Percutaneous Coronary Intervention via Transulnar Sheathless Approach

ABSTRACT: Diagnostic and interventional coronary procedures via cannulation of the radial artery have proven to be useful in patients with acute coronary syndrome (ACS) ST-segment elevation myocardial infarction, non-ST-segment elevation ACS, and non-ACS clinical syndromes.^1,2 In many patients, vascular access and catheter advancement can be difficult due to vessel size, vasospasm, anatomical branching variations, and catheter manipulation. The ulnar artery may prove to be a preferred alternative in many cases where the radial artery is unable to be utilized.³ Furthermore, the use of large caliber catheters through these smaller caliber vessels also limits the use of some devices for treatment of bifurcation lesions. We report the use of a sheathless percutaneous coronary intervention through the ulnar artery.

In this case a sheathless technique was shown. The sheathless catheter has already been shown as safe in small case series and in a multicenter registry.^4-6 With a smaller luminal diameter than that of traditional sheath systems, the risk of vasospasm, vascular damage, radial artery occlusion, and bleeding complications, even in maximal platelet inhibition, is theoretically reduced.⁷  

J INVASIVE CARDIOL 2011;24(7):E157-E158

Key words: PCI, transulnar, sheathless

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Case Report. A 78-year-old woman with history of hypertension and coronary artery disease was admitted for unstable angina. Her physical examination showed no jugular venous distention, normal heart sounds, and no lower extremity edema. Her 12-lead EKG showed sinus rhythm with non-specific ST-T abnormalities. Her right radial artery patency was documented by a normal Allen’s test and we then cannulated the right ulnar artery with a micro-puncture kit (Cook Medical). A 5 Fr glide-sheath (Terumo) was inserted. Heparin 5000 U, nitroglycerin 100 ug, and verapamil 1 mg was given as a cocktail through the sheath. Cardiac catheterization showed a patent left main artery, a tight stenosis in left anterior descending artery (LAD)/diagonal bifurcation lesion, a patent left circumflex artery, and a patent right coronary artery. Left ventriculogram showed normal left ventricular ejection fraction and wall motion. We planned percutaneous coronary intervention for the LAD/diagonal bifurcation lesions and performed a sheathless approach using a cook Flexor sheath (Cook) as inside dilator in a 7 Fr EBU 3.5 guiding catheter (Medtronic Medical) (Figure 1). The LAD/diagonal bifurcation lesions were treated with a 3.5 mm x 15 mm Promus stent (Boston Scientific) and kissing balloon inflations of LAD/diagonal lesions (Figure 2). The final angiogram showed excellent result (Figure 3). The patient did clinically well and was able the leave the hospital the following day. Ulnar artery was patent by palpation and plethysmography at 1-, 7-, and 30-day follow-up.

Discussion. Use of the radial artery is often preferred for many reasons. In addition to patient comfort, rapidity of mobility post-procedure, and reduced bleeding complications, other advantages include its superficial course, the dual blood supply to the hand, its distance from major veins and nerves, and the protection of surrounding bony and tendinous structures. As a result the radial procedure is cost-effective and allows for shorter hospital stays. For the vast majority of patients, the smaller caliber and more superficial radial artery is easier to palpate at the wrist than the ulnar artery. The radial artery is properly the target for access in these individuals.

There are also reasons to consider the ulnar artery. The radial artery access site failure is 4%-6%. According to Benit et al, nearly 30% of consecutive patients undergoing cardiac catheterization had an abnormal modified Allen’s Test as in our patient. In a small number of patients, however, the ulnar artery is palpably the larger vessel at the wrist and is the reasonable choice for cannulation. It is also larger in diameter with fewer alpha-receptors than the radial artery, and also likely has a lower risk of vasospasm when compared to transradial access. But numerous studies suggest smaller catheter size leads to fewer vascular complications.⁸ The use of a sheathless system can reduce the access site size by approximately 2 Fr and can theoretically reduce the complications of vascular access including arterial occlusion.⁹

Some special considerations should be taken when using the ulnar artery. Significant anatomic variations include tortuous configurations, stenoses, hypoplasia, and radioulnar loops. Approximately 25% of these variations were deemed inaccessible. The ulnar artery also courses near the ulnar nerve and special precautions should be undertaken to avoid serious complication. Neural trauma to the ulnar nerve, which runs parallel and along its medial border, can be avoided with careful placement of a small-gauge needle. Despite these stipulations there is a high success rate for ulnar interventions with few vascular complications. Occlusion with ischemic hand injury appears to be uncommon but complications also include ulnar nerve damage, spasm, hematoma, and pseudoaneurysm. The superficial palmar arch and the deep palmar arch are functionally important arterial connections between their major sources, the ulnar artery, and the radial artery, respectively. Although the deep palmar arch is found to be angiographically complete in 95% of subjects, a complete superficial palmar arch is seen in only 40%-80% of individuals depending on the mode of study. This probably explains the relatively high incidence of abnormal Allen tests, an indication that ulnar collateral support to the hand is inadequate in a significant number of individuals. Thus, the collaterals of radial and ulnar arteries can provide adequate collaterals despite abnormal Allen tests.

In conclusion, this case report shows evidence that a sheathless system via the ulnar artery for percutaneous intervention is safe and feasible. With smaller Fr size catheters and access to the ulnar artery in the wrist, it can provide an alternative means for access in both diagnostic and percutaneous coronary intervention.

References

1. Jolly SS, Yusuf S, Cairns J, et al; for the RIVAL trial group. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377(9775):1409-1420.
2. Kanei Y, Kwan T, Nakra NC, et al. Transradial cardiac catheterization: a review of access site complications. Catheter Cardiovasc Interv. 2011;78(6):840-846. 
3. Agostoni P, Zuffi A, Biondi-Zoccai G. Pushing wrist access to the limit: homolateral right ulnar artery approach for primary percutaneous coronary intervention after right radial failure due to radial loop. Catheter Cardiovasc Interv. 2011;78(6):894-897.
4. Youn YJ, Yoon J, Han SW, et al. Feasibility of transradial coronary intervention using a sheathless guiding catheter in patients with small radial artery. Korean Circ J. 2011;41(3):143-148.
5. Sciahbasi A, Mancone M, Cortese B, et al. Transradial percutaneous coronary interventions using sheathless guiding catheters: a multicenter registry. J Interv Cardiol. 2011;24(5):407-412.
6. Chiam PT, Liu B, Wong AS, et al. Comparison of novel 6.5 Fr sheathless guiding catheters versus 5 Fr guiding catheters for transradial coronary intervention. EuroIntervention. 2011;7(8):930-935.
7. Mamas M, D'Souza S, Hendry C, et al. Use of the sheathless guide catheter during routine transradial percutaneous coronary intervention: a feasibility study. Catheter Cardiovasc Interv. 2010;75(4):596-602.
8. Saito S, Ikei H, Hosokawa G, Tanaka S. Influence of the ratio between radial artery inner diameter and sheath outer diameter on radial artery flow after transradial coronary intervention. Catheter Cardiovasc Interv. 1999;46(2):173-178.
9. Kwan T, Cherukuri S, Huang Y, et al. Feasibility and safety of 7F sheathless guiding catheter during transradial coronary intervention. Catheter Cardiovasc Interv. 2011. [Epub ahead of print]

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From the Asian Service Center, Beth Israel Medical Center, New York, New York.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted February 22, 2012, provisional acceptance given March 29, 2012, final version accepted April 4, 2012.
Address for correspondence: Dr. Tak W. Kwan, Executive Chief, Asian Service Center, 139 Centre Street, Rm 307, New York, NY 10013, USA. Email: kwancardio@aol.com