1. Transulnar Access Ugo Limbruno Cardiovascular Department, ASL 6 Livorno, Italy

2. Why Transulnar? Limitations of transradial access: rate Insufficient collateral circulation5-10 % 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 circulation5-10 % Anatomic variations (radial loop, high take-off) 8-10 % Technical failures 2-3 % Radial artery occlusion 3-5 % Radial artery as a graft conduit… -

3. 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?

4. Transulnar: a Medline scan Keywords: “transulnar” & “coronary” Terashima et al Catheter Cardiovasc Interv 2001;53:410-4 Dashkoff et al Catheter Cardiovasc Interv 2002;55:93-6 Limbruno et al Catheter Cardiovasc Interv 2004;61:56-9 Lanspa et al Catheter Cardiovasc Interv 2004;61:211-3 Keywords: “transulnar” & “coronary” Terashima et al Catheter Cardiovasc Interv 2001;53:410-4 Dashkoff et al Catheter Cardiovasc Interv 2002;55:93-6 Limbruno et al Catheter Cardiovasc Interv 2004;61:56-9 Lanspa et al Catheter 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

5. 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, bilateral 2) Ulnar artery palpability, bilateral 3) 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, bilateral 2) Ulnar artery palpability, bilateral 3) Reverse Modified Allen’s Test. Submitted

6. Transulnar feasibility : different strategies 1.“1 st CHOICE” STRATEGY: Transulnar in all patients with palpable ulnar artery and neg. reverse Allen test, regardless of the radial artery availability. 2. “2 nd 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.“1 st CHOICE” STRATEGY: Transulnar in all patients with palpable ulnar artery and neg. reverse Allen test, regardless of the radial artery availability. 2. “2 nd 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.

7. Transulnar feasibility : a prospective study Two different strategies: “1 st choice” strategy (applied) “2 nd choice” strategy (retrospective)

8. + _ 307 pts Allen test (cut-off 7sec) Allen test (cut-off 7sec) + _ Ulnar palpability Ulnar palpability Radial Femoral Reverse Allen test Reverse Allen test _ + Ulnar “2 nd choice” strategy (retrospective) 12 % 88 % 5%5% 5%5% 7%7% 7%7% 5%5% 5%5% 0%0% 0%0%

9. _ 307 pts Ulnar palpable Ulnar palpable + _ Reverse Allen test Reverse Allen test Radial Femoral (radial control.) Femoral (radial control.) Ulnar access successful Ulnar access successful + _ Ulnar 60 % 40 % 59 % 1%1% 1%1% 48 % Allen test (cut-off 7sec) Allen test (cut-off 7sec) + _ + 36 % 16 % “1 st choice” strategy (applied)

10. Ulnar (n=181) Radial (n=110) 6F/7F 141/697/4 Artery access rate 81 % 98 % Aortic access 81 % 95 % PCI 37 % 39 % PCI procedural success 98 % Transulnar feasibility: “ 1 st choice” strategy P<0.05 vs radial * * * *

11. p<0.05 Transulnar feasibility: time consumption

12. 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 safety

13. 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. 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.

14. 81% success 81% success 98% success 98% success Transulnar: technical issues

15. RA UA 0% failure 0% failure 3% failure 3% failure RA anatomic variations: 9% RA-UA: similar size Transulnar: technical issues recurrent RA

16. Pts (n) Access rate OcclusionNerve injury A-V Fistula Hema toma Sun et al TCT’04 40100 % 0000 Aptecar et al TCT ‘04 18694 % 2 % 00,5 % 0 Limbruno et al Submitted 18181 % 6 % 000,6 % Limbruno et al CCI 2003;61:56-9 1377 % 0000 Dashkoff et al CCI 2002;55:93-6 5--000 Terashima et al CCI 2001;53:410-4 978 % 0000 Total43488 % 3 %3 % 00,2 % Transulnar: a comprehensive overview Echo-selection for: Radial anatomic variations Ulnar larger than radial

17. Transulnar: which strategy? (if any) 1.“1 st choice” strategy: might be of limited value due to a somewhat lower artery access rate with respect to transradial. 1.“1 st choice” strategy: might be of limited value due to a somewhat lower artery access rate with respect to transradial. 3.“2 nd choice” + Echo: as in #2, and in pts with unfavourable radial anatomic variations detected by a pre-procedural echo. 2.“2 nd choice” strategy: might slightly increase the feasibility of wrist access in pts with inadequate Allen test. 2.“2 nd choice” strategy: might slightly increase the feasibility of wrist access in pts with inadequate Allen test. +4 % Wrist access +6 % ? -6 %