Post-procedural ultrasound findings linked to symptomatic radial artery occlusion following transradial coronary intervention

BACKGROUND: Radial artery occlusion (RAO) after transradial PCI is the most common vascular complication. While prior studies highlight sheath size, sheath-to-artery ratio and hemostasis technique, radial tortuosity and a dominant ulnar artery have been less explored. OBJECTIVES: Evaluate post-procedural vascular ultrasound-defined anatomical features linked to established, symptomatic RAO and describe reperfusion outcomes. METHODS: In a single-center observational cohort, 103 post-PCI patients underwent vascular ultrasound (51 RAO, 52 controls). Measured variables included radial/ulnar diameters, tortuosity and high brachial bifurcation. Multivariable logistic regression with Firth correction identified independent associated factors. Follow-up vascular ultrasound was available in a subset. RESULTS: Dominant ulnar artery (≥0.24 cm and larger than the radial) was independently associated with RAO (OR 8.0, p = 0.02), as was radial tortuosity (OR 4.0, p = 0.03). Prior ipsilateral radial access carried a strong association (OR = 15) but was insignificant (p = 0.06). The final model showed excellent discrimination (AUC 0.93). At follow-up (n = 26), most RAO cases remained occluded despite anticoagulation; only two patients demonstrated late reperfusion at 5-6 months. CONCLUSIONS: Post-procedural vascular ultrasound demonstrated that dominant ulnar perfusion and radial tortuosity were strongly associated with symptomatic RAO. While causality cannot be inferred, these findings generate hypotheses that selected anatomical patterns may be associated with increased susceptibility and warrant prospective validation. A "vascular ultrasound-first" strategy warrants evaluation prospectively to preserve radial patency.