Abstract
Trans-ulnar access is a viable alternative approach by experienced operators when the radial and femoral arteries cannot be accessed or used to preserve the contralateral radial artery as possible vascular graft for coronary bypass surgery, hemodynamic monitoring, or shunt creation for hemodialysis. We report a challenging case of ipsilateral trans-ulnar recanalization of a chronic radial artery occlusion, which allowed us to perform a complex trans-ulnar PCI.
Highlights
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With the increasing rates of trans-radial access use in catheterization laboratories, patency and functional integrity of radial artery becomes an important aspect of patient care. Significant radial artery injury with radial artery occlusion (RAO) can be permanent and preclude its future use as a conduit for cardiac catheterization, intervention, coronary graft, hemodialysis or invasive monitoring.
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Trans-ulnar access demonstrated to be a viable alternative approach in such cases. However, RAO is usually considered a contraindication to use the ipsilateral ulnar artery as alternative access site.
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This is a challenging case reportingthe first description of ipsilateral trans-ulnar recanalization of a chronic RAO allowing for a subsequent complex trans-ulnar PCI.
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Our case reports an alternative access to recanalize RAO and emphasizes the role of ulnar access as alternative to radial approach, in highly selected cases.
A 55-year-old man with a history of severe iliaco-femoral artery disease treated with previous stenting, and a stage 4 chronic kidney disease was admitted for recurrent exertional angina. He previously underwent to right transradial percutaneous coronary interventions (PCI) on circumflex and right coronary arteries. Right radial artery approach was planned to perform coronary angiography because of a positive modified Allen test. However, after a micropuncture of the radial artery, despite pulsatile blood flow back, a 0.021″ introducer wire and subsequently several 0.014″ wires failed to advance more than a few centimeters into the vessel. Given the issues with peripheral accesses and to preserve the left radial artery for an eventual hemodialysis, a right ulnar approach was attempted. The ulnar artery was cannulated with a 6-French hydrophilic sheath and a cocktail (composed of 200 μcg of nitroglycerine, 2 mg of verapamil, 2 ml of xylocaine2%) and 5000 IU of heparin were given intra-arterially as a rapid bolus. A 6-French Sones type 2 catheter (Cordis Corporation, Fremont, CA, USA) was then advanced into the vessel. Angiography of right forearm and palmar arteries confirmed the presence radial artery occlusion (RAO) with small anastomotic branches between interosseous arteria and distal radial artery ( Fig. 1 A , Video 1 ). An attempt to recanalize the RAO through the ulnar access was therefore performed. A 5-French Bartorelli-Cozzi catheter (Cordis) was used to engage the radial artery from the ulnar artery ( Fig. 1 B). The true lumen of the radial artery was gained with an HT Pilot 50 (Abbott Vascular, Illinois, USA) wire ( Fig. 1 C). A 1.5× 10mm Sprinter Legend (Medtronic Minneapolis, MN, USA) over the wire balloon and an Emerge 3.0 × 30mm (Boston Scientific Minneapolis, MN, USA) balloon were then inflated up to 18 atm. Further, a 3.0 × 40mm Impact Falcon paclitaxel eluting balloon (Medtronic) was inflated at 14 atm for 60′ in the site of the previous RAO ( Fig. 1 D). Final angiography showed a complete radial artery recanalization with flow in the palmar arch ( Fig. 2 , Video 2 ). The patient underwent to coronary angiography ( Videos 3 and 4 ) which demonstrated an intrastent chronic total occlusion of the RCA that was successfully recanalized through trans-ulnar approach ( Video 4 ). No major complications occurred. At 1-year follow-up the patient was asymptomatic and the right radial and ulnar pulses were appreciable on palpation and patent at Doppler evaluation.
