TUI

1. Transulnar Approach
of Coronary Angiogram and Angioplasty
- our experience in NHFH & RI.
Dr. Ashok Dutta
FCPS, MD.
Asst. Prof. & Consultant Cardiologist
NHFH & RI.

2. A comparative study of
Transulnar vs. Transradial
approach of Coronary angiography and angioplasty

3. 80 yrs old male , with stable angina, refused to give permission
for groin puncture . Radial puncture was done but failed to
proceed proximally. Dye injected to check the proximal radial
artery !!!

4. Rudimentary Radial artery with good collateral
between R & U artery at wrist & elbow

5. The first coronary angiography - A happy accident .
Figure 2 The 11-inch image intensifier used for
the first coronary angiogram performed by Dr. F.
Mason Sones, Jr., a pediatric cardiologist at the
Cliveland Clinic in 1958. The arrow points to the
Figure 1 Article by Sones and Shirey about
selective coronary arteriography via brachial
cutdown approach, published in 1962,(adopted
from AJR 1996;)

6. Objectives
The aim of this study was to compare
the safety ,
efficacy ,
feasibility
& procedural variables
of transulnar approach (TUA) with the transradial
access(TRA) in standard population of patients und
ergoing coronary catherization(angiogram or angi
oplasty ) in NHFH & R I, Dhaka.
This is first time in Bangladesh.

7. Objectives
The aim of this study was to compare
the safety ,
efficacy ,
feasibility
& procedural variables
of transulnar approach (TUA) with the transradial
access(TRA) in standard population of patients und
ergoing coronary catherization(angiogram or angiopl
asty ) in NHFH & R I, Dhaka.
This is first time in Bangladesh.

8. Background
• Cardiovascular disease remains the
most common disease worldwide,
in individuals older than 50 years of age.
• Many patients with cardiovascular problems
need invasive procedure to investigate or treat
coronary artery disease.

9. • Coronary angiogram and angioplasty are usual
ly performed via transfemoral approach.
• Transradial approach, which is now widely pr
acticed in coronary angiography and interventi
on, may be advantageous with respect to the
femoral access due to lower incidence of
vascular complications, patient's comfort and
short duration of hospital stay.

10. • Recently transulnar angiography and angiopl
asty have been described as an alternative to
transfemoral and transradial procedure. It was
proposed for elective procedure in patient not
suitable for transradial approach.
Transulnar approach was first reported by
Terashima et al in 2001.

11. • In our country transfemoral approach is most
commonly used.
• Many of our interventional cardiologists pract
ice transradial approach as well. However as
far we know, till now transulnar route is used
very infrequently and there is no data or
article on this approach.

12. • For last twelve months we are using this ulnar route
for angiogram and angioplasty along with transradial
approach.
• Till now this is not a routine default procedure but on
about 225 patients we have done angiography and a
ngioplasty through ulnar route. We have compared h
ere the 225 patients of transulnar with 229 patients
who underwent transradial approach regarding the
puncture time, total procedure time, X-ray and fluor
oscopy time, complications, safety, advantages and
disadvantages of two approaches.

13. TUA in NHFH
• Started in November 2011
• Over 12 months period
• 229 TRA
• 225 TUA
• Including 45 PTCA including LMCA stenting.

14. Why TUA ?
• Transulnar cannulation (TUC) is as safe as transradial cannulation,
however it takes a bit longer time especially for the beginner becau
se of more flat learning curve. Chances of loss of pulsation (arteria
l occlusion) are similar or less in ulnar group. However as ulnar art
ery is not used in clinical practice for pulse examination and by the
cardiac surgeon for radial grafting , it does not carry significant im
portance. . LIMA is proved to be the best vessel for use as bypass co
nduit, but second best conduit for use in CABG is radial artery. Kamy
a and co-authors showed that prior puncture of radial artery was rel
ated to more intimal hyperplasia and reduced early graft patency.
In consideration of chronic nature of cardiovascular disease and of r
adial artery’s possible use as an alternative bypass graft , many auth
ors suggest ulnar cannulation as a means of preserving the radial ar
tery for future CABG.

15. Ulnar artery is bigger !!
• Average diameter of ulnar artery is bigger than radial one but the area and
amount of blood supplied by radial artery is larger with radial one. So chan
ce of hand ischaemia is higher in radial artery occlusion.
• Spasm is quite common in radial artery, that very less frequent in ulnar b
ecause it’s larger caliber and fewer alpha receptors. Spasm sometimes m
akes catheter manipulation and arterial puncture difficult.
• Cross over to femoral needs pt’s permission ! When the patient is convin
ced for procedure at wrist site and got ready for that on Cath lab table an
d radial approach is failed for radial artery spasm or other reason, its mean
s failure to do what was promised. It’s embarrassing for operator and cathl
ab staff. Here ulnar artery is a good alternative.

16. • Sometime for ad hock PCI when pt is waiting for, radial may
go into spasm, that less likely in ulnar.
• Once cannulation is done, rest of the procedure regarding
catheter manipulation and engagement are same.
• The weakness of TUA is that ulnar artery puncture is techni
cally more difficult and takes a longer time to master. It ma
y be arduous for the beginner, but for the extensive experie
nced operator with transradial procedure, the learning curv
e is obvious short. It is an attractive option for institutions
that uses the transradial approach routinely.

17. Method
• Study period was from November 2011 to October, 2012.
• Total 454 patients undergoing coronary angiography, followed by or not by
intervention, we randomized to transulnar (TUA) or transradial approach (
TRA).
Exclusion Criteria –
1. Patients with an abnormal Allen’s or reverse Allen’s test ,
2. History of CABG,
3. Simultaneous right heart catheterization,
4. Moderate or severe renal insufficiency.
• Primary endpoint was success rate , access point vascular complications d
uring hospitalization and 30 days follow up.
• Secondary endpoints are major adverse cardiac events (MACE),
puncture & procedure time, fluoroscopy time, DAP.

18. Following data are analyzed :-
• Age,
• Sex,
• Height, Weight & BMI,
• Coronary risk factors (hypertension, diabetes mellitus, dyslipidemia,
smoking, obesity),
• Pattern of CAD
• Puncture time, Total procedure time, X-ray and fluoroscopy time
• Local complication at wrist (pain, hematoma/swelling , early and int
ermediate-loss of pulse, aneurysm, AV fistula , hand ischemia)

19. Results
• Successful arterial cannulation was achieved in 81.72%
of total 225 patients in transulnar and 92.14% of 229
in transradial group (p value<.01 ).
• Median puncture time 140 sec TUA vs.128.95 sec TRA
( p- value .209)
• Procedural duration 13.19 min vs. 12.25 ( p-value .081)
• Median DAP (dose area product) was similar in both gr
oup.
• Vascular access site complications were less in ulnar gr
oup.

20. Baseline clinical characteristics
character TRA TUA P-value
Patients No. 229 225
Mean age (Years), Ranges 48, 26-80 49, 28-78 .56
Male Gender 139(61%) 130(58%) .231
BMI, mean, range 25.35+_3.85 , 16-39 24.95+-3.50, 17-38 .319
HTN 129(56.4%) 126(56%) .424
DM 91(39.9%) 74(33.1%) .566
DL 60(26.4%) 52(22.9) .244
Smoking 65(28.5%) 66(29.7%) .771

21. Baseline clinical characteristics
0
50
100
150
200
250
pt.'s No. Mean
age ,yrs.
Male
Gender
BMI HTN DM DL Smoking
TRA
TUA

22. Clinical presentation
Characters TRA TUA P-Value
Stable Angina 113(49.7%) 118(52.6%) .555
UA 36(15.6%) 33(14.9%) .431
NSTEMI 13(5.6) 16(6.9%) .110
Post MI angina 14(6.1%) 15(6.9) .369
Post PCI angina 9(3.9) 4(1.7%) .189
AMI 14(6.1) 11(5.1%) .526
RMI 8(3.4%) 9(4.0%) .638
OMI 37(16.2) 25(11.4%) .828
H/o LVF 36(15.6) 24(10.9) .913

23. Clinical presentation
0
20
40
60
80
100
120
140
Stable
angina
UA NSTEMIPost MI
angina
AMI RMI OMI Post
PCI
angina
H/O
LVF
TRA
TUA

24. Echo Findings
Characters TRA TUA P
RWMA present % 116(50.6) 100(44.4%) .256
Global LVEF, mean, range 58+_9.45%, 20-73% 58.23+_9.18, 25-74% .898

25. Echo Findings
0
10
20
30
40
50
60
70
RWMA + ,% LVEF
TRA
TUA

26. Puncture No. & time, Procedure time,
Hemostasis time, No. of cath.
Items TRA TUA P-value
No. of Puncture 1.79+_0.22 1.80+_0.08 .960
Single puncture 142(62%) 117(52.0%)
Puncture time , sec 128.95 ±95.91 140±69 .209
Access Success rate % 92.14 81.72 <.01
Cross over/access failure 18(7.86%) 47(18.28%) .000
Total Procedure time, mean in
mint
12.25 ± 4.91 13.19±5.68 .081
Time of arterial hemostasis- hrs 6.10±0.85 6.32±0.94 .022
No. of Catheter used 1.21±0.55 .251
Single Cath 189(82.7%) 189(84%)
Two cath 23(10.04%) 25(11.1%)

27. Puncture No. & time, Procedure time,
Hemostasis time, No. of cath.
0
20
40
60
80
100
120
140
160
TRA
TUA

28. CAG Findings
Characters TRA TUA
CAD present 176(76.8%) 160(71.1%) .245
SVD 46(20.1%) 49(21.7%)
DVD 42(18.34%) 43(19.11%)
TVD 37(16.2%) 34(15.1%)
N/C CAD 51(22.2%) 36(16.0%)
Normal 51(22.27) 59(26.22%)

29. CAG Findings
0
10
20
30
40
50
60
70
80
90
CAD prsent
%
SVD DVD TVD N/C CAD Normal
TRA
TUA

30. Radiation Exposure
iItem TRA TUA p-value
X ray time, mins 2.63±1.17 2.53+-1.31 .420
Fluroscopy time 1.97±1.02 1.90+1.13 .581

31. Radiation Exposure
0
0.5
1
1.5
2
2.5
3
X-Ray time min Fluro time,min
TRA
TUA

32. Items TRA TUA
Total DAP 2279±1247 2252+-1355 .847
Acquision DAP 1816±898 1825+-1461 .945
Fluro- DAP 467±504 524+-563 .315

33. Radiation Exposure
0
500
1000
1500
2000
2500
Total DAP Acquision DAP Fluro DAP
TRA
TUA

34. Complications during Procedure
Items TRA TUA P-value
Patient discomfort 15(6.55%) 14(6.22%) .750
Arterial spasm 38(16.59%) 8(3.55%) .001
Local pain 15(6.55%) 25(11.11%) .111
Bleeding or swelling 8(3.49%) .044

35. Complications during Procedure
0
5
10
15
20
25
30
35
40
TRA
TUA

36. Loss of arterial Pulse
Items TRA TUA P-value
Loss of pulse- in hospital 36(15.7%) 15(6.66%) .043
Loss of pulse-at month 15(6.55%) 5(2.22%) .021

37. Loss of arterial Pulse
0
5
10
15
20
25
30
35
40
In Hospital At 1 month
Series 1
Series 2

38. Conclusion
The findings of the present study show transulnar coro
nary angiography and angioplasty are safe, feasible
and effective with similar results to those of the trans
radial approach.
However initial procedural duration is longer in transu
lnar group because of longer puncture duration especi
ally in first 50 to 100 cases but arterial spasm and loss
of arterial pulse are less frequent in TU group
and TUA can spare the radial artery for future use in cli
nical purpose, intervention and CABG.

39. • Thanks