transulnar: technical issuesTransulnar: technical issues

RARA

UAUAUAUA0%failure0%failure

3%failure

3%failure

RA anatomic variations: 9%RA anatomic variations: 9%RA-UA: similar size

Transulnar: technical issuesTransulnar: technical issues

recu

rrent R

A

recu

rrent R

A

Pts(n)

Accessrate

Occlusion

Nerve injury

A-VFistul

a

Hematoma

Sun et alTCT’04

40 100% 0 0 0 0

Aptecar et alTCT ‘04

186 94 % 2 % 0 0,5 % 0

Limbruno et alSubmitted

181 81% 6 % 0 0 0,6 %

Limbruno et alCCI 2003;61:56-9

13 77 % 0 0 0 0

Dashkoff et alCCI 2002;55:93-6

5 - - 0 0 0

Terashima et alCCI 2001;53:410-4

9 78 % 0 0 0 0

Total 434 88 % 3 % 0 0,2 % 0,2 %

Transulnar: a comprehensive overview

Transulnar: a comprehensive overview

Echo-selection for:•Radial anatomic

variations•Ulnar larger than radial

Transulnar: which strategy? (if any)Transulnar: which strategy? (if any)

1. “1st choice” strategy: might be of limited value due to a somewhat lower artery access rate with respect to transradial.

1. “1st choice” strategy: might be of limited value due to a somewhat lower artery access rate with respect to transradial.

3. “2nd choice” + Echo: as in #2, and in pts with unfavourable radial anatomic variations detected by a pre-procedural echo.

2. “2nd choice” strategy: might slightly increase the feasibility of wrist access in pts with inadequate Allen test.

2. “2nd choice” strategy: might slightly increase the feasibility of wrist access in pts with inadequate Allen test.

+4%+4%

Wrist accessWrist access

+6%?+6%?

-6%-6%