Deborah Brauser

March 24, 2015

SAN DIEGO, CA — Although "rarely selected," ulnar-artery catheterization is comparable, with respect to clinical outcomes, to the more common radial access during PCI, report investigators from the Ajmer Ulnar Artery Working Group Study (AJULAR)[1].

The study, which included more than 2500 patients, showed no significant differences in major adverse cardiac events (MACE), major vascular events, and the need to switch to a different arterial access site between those who underwent cannulation through transulnar access (by very experienced operators) and those who underwent the same procedure but with transradial access. However, although not significant, those in the ulnar-access group did show fewer occurrences of vasospasm.

The findings were presented at a featured clinical-research session here at the American College of Cardiology (ACC) 2015 Scientific Sessions by Dr Rajendra Gokhroo (Jawaharlal Nehru Medical College, Ajmer, India).

Gokhroo told meeting attendees that when given a choice between both access points for a patient, he will choose the ulnar artery. In fact, "we are doing all palpable ulnar arteries first at our center," he reported.

Experience Matters

Gokhroo noted that past trials, including the AURA study, have shown that ulnar access was inferior to radial access in number of adverse events, including MACE and vagal reactions. However, he pointed out that AURA used operators who were inexperienced in ulnar access and "attempted to cannulate even nearly absent ulnar arteries."

The current study, which sought to determine whether operator experience matters when comparing ulnar-access and radial-access PCI, randomized 2532 patients to either transulnar access (n=1270) or transradial access (n=1262). All operators used in the study had performed at least 50 previous ulnar catheterizations and were considered to be experts in radial catheterizations. The primary outcome measure was a composite of MACE and major vascular events of the arm (such as large hematomas) during hospital stay, crossovers, and occlusion rate.

Results showed that the composite did not differ significantly between the two access sites (14.6% of the ulnar group vs 14.4% of the radial group; risk ratio 1.01). There were also no significant between-group differences for any of the individual components, including MACE (2.9% vs 3.2%, respectively), large hematomas (1% vs 0.9%, respectively), occlusions (6.14% vs 6.6%, respectively), and crossovers (4.4% vs 3.8%, respectively).

Of the 48 transradial crossover events, 10 (20.8%) used contralateral radial access for their second site and 36 (75%) used ulnar access for their second or third site. Only two used the femoral artery for their final crossover site.

In other words, "if you are confident in ulnar cannulation, you can reduce 75% of femoral-artery cannulations, at least in this instance," said Gokhroo.

Although there were fewer spasms in the ulnar group than in the radial group (6.9% vs 8.7%), this wasn't found to be statistically significant.

"My conclusion is that transulnar cannulation is easy, safe, and comfortable. If used as a default strategy, it's a noninferior approach—when performed by an experienced operator," said Gokhroo. "It really is reality, not a myth."

"Another Option"

When asked for comment, Dr William Bommer (University of California-Davis Medical Center) told heartwire from Medscape that he has seen a "migration from what used to be an entirely femoral-artery approach to now using radial," adding that this has led to fewer bleeding complications in many patients.

"We have a lot of operators who prefer a radial approach because they can get quick access to it, they can get much better control of it, and there's less chance of requiring transfusions," said Bommer, who was not involved with the research.

"However, not all patients have an easy access by radial. So in that situation you have to switch to the other side radial or convert to a femoral-artery approach. But if another artery in the hand is included for access, the ulnar artery, that increases your capability of achieving access for the procedure, and you don't have to move to the leg."

Bommer noted that there are now smaller and smaller catheters being used for PCIs, as well as better guidewires. All of this allows access into smaller arteries. However, he also pointed out that there is a learning curve for both radial and ulnar approaches.

"For individuals who've been trained on this and become experienced, this shows they can achieve comparable complication rates and success rates. There was no real preference to do one or the other; but if one doesn't work out, that means you can switch to the other wrist artery at that time," he said.

Gokhroo reports no relevant financial relationships. Bommer reports running the PCI campus program for the California Department of Public Health and being on the speaker's bureau for AstraZeneca, Boehringer Ingelheim, Bristol-Meyers Squibb, and Pfizer.

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