Presentazione di PowerPoint

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Transulnar Access
Ugo Limbruno
Cardiovascular Department, ASL 6 Livorno, Italy
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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 -

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Diffuse narrowing of radial artery after repeat
procedures
Would you use it as a graft?
Yoo et al, Catheter Cardiovasc Interv 200358301
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Transulnar a Medline scan

• Keywords transulnar coronary
• Terashima et al
• Catheter Cardiovasc Interv 200153410-4
• Dashkoff et al
• Catheter Cardiovasc Interv 20025593-6
• Limbruno et al
• Catheter Cardiovasc Interv 20046156-9
• Lanspa et al
• Catheter Cardiovasc Interv 200461211-3

9 coro 3 coro, 2 PCI 13 primary PCI 1
coro
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Transulnar safety-feasibility a single-center
prospective study

• Site Cardiovascular Dpt, Livorno, Italy.
• Population 307 consecutive pts (224 M, 698
  yrs) referred for elective coronary angiography
  and/or PCI (April 04 - Aug 04).
• Screening 1) Modified Allens Test, bilateral
• 2) Ulnar artery palpability, bilateral
• 3) Reverse Modified Allens Test.

Submitted
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Transulnar feasibility different strategies

• 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.
• CROSS-OVER STRATEGY
• Transulnar in case of transradial failure.

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Transulnar feasibility a prospective study

• Two different strategies

• 1st choice strategy (applied)
• 2nd choice strategy (retrospective)

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2nd choice strategy (retrospective)
307 pts
Allen test (cut-off 7sec)
_
12
88

Ulnar palpability
_
5
7

Reverse Allen test
_
5
0

Radial
Femoral
Ulnar
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1st choice strategy (applied)
307 pts
Ulnar palpable
_
60

40
Reverse Allen test
_
59
1

Ulnar access successful
Allen test (cut-off 7sec)
_
_
36


48
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Radial
Femoral (radial control.)
Ulnar
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Transulnar feasibility 1st choice strategy
Ulnar (n181) Radial (n110)
6F/7F 141/6 97/4
Artery access rate 81 98
Aortic access 81 95
PCI 37 39
PCI procedural success 98 98


Plt0.05 vs radial
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Transulnar feasibility time consumption
plt0.05
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Transulnar safety
Ulnar (n181) Radial (n110)
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)
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Transulnar technical issues

• CORDIS Radial Kit (6F, 11cm) or
• Terumo 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.

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Transulnar technical issues
98 success
81 success
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Transulnar technical issues
RA anatomic variations 9
RA-UA similar size
3 failure
RA
recurrent RA
0 failure
UA
UA
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Transulnar a comprehensive overview
Pts (n) Access rate Occlusion Nerve injury A-V Fistula Hema toma
Sun et al TCT04 40 100 0 0 0 0
Aptecar et al TCT 04 186 94 2 0 0,5 0
Limbruno et al Submitted 181 81 6 0 0 0,6
Limbruno et al CCI 20036156-9 13 77 0 0 0 0
Dashkoff et al CCI 20025593-6 5 - - 0 0 0
Terashima et al CCI 200153410-4 9 78 0 0 0 0
Total 434 88 3 0 0,2 0,2

• Echo-selection for
• Radial anatomic variations
• Ulnar larger than radial

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Transulnar which strategy? (if any)
Wrist access

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

-6

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

4

• 2nd choice Echo
• as in 2, and in pts with unfavourable radial
  anatomic variations detected by a pre-procedural
  echo.

6?