Transulnar artery access (TUA) with ipsilateral radial artery occlusion (RAO) for percutaneous coronary procedures: Results from the TUA RAO study

Aims This research comes from the increasing need for an alternative wrist access approach in PCI when the standard right radial is not accessible, most commonly due to the presence of RAO. Its use is still controversial in the interventional community, due to lack of data. Our purpose was to present long-term experience of over a decade with this approach. Materials and methods In a 10-year period from March 2011 until December 2021, 1756 patients at our center underwent PCI through primarily chosen TUA with ipsilateral radial occlusion. All patients were followed for procedural success and safety. In a the period from 2019 until 2021, we additionally performed a thorough analysis of 103 of these consecutive TUA RAO patients with anatomical, functional and pain assessment of the punctured arm, performed at baseline and after the procedure and up to 1 year of follow-up. Functional assessment of the arm was performed using JAMAR dynamometer for hand strength and self-assessment with QUICK DASH questionnaire. VAS score was used for pain assessment. Clinical and duplex ultrasound evaluation for ulnar patency were examined. Pre-procedural UA angiography was used to measure the diameter of the UA and the collateral circulation for the occluded RA, using QCA (Quantitative angiography). Results All 1756 TUA procedures were successfully performed without ischemic complications of the punctured arm. The main analyzed group of 103 patients had a mean age of 62.9 ± 9 years with 30% females. Previous TRA was present in all patients, 32% of patients had multiple previous TRA (>3), with 10 being the largest number. Puncture success through primary chosen TUA with ipsilateral RAO was 96,2%. In 4 (3,8%) patients we had an inability to puncture the right UA and were transferred to left TRA. Procedural success after UA puncture was 100%. The number of punctures of the UA was 1.6±0.9 (1-6 punctures). Access site bleeding complications were detected in 4% (EASY score > 2). On duplex ultrasound follow up, there wasn’t a single case of UAO detected. There were no clinical or ischemic hand complications seen during long-term follow up. Local bleeding complications were found to be related to higher number of punctures, time of puncture and longer procedural time (p<0.0001). Dynamometer values of hand strength showed a small decrease in values 12 hours after procedure (72.6±23 vs.71.9p, p=0.029), but without changes in initial strength on follow up on 1, 6 and up to 1 year after procedure. QUICK DASH self-assessment showed no significant changes in the follow-up period. QCA assessment showed an increasing of UA diameter after RAO of 0.28±0.35мм over time (p<0,0001). Conclusion Transulnar approach with ipsilateral RAO is safe and successful for PCI in experienced radial centers. Anatomical, functional and pain assessment of the punctured arm affirmed the safe use of this approach as the best alternative for right TRA and preservation of wrist access benefits.TUA RAO QCA measurment