Ulnar Artery Access in Chronic Total Occlusion Percutaneous Coronary Intervention

BACKGROUND: Ulnar artery access may provide an alternative access route for chronic total occlusion percutaneous coronary intervention (CTO PCI), but data is limited. AIMS: To assess the utilization, patient characteristics, and in-hospital outcomes of ulnar artery access compared with radial access and non-ulnar access in patients undergoing CTO PCI. METHODS: We analyzed patients who underwent CTO PCI between 2012 and 2024 at 51 centers within the PROGRESS-CTO Registry. Patients were stratified by access: (1) no radial/ulnar, (2) radial without ulnar, and (3) ulnar. The primary endpoint was in-hospital major adverse cardiovascular events (MACE). Secondary endpoints included technical success. Multivariable logistic regression was used to identify independent predictors of outcomes. RESULTS: Among 18,826 patients, 8844 (47.0%) had no radial/ulnar access, 9835 (52.2%) radial without ulnar, and 147 (0.8%) ulnar. Ulnar patients were younger (62.5 ± 10.4 vs. 64.0 ± 10.4 radial and ulnar, 65.1 ± 10.5 no radial/ulnar, p < 0.001) and had higher prevalence of prior PCI (73.6% vs. 59.3% and 64.0%, p < 0.001) and peripheral arterial disease (23.9% vs. 12.1% and 15.1%, p < 0.001). Lesion complexity was lower with ulnar access (J-CTO 2.19 ± 1.27 vs. 2.32 ± 1.27 radial and 2.47 ± 1.21 no radial/ulnar, p < 0.001). In-hospital outcomes were similar: MACE (2.7% ulnar vs. 1.8% radial vs. 2.0% no radial/ulnar, p = 0.315), technical success (83.7% vs. 87.3% vs. 87.2%, p = 0.425), and access complications (0.7% vs. 0.7% vs. 1.2%, p = 0.001). Logistic regression showed no independent association between ulnar access and MACE, technical success, or access-site complications. CONCLUSION: In the largest series to date, ulnar access was used in 0.8% of CTO PCI with similar outcomes to radial and femoral access. Given its use in lower complexity cases, these findings are hypothesis-generating and warrant prospective evaluation.