Distal Radial and Ulnar Arteries: the Alternative Forearm Access
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Purpose of review
Radial artery access for catheter-based procedures has demonstrated improved margins of safety and patient comfort without a loss of efficacy compared with femoral access. Unfortunately, radial access is not always available, so a review of the alternatives such as the ulnar artery and distal radial artery has been completed to understand alternative access sites that may preserve the benefits of distal forearm access without losing the efficacy of traditional transradial access.
Several different trials have demonstrated the utility of ulnar access as a possible workhorse access point. These suggest efficacy and safety, but inferior ease-of-access and more crossover than traditional radial access exists. Distal (dorsal) radial access has also been shown to have reasonable efficacy and offer some ergonomic advantages, but this comes at the price that 20–30% of all comers may not have a sufficiently large artery to use.
Understanding the anatomy and techniques required to access the non-traditional, distal forearm arteries increases the skill set of operators. While neither the ulnar nor distal radial appears to substitute completely for radial access, both have potential applications that should be considered, and their utility should not be ignored.
KeywordsComplications Cardiac catheterization Vascular access Review Hemostasis
Compliance with Ethical Standards
Conflict of Interest
Ian C. Gilchrist reports personal fees from Terumo Interventional Systems, Inc., personal fees from Cardinal Health, Inc., personal fees from Abiomed, Inc., outside the submitted work.
Analkumar Parikh declares that there is no conflict of interest. Kelly Q Jia declares that there is no conflict of interest. Sumeet K Lall declares that there is no conflict of interest. Ravi S Shah declares that there is no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
ICG has consulting interests with Terumo Interventional Systems and Cardinal Health without connection to this manuscript. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Mason PJ, Shah B, Tamis-Holland JE, Bittl JA, Cohen MG, Safirstein J, et al. An update on radial artery access and best practices for transradial coronary angiography and intervention in acute coronary syndrome: a scientific statement from the American Heart Association. Circ Cardiovasc Interv. 2018;11:e000035. https://doi.org/10.1161/HCV.0000000000000035.CrossRefPubMedGoogle Scholar
- 2.Shroff AR, Gulati R, Drachman DE, et al. SCAI expert consensus statement update on best practices for transradial angiography and intervention. Catheter Cardiovasc Interv. 2019 Dec 27. https://doi.org/10.1002/ccd.28672.
- 3.•• Bernat I, Aminian A, Pancholy S, Mamas M, Gaudino M, Nolan J, et al. Practice guidelines for the prevention of radial artery occlusion after transradial diagnostic angiography and intervention: an international consensus paper. JACC Cardiovasc Interv. 2019;12(22):2235–46. Recent consensus paper by many of the world experts on radial access on how to prevent radial occlusion. The techniques described not only reduce the need for non-radial forearm access in the future, but are just as applicable to the non-traditional access points of ulnar and distal radial arteries when hemostasis is needed.CrossRefGoogle Scholar
- 6.Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377(9775):1409–20. https://doi.org/10.1016/S0140-6736(11)60404-2.CrossRefPubMedGoogle Scholar
- 7.Mehran R, Pocock S, Nikolsky E, Dangas GD, Clayton T, Claessen BE, et al. Impact of bleeding on mortality after percutaneous coronary intervention: results from a patient-level pooled analysis of the REPLACE-2 (Randomized Evaluation of PCI Linking Angiomax to Reduced Clinical Events), ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy), and HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trials. JACC Cardiovasc Interv. 2011;4(6):654–64. https://doi.org/10.1016/j.jcin.2011.02.011.CrossRefPubMedGoogle Scholar
- 8.Valgimigli M, Gagnor A, Calabró P, Frigoli E, Leonardi S, Zaro T, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomized multicentre trial. Lancet. 2015;385(9986):2465–76. https://doi.org/10.1016/S0140-6736(15)60292-6.CrossRefPubMedGoogle Scholar
- 9.Feldman DN, Swaminathan RV, Kaltenbach LA, Baklanov DV, Kim LK, Wong SC, et al. Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention: an updated report from the National Cardiovascular Data Registry (2007-2012). Circulation. 2013;127(23):2295–306. https://doi.org/10.1161/CIRCULATIONAHA.112.000536.CrossRefPubMedGoogle Scholar
- 10.Romagnoli E, Biondi-Zoccai G, Sciahbasi A, Politi L, Rigattieri S, Pendenza G, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012;60(24):2481–9. https://doi.org/10.1016/j.jacc.2012.06.017.CrossRefPubMedGoogle Scholar
- 11.Bernat I, Horak D, Stasek J, Mates M, Pesek J, Ostadal P, et al. ST-segment elevation myocardial infarction treated by radial or femoral approach in a multicenter randomized clinical trial: the STEMI-RADIAL trial. J Am Coll Cardiol. 2014;63(10):964–72. https://doi.org/10.1016/j.jacc.2013.08.1651.CrossRefPubMedGoogle Scholar
- 13.Mitchell MD, Hong JA, Lee BY, Umscheid CA, Bartsch SM, Don CW. Systematic review and cost-benefit analysis of radial artery access for coronary angiography and intervention. Circ Cardiovasc Qual Outcomes. 2012;5(4):454–62. https://doi.org/10.1161/CIRCOUTCOMES.112.965269.CrossRefPubMedPubMedCentralGoogle Scholar
- 14.Amin AP, Patterson M, House JA, Giersiefen H, Spertus JA, Baklanov DV, et al. Costs associated with access site and same-day discharge among Medicare beneficiaries undergoing percutaneous coronary intervention: an evaluation of the current percutaneous coronary intervention care pathways in the United States. JACC Cardiovasc Interv. 2017;10(4):342–51. https://doi.org/10.1016/j.jcin.2016.11.049.CrossRefPubMedGoogle Scholar
- 17.Hahalis G, Tsigkas G, Xanthopoulou I, Deftereos S, Ziakas A, Raisakis K, et al. Transulnar compared with transradial artery approach as a default strategy for coronary procedures: a randomized trial. The Transulnar or Transradial Instead of Coronary Transfemoral Angiographies Study (the AURA of ARTEMIS Study). Circ Cardiovasc Interv. 2013;6(3):252–61. https://doi.org/10.1161/CIRCINTERVENTIONS.112.000150.CrossRefPubMedGoogle Scholar
- 21.Roghani-Dehkordi F, Mansouri R, Khosravi A, Mahaki B, Akbarzadeh M, Kermani-Alghoraishi M. Transulnar versus transradial approach for coronary angiography and angioplasty: considering their complications. ARYA Atherosclerosis. 2018;14(3):128–31. https://doi.org/10.22122/arya.v14i3.1586.CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Dahal K, Rijal J, Lee J, Korr KS, Azrin M. Transulnar versus transradial access for coronary angiography or percutaneous coronary intervention: a meta-analysis of randomized controlled trials. Catheter Cardiovasc Interv. 2016;87(5):857–65. https://doi.org/10.1002/ccd.26221.CrossRefPubMedGoogle Scholar
- 24.Agostoni P, Zuffi A, Faurie B, Tosi P, Samim M, Belkacemi A, et al. Same wrist intervention via the cubital (ulnar) artery in case of radial puncture failure for percutaneous cardiac catheterization or intervention: the multicenter SWITCH registry. Int J Cardiol. 2013;169(1):52–6. https://doi.org/10.1016/j.ijcard.2013.08.080.CrossRefPubMedGoogle Scholar
- 27.Kedev S, Zafirovska B, Antov S, Kostov J, Spiroski I, Boshev M, et al. Total wrist access for angiography and interventions: procedural success and access site crossover in a high volume transradial center. Cardiovasc Revasc Med. 2018;19(5 Pt B):570–4. https://doi.org/10.1016/j.carrev.2017.12.009.CrossRefPubMedGoogle Scholar
- 28.Baumann F, Roberts JS. Evolving techniques to improve radial/ulnar artery access: crossover rate of 0.3% in 1,000 consecutive patients undergoing cardiac catheterization and/or percutaneous coronary intervention via the wrist. J IntervCardiol. 2015;28(6):396–404. https://doi.org/10.1111/joic.12213.CrossRefGoogle Scholar
- 31.• Roghani-Dehkordi F, Hashemifard O, Sadeghi M, Mansouri R, Akbarzadeh M, Dehghani A, et al. Distal accesses in the hand (two novel techniques) for percutaneous coronary angiography and intervention. ARYA Atheroscler. 2018;14(2):95–100. https://doi.org/10.22122/arya.v14i2.1743. A summary of both distal radial and palmar approaches for access from the group that pioneered these non-traditional radial approaches.CrossRefPubMedPubMedCentralGoogle Scholar
- 38.•• Kar S. Systematic review of alternative access for cardiac catheterization and percutaneous coronary intervention: dorsal distal radial and ulnar artery catheterization. Catheter Cardiovasc Interv. 2019;94(5):706–13. https://doi.org/10.1002/ccd.28398. This review not only distills the published trials of ulnar vs. radial artery access, but also provides a review of technical approaches for these access points.CrossRefPubMedGoogle Scholar
- 39.Gupta C, Ray B, Dsouza AS, Nair N, Pai SR, Manju M. A morphological study of variations in the branching pattern and termination of the radial artery. Singap Med J. 2012;53(3):208–11.Google Scholar
- 41.Naito T, Sawaoka T, Sasaki K, Iida K, Sakuraba S, Yokohama K, et al. Evaluation of the diameter of the distal radial artery at the anatomical snuff box using ultrasound in Japanese patients. Cardiovasc Interv Ther. 2019;34(4):312–6. https://doi.org/10.1007/s12928-018-00567-5.CrossRefPubMedGoogle Scholar