alternative approach trans-ulnar approach feasibility of percutaneous coronary intervention via...

AlternativeApproach

Trans-Ulnar Approach

Feasibility of Percutaneous Coronary Feasibility of Percutaneous Coronary Intervention Via Transulnar Artery Intervention Via Transulnar Artery Approach in Selected Patients with Approach in Selected Patients with

Coronary Heart DiseaseCoronary Heart Disease

Xianghua Fu, MD, PhD et al

Center of Interventional Cardiology, the 2nd Affiliated Hospital of Hebei Medical University, Shijiazhuang,

Hebei,China

AlternativeApproach


Background Advantages of transradial intervention :Advantages of transradial intervention :

-earlier ambulation-earlier ambulation

-less complications-less complications

-shorter hospital stay and lower cost-shorter hospital stay and lower cost Unfeasible for TRI(10-30%) :Unfeasible for TRI(10-30%) :

-anatomic variation-anatomic variation

-malformation-malformation

-puncture trouble : spasm, tortuous, -puncture trouble : spasm, tortuous, thin,calcification, etc. thin,calcification, etc.

-used for other purpose (graft, etc.)-used for other purpose (graft, etc.)

AlternativeApproach


Dr. Terashima et al (2000): Dr. Terashima et al (2000):

7/9 cases of ulnar artery for angiography7/9 cases of ulnar artery for angiography

How about PCI via ulnar artery How about PCI via ulnar artery access?access?

Feasibility?

Easy or difficult?

Safety?

Complication?

AlternativeApproach


ObjectiveObjective

• To explore the clinical feasibility of To explore the clinical feasibility of percutaneous coronary intervention via percutaneous coronary intervention via transulnar artery approach (TUI)transulnar artery approach (TUI)

AlternativeApproach


Enrolled Patients

• Total patients(2001-2003): 40 (Male 34;Female,6) from 482 PCI patients with CHD.

• Age : 41-79 years old

• Clinical diagnosis:

– AMI(7-14d): 12 patients

– OMI: 7 patients

– UAP: 21 patients (Including 2 cases of restenosis after stent)

• All of them gave written informed consent approved by the academic committee of The 2nd hospital of HBMU

AlternativeApproach


Reason of transulnar PCI

• Tortuous/thin radial artery or failured radial artery puncture : 30 patients

• Radial artery was used previously (angiography/PCI) : 8 patients

• Abnormality of radial artery : 2 patients

AlternativeApproach


Ulnar Artery v.s Radial Artery

- - Diameter: UA >RADiameter: UA >RA

- Allen’s test time: UA<RA, both sides - Allen’s test time: UA<RA, both sides positive positive

- Pulsation: UA>RA- Pulsation: UA>RA

- Puncture feeling: ulnar access may be easier.- Puncture feeling: ulnar access may be easier.

AlternativeApproach


EEcho/Doppler : diameter of ulnar artery is larger cho/Doppler : diameter of ulnar artery is larger than that of radial artery, UA/RA Ratio is 1.35 than that of radial artery, UA/RA Ratio is 1.35

AlternativeApproach


Devices

All same as with transradial PCI 21G （ 8# ） naked needle （ Cordis ， USA ） 0.019 inch hydrophilic guidewire （ Cordis ， USA ） 6F radial special sheath （ Cordis ， USA ） 4F angiograph catheter (Cordis, USA) 6F guiding catheter:

-LCA ： XB-LAD3.5 EBU3.5 XB3.5 JL3.5

-RCA ： ART JR4.0 ZUMA

AlternativeApproach


ProcedureProcedure

Puncture site: 3 cm up the right wrist with the most powerful pulsation of ulnar artery

Puncture angle: 45º along the axis of vessel Prevention of ulnar artery spasm: nitroglycerin, verapamil

, lidocaine and dilthiazem ,or combinted dual agents by intra-sheath for some patients

Removal artery sheath: without ceasing heparin infusion Management of puncture site: 6 hrs compression with

gradual release of pressure Ambulate immediately if patients condition permit

AlternativeApproach


TRU-PCI

AlternativeApproach


Clinical Outcome• First time success rate for puncture : 87.5% (35

patients),the rest ( 5 patients) : 2-4 times • Forty-eight lesions of 42 vessels were

angioplasticied successfully• The average procedure duration of manipulation :

56.6 min• Ulnar artery hemodynamics (flow velocity, ulnar

blood pressure) : no difference before and after the procedure

• One month follow-up : no significant difference before and after transulnar PCI

AlternativeApproach


Comparison of UA hemodynamic parameterbefore and after PCI operation

95.0±1.5195.0±1.5197.6±1.1297.6±1.120.82±0.030.82±0.0348.6±7.1448.6±7.14131±28/59 131±28/59 ±4±4

Post-PCIPost-PCI

95.5±1.7095.5±1.7099.1±1.8399.1±1.830.80±0.050.80±0.0551.4±7.0351.4±7.03136±33/60 136±33/60 ±5±5

Pre-PCIPre-PCI

SoSo22

%%

PaoPao22

(mmHg)(mmHg)

RIRIVs Vs maxmax

(cm/s)(cm/s)

UA BPUA BP

(mmHg)(mmHg)

UA: ulnar arteryBP: blood pressureVs: blood velosityRI: resistance indexPao2: oxygen pressureSo2: oxygen saturation

AlternativeApproach


vessel comparison of UA and RA before and after PCI

UA Allen`s UA Allen`s time(s) time(s)

RA RA Allen`s Allen`s time (s)time (s)

UA UA diameterdiameter

(mm)(mm)

RA RA diameterdiameter

(mm)(mm)

UA cross UA cross section section areaarea

(mm(mm22))

RA cross RA cross section section area area

(mm(mm22))

Pre-Pre-PCIPCI

2.70±0.36*2.70±0.36* 4.68±0.54.68±0.522

3.26±0.22*3.26±0.22* 2.62±0.282.62±0.28 5.68±1.16*5.68±1.16* 4.08±1.334.08±1.33

PostPost--PCIPCI

2.96±0.98 2.96±0.98 ## 4.82±0.34.82±0.355

3.22±0.48 3.22±0.48 ## 2.53±0.402.53±0.40 5.02±1.605.02±1.60## 3.91±1.503.91±1.50

* p<0.05 UA vs RA before PCI

# p<0.05 UA vs RA after PCI

AlternativeApproach


Complications

-No serious complication-No ulnar nerve damage

-No ulnar artery occlusion

-No A-V fistula

-No pseudoaneurism

-Mild complications-Slight haematoma: 2 patients

AlternativeApproach


SummarySummary

1.1. PCI by ulnar artery approach has been successfully performed in forty patients with difficulty to perform TRI

2. Possible consideration for transulnar artery PCI:

a. Transradial access PCI with difficulty but dual sides Allen’s test positive

b. The pulsation of ulnar artery is stronger than that of radial artery

c. The diameter of ulnar artery is larger than that of radial artery (≥2.5mm and ≥4.5mm2 )

AlternativeApproach


Conclusions and Clinical Experience

• The outcome of our clinical practice demonstrated that transulnar PCI is practical, safe and beneficial for the patients with TRI difficulty, but more clinic practice will be need

• More patients to reach threshold for trans-forearm artery approach PCI

• More practice for skill performance

alternative approach trans-ulnar approach feasibility of percutaneous coronary intervention via...

Documents