Feasibility and safety of a modified transulnar artery access for coronary angiography and percutaneous intervention in case of radial artery occlusion. Retrospective analysis out of the FIFA Registry

Franziska Fochler (Regensburg)1, M. Grewe (Neumarkt i. d. Oberpfalz)2, C. M. Sag (Regensburg)1, U. Reiser (Neumarkt i. d. Oberpfalz)2, C. Schmidt (Neumarkt i. d. Oberpfalz)2, K. Meier (Neumarkt i. d. Oberpfalz)2, M. Wacker (Neumarkt i. d. Oberpfalz)2, T. Röschl (Berlin)3, L. S. Maier (Regensburg)1, P. H. Grewe (Neumarkt i. d. Oberpfalz)2

1Universitätsklinikum Regensburg Klinik und Poliklinik für Innere Med. II, Kardiologie Regensburg, Deutschland; 2Klinikum Neumarkt Medizinische Klinik I - Kardiologie Neumarkt i. d. Oberpfalz, Deutschland; 3Deutsches Herzzentrum der Charite (DHZC) Klinik für Herz-, Thorax- und Gefäßchirurgie Berlin, Deutschland



The transradial access (TRA) is used with a class IA indication for Coronary Angiography (CA) or Percutaneous Intervention (PCI). But in daily clinical routine, TRA shows limitations such as severe atherosclerosis, difficult vascular anatomy (DVA) like anomalous branching patterns, varying degrees of calcification or tortuosity. In addition, the radial artery (RA) may have been used or will be needed as a coronary artery bypass graft or in arteriovenous fistula procedures. Furthermore, RA occlusion may have happened consequential to prior interventions. The transulnar access (TUA) represents an alternative access route for CA ± PCI. Especially in ‘Single ulnaris circumstances` data regarding feasibility and safety for this access route are missing. 



The Forearm artery if feasible access (FIFA) Registry is an all-comer database, which includes all cases of CA ± PCI at the hospital of Neumarkt i.d. OPf., Germany. From 11/2019 until 10/2023 4.733 cases where included. For this retrospective analysis we investigated 227 TUA cases, of which 30 cases represent “single ulnaris circumstances”. We decided for this special access route as 23 cases needed CA ± PCI of the left internal mammaria artery (LIMA) bypass graft and in 7 cases the UA was the last remaining vessel for access route known due to prior CA. The puncture of the ulnar artery (UA) was performed with ultrasound-guidance, for sheat insertion a hydrophilic 0.014-inch PCI-wire was used and then a standardized forearm angiography (SFA) was executed for visualization of the vascular network.  Afterwards it was documented, if guidewire passage was complicated by DVA. As secondary outcomes, we evaluated the incidence of complications during the procedure.


Out of 227 TUA cases, 30 „single ulnaris circumstances” were found (age 70.4±10.5 years, 32.1% female gender, BMI 28.9±5.8 kg/m2, Diabetes mellitus 23.5%, arterial hypertension 82.3%). In 13 cases the RA was used as bypass graft, a functional occlusion of the RA was found by ultrasound and SFA in 5 cases due to prior intervention and in 12 cases due to severe atherosclerosis. In all cases it was the primary access route (100%). Because of DVA, 2 cases required a crossover to the transfemoral access route. In the remaining 28 cases, no case of ischemia or sensorineuronal damage and 4 cases of local hematoma were observed during index hospitalization.


In this retrospective analysis we show, that in “single ulnaris circumstances” the TUA is a feasible and safe alternative acces route for CA ± PCI. Especially in patients requiring a special and alternative access route, this puncture side may be considered.

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