1. Trans-Ulnar Interventions
Edo Kaluski M.D. FACC, FESC, FSCAI
Director of Cath-Lab & Interventional Cardiology
Robert Packer Hospital & Guthrie Health Systems, PA, USA

2. Edo Kaluski M.D. I have no relevant financial relationships
I have no relevant financial relationships
Examples of relationships are:
Advisory Board/Board Member Inspire MD
Consultant, Honoraria: Astra Zeneca, Amgen, Zoll, Janssen, Daiichi Sankyo,
Research Support: Astra Zeneca, Amgen, Zoll, Janssen, Daiichi Sankyo,

3. Why to Use Trans-Ulnar Access?

4. Trans-radial is not feasible in 5-10% (Reduce wrist to femoral crossover to0.3%*)
Anatomical variations: hypoplastic radial artery
Loops (radial, brachial, axillary, innominate)tortuosity
Stenosis & calcifications
Spasm or Pain (females with larger sheaths & guides)
Occluded / stenosed radial from previous PCI
Planned radial shunt or radial CABG
*Baumann F, Roberts JS. Evolving Techniques to Improve Radial/Ulnar Artery Access: Crossover Rate Catheterization and/or Percutaneous Coronary Intervention via the Wrist. J Interv
Cardiol Aug;28(4): % in 1,000 Consecutive Patients Undergoing Cardiac.

5. Radial
Ulnar

6. Radial
Ulnar

7. Ulnar artery is straight Ulnar artery does not taper down distally

8. Use of Trans-Ulnar Access
Failed TRA? What’s the next access?
Bertrand O.F. J Am Coll Cardiol Intv 2010;3:

9. Ulnar Artery Access is Not Even Mentioned !
TUI??
The SCAI is the limit?
Ulnar Artery Access is Not Even Mentioned !

10. TUI??
The SCAI is the limit?

11. Anatomy

12. Palmar Arches Deep (radial dependent) complete in 99%
Superficial (ulnar dep.) complete in 40-80%

13. Superficial Palmar Arch (red shade) 99%
Fed by Ulnar Artery (brown)& superficial branch of radial artery (green)
superficial branch of radial artery (green)
Ulnar
artery
superficial palmar arch (blue)

14. Deep Palmar Arch (green shade purple arrows) fed by: Radial artery & Deep Palmar Branch of Ulnar artery
Radial artery
superficial branch of radial artery (green)
Deep palmar branch of ulnar artery
Deep palmar arch
(purple arrows)

15. 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.

16. Anterior interosseous artery
Posterior interosseous
artery
Anterior interosseous artery
RADIAL A.
ULNAR A.
With occlusion or removal of radial artery can serve as deep carpal collateral however…..anatomic variability is extreme
Anterior interosseous
artery

17. Sattur S, et al .

18. Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.
(AIA)
AIA
Occluded
Radial
Ulnar artery
(long ulnar sheath)
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.

20. No Anterior Interosseous Artery
Radial A.
Ulnar A.

22. Can We Palpate the Ulnar Artery?

23. How well 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
Ulnar vs Radial
Total
Male
Female
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?

24. Size of Ulnar
Artery

25. Ulnar Artery Diameter Rt radial >Rt Ulnar (M & F by 0.1 mm)
Lt Radial Lt Ulnar(M &F)
Females have smaller ulnar & radials

26. Ulnar Artery Diameter (Liu et al, J Invasive Cardiol
Ulnar Artery Diameter (Liu et al, J Invasive Cardiol. 2014, Hebei University Hospital)
Ulnar Artery Diameter (Liu et al, J Invasive Cardiol. 2014, Hebei University Hospital)

27. 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

28. Ulnar Artery Diameter Baumann F, et al, J Interv Cardiol 2015 Dec;28(6):574-82l
Radial Ulnar 58.5%
Ulnar >Radial 6.5% (>20%)
Radial> Ulnar 35% (>20%)
Baumann F, et al,
J Interv Cardiol
2015 Dec;28(6):574-82l
AIA
Radial A.
Ulnar A.
Ulnar A.

29. Technique

30. Medial
Lateral

31. Technique Allen test? (not to be abandoned for now?)
Wrist hyperextension
Puncture site (between the wrist creases)
21G Needle (anterior wall puncture) not cannula
Angulation (60-80) & depth (<1 cm)
Sheath size- minimal (4F?)

32. Technique (continues)
7. Anti-spasm medications (Verapamil 5 mg, ± NTG)
8. IV heparin (3-5k) depends on patient & sheath size procedure duration
9. Injection (especially if ipsilateral radial artery is occluded)
J wire or angled glide wire with fluoroscopy (Coronary wire Whisper)
11. Sheath removal (higher pressure?)

33. 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: ], p= ) (multivariate analysis).
Variable
Sig.
Exp (B)
95% CI
Inferior
Superior
Puncture site proximal
81,831
10,40
643.19
Hypertension
0.04
0,115
0,01
0.93
Diabetes
0.9
0,780
0,05
11.65
IIbIIIa inh.
0.1
12,670
0,62
259.86
Cath French
0,816
0,07
9.48
Male
0.8
0,734
0,10
5.46

34. Puncture Site
No!!!
Proximal*
OK*
Kedev S. et al TCTMD.COM

35. Technique Skin to Ulnar Bone Distance As You Stick More Proximal
Sattur S, J Invasive Cardiol 2014; 404-8

36. Feasibility

37. Feasibility Procedural success: 68-99% Crossover rate 2-25%
Author, Year
Pts. (n)
Procedures
(n)
Sheath (French)
Success (%)
Crossover (%)
Complications (n)
Mangin
117
122
(Cath/PCI)
4-7F
85.2
14.8
local hematomas 4%
large hematoma 0.8%
pseudoaneurysm 0.8%
Aptecar
172
173
4-6F 91 9
ulnar occlusion 0.6% pseudoaneurysm 0.6%
Rath
100
5-6F 95 5
local hematoma1%
artery perforation1%
transient paraesthesia1%
Aptecar
216
319
4-5F
93.1
6.9
large hematomas 0.4%
local hematomas 2.3%
AV fistula 0.4%
transient paraesthesia1.4%
ulnar occlusion 2.3%
Vassilev 92 6F
74.8
25.2
local hematomas 5.4%
large hematomas 2.2%
Li26
2010
120
5-7F
98.3
1.7
local hematomas 5.8%
ulnar occlusion1.7%
Liu34
2014
317
92.7 NA
Ulnar occlusion 6.3%
Access hematoma 2.6%
Forearm hematoma 1.6%
Uribe
255
240
4-7 F
94.1
5.9
Silent thrombosis 2.1%
Small hematoma 5.4%
Large hematoma 0.4%
Andrade
387
410
98.5
1.5
local hematomas 2.8%
large hematomas 0.5%
ulnar occlusion 0.5%
Chugh
266
4-8F
98.7
1.3
Hahalis
462
5-7 F
67.7
32.3
large hematomas1.9%
arterial occlusions 6% 60 days
Procedural success:
68-99%
Crossover rate 2-25%
Sattur S, J Invasive Cardiol 2014; 404-8

38. Safety

39. Safety Issues Hematomas (<6%) Ulnar artery occlusions (6%)
Author, Year
Pts. (n)
Procedures
(n)
Sheath (French)
Success (%)
Crossover (%)
Complications (n)
Mangin
117
122
(Cath/PCI)
4-7F
85.2
14.8
local hematomas 4%
large hematoma 0.8%
pseudoaneurysm 0.8%
Aptecar
172
173
4-6F 91 9
ulnar occlusion 0.6% pseudoaneurysm 0.6%
Rath
100
5-6F 95 5
local hematoma1%
artery perforation1%
transient paraesthesia1%
Aptecar
216
319
4-5F
93.1
6.9
large hematomas 0.4%
local hematomas 2.3%
AV fistula 0.4%
transient paraesthesia1.4%
ulnar occlusion 2.3%
Vassilev 92 6F
74.8
25.2
local hematomas 5.4%
large hematomas 2.2%
Li26
2010
120
5-7F
98.3
1.7
local hematomas 5.8%
ulnar occlusion1.7%
Liu34
2014
317
92.7 NA
Ulnar occlusion 6.3%
Access hematoma 2.6%
Forearm hematoma 1.6%
Uribe
255
240
4-7 F
94.1
5.9
Silent thrombosis 2.1%
Small hematoma 5.4%
Large hematoma 0.4%
Andrade
387
410
98.5
1.5
local hematomas 2.8%
large hematomas 0.5%
ulnar occlusion 0.5%
Chugh
266
4-8F
98.7
1.3
Hahalis
462
5-7 F
67.7
32.3
large hematomas1.9%
arterial occlusions 6% 60 days
Hematomas
(<6%)
Ulnar artery occlusions (6%)
Ulnar nerve injury- rare
Sattur S, J Invasive
Cardiology 2014; 404-8

40. Safety Issues Hematomas (<6%) Ulnar artery occlusions (6%)
Author, Year
Pts. (n)
Procedures
(n)
Sheath (F)
Success (%)
Crossover (%)
Complications (n)
Mangin(13)
2005
117
122
(Cath/PCI)
4-7F
85.2
14.8
local hematomas 4%
large hematoma 0.8%
pseudoaneurysm 0.8%
Aptecar(14) 2005
172
173
4-6F 91 9
ulnar occlusion 0.6% pseudoaneurysm 0.6%
Rath(15)
100
5-6F 95 5
local hematoma1%
artery perforation1%
transient paraesthesia1%
Aptecar(2) 2006
216
4-5F
93.1
6.9
large hematomas 0.4%
local hematomas 2.3%
AV fistula 0.4%
transient paraesthesia1.4%
ulnar occlusion 5.7%
Gookroo(16)
2015
410
(Cath>PCI)
97.8
2.2
Ulnar occlusion < 1%
Minor bleed 2.2%
Li(12)
2010
120
5-7F
98.3
1.7
local hematomas 5.8%
ulnar occlusion1.7%
Liu(1)
2014
317 6F
92.7 NA
Ulnar occlusion 6.3%
Access hematoma 2.6%
Forearm hematoma 1.6%
UribeTCT 2011
255
240
4-7 F
94.1
5.9
Silent thrombosis 2.1%
Small hematoma 5.4%
Large hematoma 0.4%
Andrade(17)
2012
387
98.5
1.5
local hematomas 2.8%
large hematomas 0.5%
ulnar occlusion 0.5%
Chugh(18)
266
4-8F
98.7
1.3
Hahalis(11)
2013
462
5-7 F
67.7
32.3
large hematomas1.9%
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
(Cath/PCI/CS)
95.1
4.9
arterial occlusion
7.3% hematomas
0.4% motor weakness
Hematomas
(<6%)
Ulnar artery occlusions (6%)
Ulnar nerve injury- rare
Sattur S, CRM
In Print

41. Ulnar as Good as Radial?

42. Trans-ulnar versus trans-radial access for coronary angiography or percutaneous coronary intervention
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):

43. Successful Occlusion Bleed Spasm 95.5 93.1 94.1 67.7 95.9 92.7 NA 7.3
PCVI-CUBA13
AURA of ARTEMIS30
Liu ACS34
TRA (N=215
TUA (N=216)
TRA (N=440)
TUA (N=462)
TRA (N=319)
TUA (N=317)
Age (yr.) ¶
63 ± 13
63 ± 12
64.6 ± 12
64.3 ± 11
59.2 ± 11
58.6 ±11
Men (%) 74 73 78
78.4
67.3
69.3
Diabetes (%)
22.6
20.7
27.7
28.4
19.4
20.5
Stable angina (%) 26
48.4
48.5
STEACS (%)
16.7
17.5
13.2
14.1
20.4
19.6
Successful
access (%)
95.5
93.1
94.1
67.7
95.9
(1st puncture)
92.7
MACE at follow up
4.2
2.1
3.4
2.8
2.5
1.9
Occlusion
4.7
5.7
8.9
10.4
6.3
Bleed
(Major hematoma)
1.1
0.5
3.2
5.6/ 3.7 forearm/site
1.6 /2.5 forearm/site
Ulnar nerve injury NA
Arterio-venous fistula
Spasm
7.3
12.7
16.9
5.0
0.9
PseudoA & Perforation

44. Ulnar Approach in the Presence of Ipsilateral Radial Occlusion
or Removal

45. Valgimigli M. et al, J Am Coll Cardiol. 2014;63(18):1833-1841
Trans-radial Coronary Catheterization &Intervention Based on Allen Test Results
RADAR
Valgimigli M. et al, J Am Coll Cardiol. 2014;63(18):

46. Plethysmography at Baseline and FU
(A) Plethysmographic readings at baseline stratified on the basis of Allen test AT result. (B) The pattern of plethysmographic readings in patients with normal AT results remained consistent at follow-up (p = 0.56). (C) Plethysmographic readings showed an increase of the prevalence of patterns A and B over time at the expenses of pattern C in patients with intermediate AT results (p < 0.001). (D) Plethysmographic readings showed an increase of the prevalence of patterns A and B over time at the expenses of patterns C and D in patients with abnormal AT results (p < 0.001).
Valgimigli M. et al, J Am Coll Cardiol. 2014;63(18):

47. Valgimigli M. et al, J Am Coll Cardiol. 2014;63(18):1833-1841
RADAR - Conclusions
Valgimigli M. et al, J Am Coll Cardiol. 2014;63(18):
-Allen Test results are NOT a prerequisite for selecting patients before TRA
-No clinical or subclinical sign of hand ischemia was detected in patients with abnormal AT results undergoing TRA.

49. Experienced Operators: Success Rate 97% (Crossover 3%)
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.

50. Procedural Characteristics
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.

51. Success Rate with RAO : Experienced Operators
3.3%
2.5%
96.6 % success
97.5% success
Ulnar occlusion
15 (6.3%)
Ischemia 0%
Ulnar occlusion
None (0%)
RAO: Ipsilateral radial artery occluded
Ischemia 0%
Kedev S. et al, Catheter Cardiovasc
Interv 2014;83:E51–60.

52. Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.
Study Endpoints
(n=476)
30 d Ulnar artery occlusion
15 (3.1%)
Crossover to TFA
14 (3%)
Heavily calcified UA
9 (64.2%)
Small UA size
3 (21.5%)
Severe clinical UAS
2 (14.3%)
Clinical ulnar artery spasm
40 (8.4%)
Grade 1: 1 additional vasodilator dose only
34 (7.1%)
Grade 2: 2 additional vasodilator doses only
4 (0.08%)
Grade 3:  2 vasodilator doses /pain/ catheter restriction
2 (0.04%)
Grade 4: crossover required pain/ catheter restriction
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.

53. Vascular Complications all study
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.

54. Complication: Experienced Operators (3%)
Access site bleeding complications
39 (8.2%)
Hematoma grade 1
18 (3.8%)
Hematoma grade 2
10 (2.1%)
Hematoma grade 3
9 (1.8%)
Hematoma grade 4
2 (0.04%)
Hematoma grade 5
Major vascular complication at 30 days
Sign of hand ischemia at 30 days
Ulnar artery occlusion (UAO) at 30 days
15 (3.1%)
Kedev S. et al, Catheter Cardiovasc Interv
2014;83:E51–60.

55. 2 Arms Study Endpoints Vascular Complications by Arms
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.

56. Closing Remarks & Conclusions

57. Trans Ulnar Access (TUA) :
Similar to trans-radial access: access site complications, discomfort, earlier ambulation, patient’s satisfaction.
Straighter course than the RA (Loops and curvatures are very rare)
Short learning curve for radial operators
Similar size, rates of spasm & occlusion
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58. Disadvantages of Trans Ulnar Access
Requires some learning curve due:
a) Puncture of the UA is more difficult than RA (deeper & not palpated as well)
b) Hemostasis more difficult (Deeper position of the UA without underlying bone)
c) Potential ulnar nerve injury (rare)
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59. Indications for Ulnar Access:
Larger/better palpated ulnar vs. weak/small radial
Failed Radial puncture (prior to sheath insertion)
Known / confirmed radial loops or pathology
Planned bypass grafting or dialysis fistula with radial artery
Prior TRI (especially 6-7F) confirmed RA patency
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60. Conclusions Alternative to trans-radial access
Requires operator experience
Larger large-scale studies are required to substantiate efficacy & safety.

61. 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.