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Transradial access is an important tool for many neuroendovascular procedures. Occlusion of the radial or ulnar artery is not uncommon after transradial or transulnar access and can present a challenge for patients requiring repeat angiography. Between March 2022 and June 2023, patients undergoing transradial or transulnar angiography who were found to have a radial artery occlusion or ulnar artery occlusion were identified. Repeat catheterization of the occluded artery was attempted using a 21-gauge single wall puncture needle and a 0.021-inch wire to traverse the occlusion and insert a 23-cm sheath into the brachial artery. A total of 25 patients undergoing 26 angiograms during the study period were found to have a radial artery occlusion or ulnar artery occlusion. Successful repeat catheterization of the occluded artery was achieved in 21 of 26 cases (80.7%). Outer diameter sheath size ranged from 5 Fr (0.0655 inch) to 8 Fr (0.1048 inch). No access complications were encountered. Number of prior angiograms, time since prior angiogram, and prior angiogram procedure time were associated with lower likelihood of successful access. Transradial or transulnar neuroangiography through an occluded radial or ulnar artery is safe and feasible by traversing the occlusion into the brachial artery with a 23-cm sheath. Repeat catheterization is most successful in patients with an arterial occlusion <6 months old. This technique is important in patients who have limited options for arterial access, avoiding access site complications inherent in transfemoral access, and in patients who specifically require radial or ulnar artery access. [ABSTRACT FROM AUTHOR]

Arterial access in coronary angiography has always been an important issue. Convincing prognostic data from large randomized controlled trials (RCTs) in the first place but also safe performance of same-day-discharge after diagnostic and interventional procedures, improved patient comfort and cost-effectiveness led to a paradigm shift from the transfemoral approach (TFA) to the transradial approach (TRA) in several clinical situations. Consequently, today's relevant guidelines recommend a radial-first strategy as default approach. However, there is still strong controversy among interventional cardiologists resulting in delayed spread of the TRA causing significant regional differences. One major critics point is the rate of postprocedural radial artery occlusion (RAO) after using the traditional puncture site at the proximal radial artery (pTRA) which was registered too high in certain centers. A new access using the distal radial artery (dTRA) in the area of the snuff box (SB) and the dorsal box (DB) has been proven to minimize RAO and enabling even complex interventions using 7F guiding catheters. Although, dTRA seems to be an advantageous option, this approach is still not widely used. This review--addressed to beginners and even advanced interventionalists--presents all arterial access routes in interventional cardiology. It focusses on those to be routinely preferred and also on the possibility to guide the puncture with ultrasound. Thereby, the various approaches, including the transulnar (TRU) but also the still relevant TFA approach, are discussed in detail. Thereby, we introduce our philosophy of "radial freedom" and a new classification for TRA. [ABSTRACT FROM AUTHOR]

Objectives: Coronary diagnostics and interventions have come a long way. For decades the femoral artery has been the access of choice , until radial artery was found to be a viable alternative for coronary and non coronary interventions. We present here our experiences and an analytical review of our transulnar journey, spanning nearly a decade of inhibitions and tentativeness of using it as an alternative , to an upfront route of choice based on arterial dominance. Materials and Methods: We did a retrospective analysis based on interventions done through the transulnar route between Jan 2015 and Dec 2023. Both the operators in the study were experts in transradial procedures with an experience of more than 5000 each radial procedures. Results: Arterial dominance was assessed by palpation , and was defined as the more intensely palpable pulse at the wrist. Ulnar dominance was seen in 57.6 percent of the cases. Spasm was encountered in the ulnar artery in just a single case, and 4 cases (2.6%) had loops and tortuosities. The mean fluoroscopy time for coronary angiography was 1.5 mins. Conclusion: Transulnar route is a safe and effective alternative to radial approach in coronary diagnostic and interventional procedures. The principle of arterial dominance at the wrist is a good way for selection of access routes. [ABSTRACT FROM AUTHOR]

Arterial access in coronary angiography has always been an important issue. Convincing prognostic data from large randomized controlled trials (RCTs) in the first place but also safe performance of same-day-discharge after diagnostic and interventional procedures, improved patient comfort and cost-effectiveness led to a paradigm shift from the transfemoral approach (TFA) to the transradial approach (TRA) in several clinical situations. Consequently, today’s relevant guidelines recommend a radial-first strategy as default approach. However, there is still strong controversy among interventional cardiologists resulting in delayed spread of the TRA causing significant regional differences. One major critics point is the rate of postprocedural radial artery occlusion (RAO) after using the traditional puncture site at the proximal radial artery (pTRA) which was registered too high in certain centers. A new access using the distal radial artery (dTRA) in the area of the snuff box (SB) and the dorsal box (DB) has been proven to minimize RAO and enabling even complex interventions using 7F guiding catheters. Although, dTRA seems to be an advantageous option, this approach is still not widely used. This review—addressed to beginners and even advanced interventionalists—presents all arterial access routes in interventional cardiology. It focusses on those to be routinely preferred and also on the possibility to guide the puncture with ultrasound. Thereby, the various approaches, including the transulnar (TRU) but also the still relevant TFA approach, are discussed in detail. Thereby, we introduce our philosophy of “radial freedom” and a new classification for TRA.

Despite the increasing worldwide adoption of the transradial access site, the ulnar artery (UA) only very infrequently serves as a primary option for coronary procedures. In contrast to the uncertainty surrounding previous reports regarding the feasibility and safety, recent data from larger registries and randomized trials provide more conclusive evidence that the transulnar route may be safely selected as an alternative arterial access approach. However, a default transulnar strategy appears time-consuming and is associated with higher crossover rates compared with the radial artery (RA). Once arterial access is obtained, the likelihood of a successful coronary procedure is high and similar between the two forearm arteries. The UA has similar flow-mediating vasodilating properties with and seems at least as vulnerable as the RA with regard to incident occlusion, with UA occlusion (UAO) rates being probably higher than previously anticipated. A learning curve effect may not be apparent for crossover rates among experienced radialists, but increasing experience is associated with reduction in the fluoroscopy time, contrast volume and frequency of large hematoma formation. The UA may represents an important alternative access site for coronary procedures, and experienced radial operators should obtain additional skills to perform the transulnar approach. Nevertheless, in view of this method's lower feasibility compared to the RA, an initial ulnar access strategy should be reserved for carefully selected patients to ensure satisfactory cannulation rates.

Objective To assess the crossover rate from primarily chosen transradial access (TRA) in a high volume transradial center. Methods All consecutive 30,848 patients, that underwent diagnostic angiography and/or intervention in the period from 2010 until 2015 were examined. Preprocedural radial artery angiography was performed in all patients since 2011. Clinical and procedure characteristics, reason for crossover and its direction were analyzed. Primary end-point of the study was the occurrence of TRA failure and need to crossover to another approach to finish the procedure. Results Procedural success of primarily chosen TRA was 94% (n = 28,988). Crossover to other access sites was 6% (n = 1860). Most common reason for crossover was inability to puncture the right radial artery in 4,1%, presence of radial artery anomalies (0,3%), high grade spasm (0,1%), or radial artery occlusion (1,2%). Crossover direction was primarily through the ipsilateral transulnar access (TUA) 3,8%, left radial access (LRA) 1,5% and in only 0,6% (n = 189) of patients to transfemoral access (TFA). Access site bleeding complications were present in 5,1% (n 1579). Conclusion Total wrist access is feasible and safe with low rate of access site complications and crossovers, especially when performed in experienced high volume transradial center. [ABSTRACT FROM AUTHOR]

BackgroundIncidence of radial artery occclusions (RAO) and ulnar artery occclusions (UAO) in coronary procedures, factors predisposing to forearm arteries occlusion, and the benefit of anticoaggulation vary significantly in existing literature. We sought to determine the incidence of RAO/UAO and the impact of anticoagulation intensity. Methods and ResultsMeta‐analysis of 112 studies assessing RAO and/or UAO (N=46 631) were included. Overall, there was no difference between crude RAO and UAO rates (5.2%; 95% confidence interval [CI], 4.4–6.0 versus 4.0%; 95% CI, 2.8–5.8; P=0.171). The early occlusion rate (in‐hospital or within 7 days after procedure) was higher than the late occlusion rate. The detection rate of occlusion was higher with vascular ultrasonography compared with clinical evaluation only. Low‐dose heparin was associated with a significantly higher RAO rate compared with high‐dose heparin (7.2%; 95% CI, 5.5–9.4 versus 4.3%; 95% CI, 3.5–5.3; Q=8.81; P=0.003). Early occlusions in low‐dose heparin cohorts mounted at 8.0% (95% CI, 6.1–10.6). The RAO rate was higher after diagnostic angiographies compared with coronary interventions, presumably attributed to the higher intensity of anticoagulation in the latter group. Hemostatic techniques (patent versus nonpatent hemostasis), geography (US versus non‐US cohorts) and sheath size did not impact on vessel patency. ConclusionsRAO and UAO occur with similar frequency and in the order of 7% to 8% when evaluated early by vascular ultrasonography following coronary procedures. More‐intensive anticoagulation is protective. Late recanalization occurs in a substantial minority of patients.

Background: Switching to femoral after a failed radial approach carries an increased risk of bleeding complications since the femoral artery puncture is performed in patients already anticoagulated. Moreover, dedicated radial operators find it more and more difficult to use the femoral approach, and ulnar artery cannulation provides them with the opportunity to further reduce its use. Our objective was to evaluate the feasibility and safety of ipsilateral radial and ulnar artery cannulation during the same coronary catheterization procedure. Methods: We performed a retrospective analysis of all cardiac catheterizations, from January 2015 until June 2016, with initial radial approach and conversion to ipsilateral ulnar approach. Patients with sheath insertion both in radial and ipsilateral ulnar arteries were further evaluated. Results: Four thousand one hundred and two procedures were performed during the study period, and 3,876 (94.5 %) of them were performed initially through a radial approach. Radial and ipsilateral ulnar catheterization was accomplished in nine patients, resulting in successful catheterization and procedure completion, without any serious complications recorded. Conclusions: Ipsilateral radial and ulnar artery catheterization proved to be feasible and safe, without any serious complications. [ABSTRACT FROM AUTHOR]