Introduction: To date, the transulnar access (TUA) is used in individual cases after the transradial access (TRA) failed. The TUA´s value for daily practice is uncertain.  

Methods: Since 2017 we performed a modified and ultrasound-guided puncture of the ulnar artery. As part of the Forearm if Feasible Access (FIFA)-protocol, starting 1/2020, we included the TUA into our daily clinical routine. For every case of CC/PCI it was documented, if guidewire passage was complicated by difficult vascular anatomy (DVA I°) or if the procedure had to be discontinued (DVA II°)¹. The data was collected in the FIFA-registry and retrospectively analyzed. The modified ultrasound-guided TUA is explained in detail on the YouTube channel “Herzkatheter 4.0”. 

Results: Out of 3033 retrospectively analyzed consecutive CC/PCI procedures (1/2020-5/2022) 185 TUA procedures were identified. In 157 cases the TUA was the primary and successful access route. In 28 cases TUA was utilized as 2^nd option after failed TRA. 18 out of 185 TUA successful cases were “single ulnaris circumstances”. In 8 cases the radial artery was duplex sonographically occluded by atherosclerosis and in 10 cases the radial artery had been used as a bypass graft. Following a standardized angiography² the unobstructed passage of a 0.035-J-wire was possible in 162 cases (DVA 0°), in 12 patients a switch to a hydrophilic 0.035 wire was necessary (DVA I°) reaching the brachial artery. Only 2 cases of TUA failed due to DVA or severe arthrosclerosis at the forearm. The remaining cases (9) required a switch to a different site due to an obstruction further proximal, like the truncus brachiocephalicus or the left A. subclavia. Relevant complications: No Ischaemia/sensorineural damage, no vasospasms, 17 cases of local haematoma, 1 case of possible compartment syndrome. 

Conclusion: This retrospective analysis of an all-comer cohort was able to prove the modified TUA as an effective and safe alternative, also in “single ulnaris circumstances”. In contrast to the TRA, the TUA success rates were nearly not influenced by DVA at the forearm (2/185, 1,01%). 

1.Prevalence and predictors of difficult vascular anatomy in forearm artery access for coronary angiography and PCI: Roeschl T et al. Sci Rep. 2022; 12: 13060. doi: 10.1038/s41598-022-17435-1

2. Standardized Forearm Angiography Increases Procedural Success Rates of Coronary Angiography and PCI: A Retrospective Analysis of an all-Comers Patient Cohort in a Real-Life Scenario Roeschl T. et al. Cardiol Cardiovasc Med 2022; 6 (2): 124-136 doi: 10.26502/fccm.92920250