Ulnar Artery Access – Tips & Tricks

Author: Edo Kaluski MD Robert Packer Hospital, Geisinger Commonwealth School of Medicine Rutgers School of Medicine

Saturday, February 22, 2020 10:53 AM – 11:01 AM Room: Gruentzig Theater Edo Kaluski M.D. I have no relevant financial relationships Why Should You Master Trans-Ulnar Access? (When our opinion leaders state “Go radial 1st”) Advanced interventional cardiology is about making the right choices for individual patients: each patient every time! To choose right for your patient it helps to: 1. know the forearm arterial anatomy 2. Possess versatility (ulnar skills) “If you don’t know where you are going you will wind up someplace else” (Yogi Berra)

Benefits of 2 ml. DSA Good Size Radial > Ulnar

U Proceed with caution Radial (R) & bigger Ulnar (U)

U Likely to injure Radial (R) & Good Ulnar (U)

U To be Dottered Radial (R) & Good Ulnar (U)

U Don’t even think about it Radial (R) & Ulnar (U)

U Occluded Radial (R) & consider Ulnar?*

N=240 0% Ulnar occlusion Trans-radial access is not feasible in 5-10% (Minimize wrist to femoral crossover to0.3%*)

1.Occluded^ /stenosed radial from previous procedure 2.Poorly palpated or small diameter radial artery by DSA 3.Known radial loops tortuosity, stenosis & calcifications 4.Planned radial AV-shunt or radial CABG 5.Spasm or Pain (females with larger sheaths & guides) -Advantage of Ulnar over femoral: • reduce bleeding complications • no anticoagulation interruption • minimal patient discomfort • Shorter time to ambulation and discharge • Sentinel placement • Aortic & lower extremity disease

*Baumann J Interv Cardiol. 2015:396-404 0.3% ^ Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60 Why Trans-Ulnar Access Not Adopted?

TUI?? The SCAI is the limit?

Ulnar Artery Access is Not Even Mentioned ! 9/2018: Forgetten ulnar artery gets some Septemberrecognition 2018 The Forgotten Ulnar Artery Gets Recognition Summary of Recommendation

unfounded ∆ 10.2% ∆ 0.17

Dahal K, et al. Transulnar versus transradial access for coronary angiography or percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Catheterization and cardiovascular interventions 2016;87(5):857-65. Ulnar Anatomy 2 Palmar Arches

Deep (radial dependent) complete in 99%

Superficial (ulnar dep.) complete in 40-80% Superficial Palmar Arch (blue) 40-80% complete Fed by Ulnar Artery (brown)& superficial branch of radial artery (green)

superficial branch of radial artery (green) Ulnar artery

superficial palmar arch (blue) 40-80% complete Deep Palmar Arch (purple arrows always complete) fed by: 100% Radial artery & Deep Palmar Branch of Ulnar artery complete

Radial artery

Deep palmar branch of ulnar artery

Deep palmar arch (purple arrows) Wrist Fold : Radial Superficial Ulnar Deepl

Flexor Carp. Ulnaris

Radius Ulna

The ulnar artery is most superficial at the level of the Wrist fold….yet still twice as deep as the radial artery. Sattur S, et al , CRM 2017; 18: 299-303 Triquetrum

scaphoid

Pisiform

Lunate

Radiologic Landmarks: Distal Ulnar Bone Anterior & Posterior Posterior interosseous interosseous artery artery

RADIAL A.

ULNAR A. • With occlusion or removal of radial artery can serve as Anterior deep carpal collateral interosseous however…..anatomic artery variability is extreme (AIA)

AIA

Radial

Proximal stick Ulnar Long occlusive sheath

Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60. Ulnar Branches: Anterior & Posterior Interosseous Arteries No Anterior Interosseous Artery

Radial Artery.

Ulnar Artery Anxiety about Ulnar Artery Access

Learning curve ??? Puncture of the UA more challenging than RA

UA is deeper without underlying Ulnar bone hemostasis more difficult?? puncture UA runs ant-lateral to the ulnar n. Can We Palpate the Ulnar Artery? How well can we palpate the Ulnar Artery? Raúl Valdesuso Aguilar- Hospital Universitario Virgen de la Arrixaca, Murcia, Spain

Pilot survey in 163 pts Palpation of the radial and ulnar by 2 independent explorers both hands

Total Male Female Ulnar vs Radial Nº (%) Nº (%) Nº (%)

Patients 163 (100) 102 (63) 61 (37)

Ulnar not Found 31 (19) 20 (19) 11 (18)

Ulnar < Radial 38 (21) 25 (24) 13 (21)

Ulnar = Radial 49 (32) 33 (33) 16 (26)

Ulnar > Radial 45 (28) 24 (24) 21 (34)

Need to: -hyperextension of wrist -Wrist fold (sensitive fingers) -Use ultrasound? Diameter of Ulnar Artery is similar to Radial Artery Ulnar Artery Diameter

Rt radial >Rt Ulnar (M & F by 0.1 mm) Lt Radial Lt Ulnar(M &F) Females have smaller ulnar & radials Ulnar Artery Diameter (Liu et al, J Invasive Cardiol. 2014, Hebei University Hospital) Ulnar Artery Diameter Baumann F, et al, J Interv Cardiol 2015 Dec;28(6):574-82l

Ultrasound based (n = 565) -Females 35.5% -mean age: 66.5 years Radial 3.03 ± 0.57 mm Ulnar 2.70 ± 0.57 mm

5F Sheath in 1.5mm Ulnar Ulnar Artery Diameter Baumann F, et al, J Interv Cardiol 2015 Dec;28(6):574-82l

Radial A. Radial Ulnar 58.5% AIA Ulnar >Radial 6.5% (>20%) Radial> Ulnar 35% (>20%)

Baumann F, et al, Ulnar A. J Interv Cardiol Ulnar A. 2015 Dec;28(6):574-82l Technique Technique

1.Allen test? (abandoned now?) 2.Wrist hyperextension 3.Puncture site (between wrist creases) 4.21G Needle (anterior wall puncture*) 5.Angulation (60) & depth (<1 cm) 6.Sheath size- minimal like radial (4-6F)

* Intuitive since through and through puncture can result in nerve injury or hematoma Technique (continues) 7. Anti-spasm medications- like radial [Verapamil 5 mg, Nicardipine 2-4 mg (bradycardia or AVB) ± NTG] 8. IV heparin -like radial 9. DSA Injection (optional) 10. Wires- like radial (0.035 J wire or 0.035, angled glide wire with fluoroscopy Coronary wire 0.014 Whisper) 11. Sheath removal (like radial: reverse radial band may be difficult if access is too distal) Like real estate

• Location • Location • Location Ulnar Access: Causes of Hematomas… Raúl Valdesuso Aguilar- Hospital Universitario Virgen de la Arrixaca, Murcia, Spain Proximal Puncture site was significantly associated with the risk of haematoma (RR 81.8 [95% CI: 10.4-643.2], p=0.00003) (multivariate analysis). Feasibility Author, Year Pts. Procedures Sheath Success (%) Crossover Complications (n) Feasibility (n) (n) (French) (%) Mangin21 2005 117 122 4-7F 85.2 14.8 local hematomas 4% • Procedural (Cath/PCI) large hematoma 0.8% pseudoaneurysm 0.8% success: Aptecar12 2005 172 173 4-6F 91 9 local hematomas 4% (Cath/PCI) ulnar occlusion 0.6% pseudoaneurysm 0.6% 68-99% Rath23 2005 100 100 5-6F 95 5 local hematoma1% (Cath/PCI) artery perforation1% • Crossover transient paraesthesia1%

rate 2-25% Aptecar13 2006 216 319 4-5F 93.1 6.9 large hematomas 0.4% (Cath/PCI) local hematomas 2.3% AV fistula 0.4% transient paraesthesia1.4% ulnar occlusion 2.3% Vassilev15 2008 92 92 6F 74.8 25.2 local hematomas 5.4% DAHAL et al (Cath/PCI) large hematomas 2.2%

Crossover Li26 120 120 5-7F 98.3 1.7 local hematomas 5.8% rate 2010 (Cath/PCI) ulnar occlusion1.7% Liu34 317 317 6F 92.7 NA Ulnar occlusion 6.3% Ulnar: Radial 2014 Access hematoma 2.6% Forearm hematoma 1.6% 14 :3.8 % Uribe29 2011 255 240 4-7 F 94.1 5.9 Silent thrombosis 2.1% (Cath/PCI) Small hematoma 5.4% Respectively Large hematoma 0.4% Andrade14 2012 387 410 5-7F 98.5 1.5 local hematomas 2.8% (Cath/PCI) large hematomas 0.5% Sattur S, J Invasive Cardiol 2014; 404-8 ulnar occlusion 0.5% Chugh31 2012 266 266 4-8F 98.7 1.3 0 (Cath/PCI) Hahalis30 2013 462 462 5-7 F 67.7 32.3 large hematomas1.9% (Cath/PCI) arterial occlusions 6% 60 days Safety Author, Year Pts. (n) Procedures Sheath (F) Success (%) Crossover (%) Complications (n) (n) Safety Mangin(13) 117 122 4-7F 85.2 14.8 local hematomas 4% 2005 (Cath/PCI) large hematoma 0.8% (TUATRA) pseudoaneurysm 0.8% Aptecar(14) 2005 172 173 4-6F 91 9 local hematomas 4% • Hematomas(<6%) (Cath/PCI) ulnar occlusion 0.6% pseudoaneurysm 0.6%

Rath(15) 100 100 5-6F 95 5 local hematoma1% • Ulnar artery 2005 (Cath/PCI) artery perforation1% transient paraesthesia1% occlusions (0.6-6%) Aptecar(2) 2006 216 216 4-5F 93.1 6.9 large hematomas 0.4% (Cath/PCI) local hematomas 2.3% • Ulnar nerve injury- AV fistula 0.4% transient paraesthesia1.4% rare ulnar occlusion 5.7% Gookroo(16) 410 410 5-6F 97.8 2.2 Ulnar occlusion < 1% 2015 (Cath>PCI) Minor bleed 2.2% • Spasm Li(12) 120 120 5-7F 98.3 1.7 local hematomas 5.8% 2010 (Cath/PCI) ulnar occlusion1.7%

Liu(1) 317 317 6F 92.7 NA Ulnar occlusion 6.3% 2014 (Cath/PCI) Access hematoma 2.6% Forearm hematoma 1.6% UribeTCT 2011 255 240 4-7 F 94.1 5.9 Silent thrombosis 2.1% (Cath/PCI) Small hematoma 5.4% Large hematoma 0.4% Sattur S, Singh M, Kaluski Andrade(17) 387 410 5-7F 98.5 1.5 local hematomas 2.8% E, CRM 2017; 18: 299-303 2012 (Cath/PCI) large hematomas 0.5% ulnar occlusion 0.5% Chugh(18) 266 266 4-8F 98.7 1.3 0 2012 (Cath/PCI) Hahalis(11) 462 462 5-7 F 67.7 32.3 large hematomas1.9% 2013 (Cath/PCI) arterial occlusions 6% 60 days Kedev (4) 476 476 (Cath/PCI/CS) 5-7f 97 3 Hematoma<1% Minor hematomas 8% Spasm<1% Geng (10) 271 271 4-6F 95.1 4.9 1. arterial occlusion (Cath/PCI/CS) 7.3% hematomas 0.4% motor weakness Closing Remarks & Conclusions 1. TUA has similar safety as TRA [Similar site complications rate (spasm, bleeding & occlusion)] and similarly reduced time to ambulation and discharge (Short learning curve for radial operators) 2. Ulnar artery is deeper & more difficult to palpate than the radial artery hence associated higher number of puncture attempts & failure rates. ultrasound may be helpful to reduce access time and failure rates. 3. Ulnar artery has similar diameter, straighter course than the radial artery (Loops and curvatures are rare) 4. Arterial imaging by ultrasound or DSA may enhance decision making for wrist based interventions. Thank You For Your Attention!

Next time before you go femoral remember: that there are at least 2 sides to every story ……and every wrist.