Lessons from transulnar access for repeat percutaneous coronary intervention after radial artery occlusion

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Lessons from transulnar access for repeat percutaneous coronary intervention after radial artery occlusion

Transradial access is the standard for most percutaneous coronary interventions (PCI) because it reduces bleeding risks and speeds recovery. But for patients who need repeated procedures, the radial artery can develop a silent complication: occlusion (RAO). A 2017 study in Angiology found RAO affects up to 5% of transradial PCI patients—often without symptoms, but it can derail future care.

Consider an 80-year-old man who arrived at The First Hospital of Qinhuangdao in China in 2017 with 20 minutes of substernal pain. His history included two transradial PCIs: one for an acute inferior wall heart attack in 2009, and a second elective procedure days later for a blocked anterior descending artery (both used 6F Cordis sheaths). He’d quit smoking after his first PCI. Before his third PCI, he had a weak radial pulse—but his hand was fine. An inverse Allen test (which checks if the ulnar artery can keep blood flowing to the hand if the radial artery is blocked) showed normal capillary refill in 6 seconds. When doctors couldn’t puncture his radial artery, they switched to the right ulnar artery.

The transulnar access worked: they implanted two stents in his circumflex artery. But a forearm arteriogram after the procedure revealed a surprise: RAO wasn’t near the old puncture sites—it was in the proximal radial artery (close to where it branches from the brachial artery). Even better, the ulnar and interosseous arteries had formed strong collateral blood flow to the blocked radial artery—explaining why his hand stayed healthy.

This finding confirmed a hypothesis from the study’s authors—Xi-Le Bi and Qing-Sheng Wang of the hospital’s Cardiology Department. In their 2017 Angiology study, Doppler ultrasound showed RAO often occurs in the proximal or middle radial artery, not the puncture site. Ethical limits had prevented them from using arteriography to prove it—until this case.

Why does RAO happen in the proximal radial artery? Research points to two key factors:

  1. Sheath and catheter damage: A 2010 Eur Heart J study using optical coherence tomography (OCT) found over half of radial artery intimal tears (damage to the inner lining) occur near the proximal end of the sheath—close to the radial artery’s origin. The sheath itself may cause these tears.
  2. Unprotected vessel trauma: When catheters are advanced or removed through the proximal radial artery (which isn’t covered by the sheath), they can cause medial dissections (tears in the artery’s middle layer)—a major driver of occlusion.

Repeated catheter use also harms the brachial artery (the main arm artery feeding the radial and ulnar arteries). A 2009 JACC Cardiovasc Interv study found more catheter insertions mean a higher risk of endothelial dysfunction (damage to the vessel lining that affects blood flow).

So what’s the takeaway for future PCIs? The authors suggest moving the radial artery puncture site proximally (closer to the elbow) might reduce RAO risk. A more proximal puncture means less of the radial artery is unprotected by the sheath—cutting down on catheter-related trauma.

This case also highlights the ulnar artery’s value as a backup. When the radial artery is blocked or hard to access, transulnar access is a safe alternative—especially if the inverse Allen test confirms good ulnar blood flow (as it did here).

Most importantly, this case teaches us RAO isn’t always where we expect it. By studying real-world examples like this, we can refine transradial techniques to lower occlusion risk—and ensure patients have reliable access for life-saving procedures.

References:

  1. Bi X, Wang Q, Liu D, Gan Q, Liu L. Is the complication rate of ulnar and radial approaches for coronary artery intervention the same? Angiology 2017;68:919–925. doi: doi.org/10.1177/0003319717703226
  2. Lanspa TJ, Reyes AP, Oldemeyer JB, Williams MA. Ulnar artery catheterization with occlusion of corresponding radial artery. Catheter Cardiovasc Interv 2004;61:211–213. doi: doi.org/10.1002/ccd.10723
  3. Yonetsu T, Kakuta T, Lee T, Takayama K, Kakita K, Iwamoto T, et al. Assessment of acute injuries and chronic intimal thickening of the radial artery after transradial coronary intervention by optical coherence tomography. Eur Heart J 2010;31:1608–1615. doi: doi.org/10.1093/eurheartj/ehq102
  4. Heiss C, Balzer J, Hauffe T, Hamada S, Stegemann E, Koeppel T, et al. Vascular dysfunction of brachial artery after transradial access for coronary catheterization: impact of smoking and catheter changes. JACC Cardiovasc Interv 2009;2:1067–1073. doi: doi.org/10.1016/j.jcin.2009.09.010
  5. Bi XL, Fu XH, Gu XS, Wang YB, Li W, Wei LY, et al. Influence of puncture site on radial artery occlusion after transradial coronary intervention. Chin Med J 2016;129:898–902. doi: doi.org/10.4103/0366-6999.179795
  6. Bi XL, Wang QS. Lessons from transulnar access for repeat PCI after radial artery occlusion. Chin Med J 2020;133:1497–1498. doi: doi.org/10.1097/CM9.0000000000000737

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