Abstract
Forearm approach for coronary catheterization is associated with better outcomes, compared to the femoral approach. However, the possibility of post catheterization forearm artery occlusion is a medical concern, which leads many patients to be treated transfemorally. We present a case series of patients who had a harvested radial artery and were successfully catheterized from ipsilateral ulnar artery without any complications recorded
Highlights
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We present ulnar approach for catheterization in patients with previously extracted ipsilateral radial artery.
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The anterior interosseous artery arising from the proximal ulnar artery supplies with blood flow the distal part of the extracted radial artery and the palmar arch.
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No complications were observed with this approach.
Forearm (radial or ulnar) approach for coronary angiography and intervention is a worldwide growing method. Compared to the transfemoral approach, the forearm approach is associated with less access site bleedings , allows patients’ earlier ambulation is associated with better patients’ comfort and with mortality reduction in patients with ST elevation myocardial infarction . The main complication of this method is the occlusion of the forearm artery after catheterization, with an incidence of 1–10% in different trials .
Hand blood supply is provided by superficial and deep palmar arches . The formation of these arches and their variations are presented in Table 1 .
Until recently, Allen’s or Barbeau’s tests were performed in most of the patients selected the forearm approach, for evaluation of functional hand perfusion. Recently we showed that the transradial approach is feasible and safe in patients with negative Allen’s test , even if the radial artery is occluded after the procedure. However, the feasibility and safety of the transulnar approach in patients with previously harvested ipsilateral radial artery has never been evaluated before. We report three cases of transulnar coronary catheterization in patients with previous ipsilateral radial artery extraction.
Case 1: A 72 year old man with history of prior myocardial infarction 12 years ago, peripheral artery disease, surgical coronary revascularization and harvested left radial artery in order to be used as a coronary graft, was referred to our department of coronary angiography due to chest pain, worsening functional status and a slight troponin I elevation. He was treated with rivaroxaban 20 mg daily due to paroxysmal atrial fibrillation. Our first option was to proceed through the right radial approach, but due to a very weak pulse the radial sheath could not be inserted successfully. The right ulnar artery was not palpable, so we chose the left ulnar approach as our next step, due to the increased risk of bleeding with the transfemoral approach in this patient (peripheral artery disease, treatment with rivaroxaban). The left ulnar artery was successfully canalized with a 5Fr, 11 cm long sheath (KDL, China) ( Fig. 1 ). Verapamil (5 mg) and unfranctionated heparin (50 IU/Kgr) were administered intra sheath. Coronary angiography was performed without any technical problems and revealed totally occluded native vessels, but open and functioning coronary grafts (left internal mammary artery to distal left anterior descending artery, vein graft to posterior descending artery and radial artery to first obtuse marginal artery). At the end of the procedure, forearm angiography was performed and showed an absent radial artery and a well functioning anterior interosseous artery arising from the proximal part of the ulnar artery ( Fig. 2 , Panel A) supplying the palmar arch through the remaining very distal part of the radial artery ( Fig. 2 , Panel B). The sheath was removed and a closure device (KDL, China) was applied over the puncture site with documented patent hemostasis. The closure device was removed after four hours and the patient was discharged without any complications and a patent left ulnar artery checked by Duplex ultrasonography.
