Abstract
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.
Recent findings
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.
Summary
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.
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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.
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.
•• 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.
Parikh A, Gilchrist IC. The pulseless radial artery in transradial catheterization: challenges and solutions. Expert Rev Cardiovasc Ther. 2019. https://doi.org/10.1080/14779072.2019.1691917.
Rao SV, Cohen MG, Kandzari DE, Bertrand OF, Gilchrist IC. The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions. J Am Coll Cardiol. 2010;55(20):2187–95. https://doi.org/10.1016/j.jacc.2010.01.039.
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.
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.
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.
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.
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.
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.
Cooper CJ, El-Shiekh RA, Cohen DJ, Blaesing L, Burket MW, Basu A, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. Am Heart J. 1999;138(3 Pt 1):430–6.
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.
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.
Aptecar E, Pernes JM, Chabane-Chaouch M, Bussy N, Catarino G, Shahmir A, et al. Transulnar versus transradial artery approach for coronary angioplasty: the PCVI-CUBA study. Catheter Cardiovasc Interv. 2006;67(5):711–20.
Li YZ, Zhou YJ, Zhao YX, Guo YH, Liu YY, Shi DM, et al. Safety and efficacy of transulnar approach for coronary angiography and intervention. Chin Med J. 2010;123(13):1774–9.
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.
Geng W, Fu X, Gu X, Jiang Y, Fan W, Wang Y, et al. Safety and feasibility of transulnar versus transradial artery approach for coronary catheterization in non-selective patients. Chin Med J. 2014;127(7):1222–8.
Liu J, Fu XH, Xue L, Wu WL, Gu XS, Li SQ. A comparative study of transulnar and transradial artery access for percutaneous coronary intervention in patients with acute coronary syndrome. J Interv Cardiol. 2014;27:525–30.
Gokhroo R, Kishor K, Ranwa B, Bisht D, Gupta S, Padmanabhan D, et al. Ulnar artery interventions non-inferior to radial approach: AJmer Ulnar ARtery (AJULAR) Intervention Working Group study results. J Invasive Cardiol. 2016;28(1):1–8.
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.
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.
Fernandez R, Zaky F, Ekmejian A, Curtis E, Lee A. Safety and efficacy of ulnar artery approach for percutaneous cardiac catheterization: systematic review and meta-analysis. Catheter Cardiovasc Interv. 2018;91(7):1273–80. https://doi.org/10.1002/ccd.27479.
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.
Hsueh SK, Cheng CI, Fang HY, Omran MM, Liu WH, Chung WJ, et al. Feasibility and safety of transulnar catheterization in ipsilateral radial artery occlusion. Int Heart J. 2017;58(3):313–9. https://doi.org/10.1536/ihj.16-244.
Kedev S, Zafirovska B, Dharma S, Petkoska D. Safety and feasibility of transulnar catheterization when ipsilateral radial access is not available. Catheter Cardiovasc Interv. 2014;83(1):E51–60. https://doi.org/10.1002/ccd.25123.
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.
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.
Amato JJ, Solod E, Cleveland RJ. A “second” radial artery for monitoring the perioperative pediatric cardiac patient. J Pediatr Surg. 1977;12(5):715–7. https://doi.org/10.1016/0022-3468(77)90399-2.
Babunashvili A, Dundua D. Recanalization and reuse of early occluded radial artery within 6 days after previous transradial diagnostic procedure. Catheter Cardiovasc Interv. 2011;77(4):530–53. https://doi.org/10.1002/ccd.22846.
• 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.
Kiemeneij F. Left distal transradial access in the anatomical snuffbox for coronary angiography (ldTRA) and interventions (ldTRI). EuroIntervention. 2017;13(7):851–7. https://doi.org/10.4244/EIJ-D-17-00079.
Davies RE, Gilchrist IC. Back hand approach to radial access: the snuff box approach. Cardiovasc Revasc Med. 2018;19(3 Pt B):324–6. https://doi.org/10.1016/j.carrev.2017.08.014.
Al-Azizi KM, Grewal V, Gobeil K, Maqsood K, Haider A, Mohani A, et al. The left distal transradial artery access for coronary angiography and intervention: a US experience. Cardiovasc Revasc Med. 2019;20(9):786–9. https://doi.org/10.1016/j.carrev.2018.10.023.
Coughlan JJ, Zebrauskaite A, Arnous S, Kiernan TJ. Left distal trans-radial access facilitates earlier discharge post-coronary angiography. J Interv Cardiol. 2018;31(6):964–8. https://doi.org/10.1111/joic.12559.
Koutouzis M, Kontopodis E, Tassopoulos A, Tsiafoutis I, Katsanou K, Rigatou A, et al. Distal versus traditional radial approach for coronary angiography. Cardiovasc Revasc Med. 2019;20(8):678–80. https://doi.org/10.1016/j.carrev.2018.09.018.
Valsecchi O, Vassileva A, Cereda AF, Canova P, Satogami K, Fiocca L, et al. Early clinical experience with right and left distal transradial access in the anatomical snuffbox in 52 consecutive patients. J Invasive Cardiol. 2018;30(6):218–23.
•• 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.
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.
Hull JE, Kinsey EN, Bishop WL. Mapping of the snuffbox and cubital vessels for percutaneous arterial venous fistula (pAVF) in dialysis patients. J Vasc Access. 2013;14(3):245–51. https://doi.org/10.5301/jva.5000127.
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.
Davies RE, Gilchrist IC. Dorsal (distal) transradial access for coronary angiography and intervention. Interv Cardiol Clin. 2019;8(2):111–9. https://doi.org/10.1016/j.iccl.2018.11.002.
Gilchrist IC. Dorsal radial access: is the back door to the arterial system ready to be the workhorse entry? Cardiovasc Revasc Med. 2019;20(9):735–6. https://doi.org/10.1016/j.carrev.2019.07.011.
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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.
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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.
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Parikh, A., Jia, K.Q., Lall, S.K. et al. Distal Radial and Ulnar Arteries: the Alternative Forearm Access. Curr Treat Options Cardio Med 22, 1 (2020). https://doi.org/10.1007/s11936-020-0801-9
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DOI: https://doi.org/10.1007/s11936-020-0801-9