Same Wrist Intervention via the Cubital (Ulnar) Artery in Case of Radial Puncture Failure for Percutaneous Cardiac Catheterization or Intervention: The Multicenter Prospective SWITCH Registry

1. Same Wrist Intervention via The Cubital
(ulnar) artery in case of radial puncture
failure for percutaneous cardiac
catHeterization or intervention: the
multicenter prospective SWITCH registry
P. Agostoni,MD,PhD; A. Zuffi,MD; B. Faurie,MD; P. Tosi,MD; M. Samim,BSc
A. Belkacemi,MD; M. Voskuil,MD,PhD; P. Stella,MD,PhD; G. Biondi-Zoccai,MD

2. Rationale for SWITCH
Premises:
• the Allen test may not be needed
• radial and ulnar arteries have on average similar diameter
• ulnar approach is as feasible as radial
Situation:
• radial puncture failure or no progression of the wire
• available ulnar pulse
Can we directly SWITCH from radial to homolateral ulnar?

3. SWITCH design
• 1 year prospective enrollment from the 1st patient included
• Operator (not center) – based complete experience
• Radialist (>50% radial procedures)
• All procedures considered (diagnostic/interventional)
• Overall rates of radial/femoral/ulnar/brachial procedures
• Overall rates of cross-overs
• Only one mandatory inclusion criterion: in case of failed
radial puncture/cannulation, immediate homolateral ulnar
attempt, if ulnar pulse present:
- Rate - Safety
- Feasibility - Outcomes

4. SWITCH centers
P. Agostoni, Utrecht
11 April 2009 – 10 April 2010
G. Biondi-Zoccai, Turin
15 May 2009 – 14 May 2010
B. Faurie, Grenoble
8 July 2009 – 7 July 2010
A. Zuffi, Cotignola (Ravenna)
24 August 2009 – 23 August 2010
P. Tosi, Legnago (Verona)
27 January 2010 – 26 July 2010

5. “Actual” final
access site
Total N=2403
(PCI N=1271)
Radial 1599 (66.5%)
Femoral 744 (31.0%)
Ulnar 50 (2.1%)
Brachial 9 (0.4%)
Failure 1 (<0.01%)
SWITCH results

6. Attempts Success Failure
Radial 1702 93.9% (1599/1702) 6.9% (117/1702)
(including cross-overs
to controlateral radial)
SWITCH results

7. Crossovers after radial failure (117)
Femoral 64 (54.7%)
(2 after ulnar failure)
Radial controlateral 14 (12.0%)
(3 after ulnar failure)
Ulnar 36 (30.8%)
Brachial 2 (1.7%)
(1 after ulnar failure)
Failure 1 (0.8%)
(from radial and from femoral)
SWITCH results

8. SWITCH patients
11 patients
4 patients
7 patients
11 patients
9 patients
Total 42 patients

9. SWITCH patients N=42
Age (years) 63 ± 14 (range: 23 – 84)
BMI (Kg/cm2) 27.6 ± 5.6 (range: 20.5 – 50.1)
Female sex (%) 13 (31%)
Diabetes (%) 8 (19%)
Prior radial cath/PCI 9 (21.4%)
Procedure:
Coronary angio
PCI
22 (52.4%)
20 (47.6%)
N. radial punctures 1.9 ± 1.7 (range: 0 – 10)
SWITCH results

10. SWITCH patients N=42
Radial left 4 (9.5%)
Indication
SA
ACS
STEMI
cardiomyopathy/pre-surgery
12 (28.6%)
17 (40.5%)
3 (7.1%)
10 (23.8%)
Allen test not done 31 (73.8%)
Radial pulse absent 3 (7.1%)
Ulnar pulse absent 3 (7.1%)
SWITCH results

11. Reason for radial failure (N=42)
Dissapearance radial pulse
after puncture attempts
18 (42.8%)
6 after previous radial cath
No wiring possible after
puncture
13 (31%)
2 after previous radial cath
No puncture possible -
pulse not to feel
3 (7.1%)
1 after previous radial cath
Perforation 2 (4.8%)
Radial loop
(1 radial and 1 ulnar sheath
simultaneously inserted)
6 (14.3%)
SWITCH results

12. 02-01 03-02 04-10
03-06 05-09
In 6 cases radial sheath left in place, when doing
the procedure via homolateral ulnar artery

13. SWITCH patients N=42
Successful crossover to ulnar 36/42 (85.7%)
Crossover to radial controlateral 3/42 (7.1%)
Crossover to femoral 2/42 (4.8%)
Crossover to brachial omolateral 1/ (2.4%)
SWITCH results

14. Reason for ulnar failure (N=6)
No wiring possible after
puncture
3
Dissapearance ulnar pulse
after puncture attempts
1
No puncture possible –
pulse not to feel
1
Oversizing to 7F –
elective femoral
1
SWITCH results

15. “Local events” till discharge N=42
Radial bleeding 1 (2.3%)
1 self limiting hematoma
Ulnar bleeding
5 (11.9%)
2 self limitng hematomas
3 hematomas requiring forearm bandage
Radial complications 1 (2.3%)
1 pseudoaneurysm
Radial pulse at discharge 39 (92.9%)
Ulnar pulse at discharge 37 (88.1%)
Hand ischemia 0 (0%)
SWITCH results

16. SWITCH results
Angiographic details
Forearm angiography performed 23 (54.8%)
Radial (sub-)occlusive spasm 9 (39.1%)
Radial loop 6 (26.1%)
Radial tortuosity 3 (13.0%)
Radial stenosis/occlusion 2 (8.7%)
Radial hypoplasia 2 (8.7%)
Radial occlusion (after previous cath) 1 (4.4%)

18. Switching directly to the homolateral ulnar artery is highly
feasible (>80% of the cases), in case of failure of radial puncture
or cannulation.
Increase in the rate of procedures performed via the wrist (failure
rate from 6.9% considering only radial to 3.8% for the “whole
wrist”), allowing avoidance of femoral puncture with its
associated bleeding risks.
This switch from radial to ulnar appears also to be safe, without
cases of symptomatic hand ischemia in this series.
Conclusions