Transulnar Access: Another Ace Up Our Sleeve Before Transfemoral Access

Transulnar access can be as safe and effective as transradial access, and it is a particularly good alternative for the preservation of radial artery patency or when such vessel presents a difficult anatomy. This new meta-analysis that will be published soon in Catheter Cardiovasc Interv showed a relatively high failure rate for that access, but that could be easily explained by a learning curve.

In terms of safety, neither excess bleeding/bruising nor other vascular complications were observed with transulnar access when compared with transradial access in patients who underwent angioplasty. However, the rate of failure for transulnar access more than doubled that for transradial access (odds ratio [OR]: 2.63).

This meta-analysis included 6 trials with about 4800 patients and showed that transulnar access was not associated with increased fluoroscopy time, contrast volume or access time.

Read also: Tips to Prevent Radial Occlusion after Catheterization.

Transulnar access can be considered an alternative in cases in which operators need to preserve the radial artery for bypass grafts or arteriovenous fistulae for patients with poor kidney function. Additionally, the ulnar artery tends to offer higher bore and lower tortuosity than the radial artery.

On the other hand, the transulnar artery is deeper and getting a pulse is often more difficult. If we only remember it when we run into problems with transradial access, we probably will not get the necessary experience in using this access site.

The ideal course of action seems to be the assessment of access on a case-by-case basis, depending on the relative size of the radial and ulnar arteries.

Read also: Transradial Access and Early Discharge in Percutaneous Interventions.

A common concern regarding this access is that the ulnar nerve lies right next to the artery through the Guyon canal, between the pisiform bone and the ulnar artery. Since, generally, the patient is positioned with his/her arm right next to his/her body, the puncture will always be more likely to fall on the free side of the artery (which is ideal) and not near the nerve. Pseudoaneurysms should also be taken into account, since the ulnar artery is deeper and there are no bony structures for good compression. In conclusion, until we gain sufficient experience, post-procedural monitoring should be closer than current monitoring of patients with transradial access.

Original title: Safety and Efficacy of Ulnar Artery Approach for Percutaneous Cardiac Catheterization: Systematic Review and Meta-Analysis.

Reference: Fernandez R et al. Catheter Cardiovasc Interv. 2018; Epub ahead of print.

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