Transulnar approach should not be used as default strategy for coronary procedures

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Published ahead-of-print in Circulation: Cardiovascular Interventions, the transulnar or transradial instead of coronary transfemoral angiographies study (the AURA of ARTEMIS study) has found that the transulnar approach should not be the default strategy in coronary procedures because it is associated with a significantly higher crossover rate than the transradial approach.

George Hahalis, Department of Cardiology, Patras University Hospital, Patras, Greece, and others wrote that the transulnar approach in coronary procedures has several potential advantages compared with the transradial approach, including circumventing a possible vascular trauma and ensuring an intact radial artery for subsequent coronary artery bypass grafting (CABG) and serving as an alternative access artery for repeated angiographies (thus, minimising the transfemoral appraoch). However, they explained that the transulnar route is rarely used as the primary strategy for coronary procedures and the data for the approach was conflicting. The authors stated: “Therefore, we aimed to compare the feasibility and safety of the transulnar approach with the transradial artery access as a default strategy for coronary angiography and percutaneous coronary intervention (PCI).”


In the prospective, randomised, multicentre, non-inferiority study of parallel design, consecutive patients (902 overall) scheduled for coronary angiography (with ad hoc PCI if necessary) or elective PCI were randomised to receive the procedure via the transulnar approach (462) or via the transradial approach (440). The primary endpoint was a composite of major adverse cardiovascular events, rates of crossover to another artery, and major vascular events at 60 days.


Hahalis et al reported that patients in the transulnar approach group required more punctures, more time to obtain arterial access, more total procedural and fluoroscopy time, and received a higher amount of contrast medium compared with patients in the transradial group. However, coronary angiography time and PCI did not differ significantly between groups.


The intention-to-treat analysis, the authors noted, showed that the primary endpoint was significantly higher in the transulnar group (42.2%) compared with the transradial approach (18%; P<0.0001). They commented: “Therefore, the study was terminated early because of the inferiority of the transulnar approach over the transradial approach. Crossover was higher in the ulnar group compared with the radial group with a difference of 26.34% (P<0.001).” Hahalis et al added that, after adjusting for clustering on operator, the transulnar approach was still associated with a significantly higher crossover rate.


However, after adjustment for the clustering effect, the primary endpoint was inconclusive. Furthermore, using a non-inferiority margin of 4.87%, the authors found that the use of the transulnar approach was non-inferior to the transradial approach in terms of MACE, large haematomas, vagal reactions, and arterial occlusions at 60 days.  


As result of their findings, Hahalis et al commented: “We do not recommend a routine ulnar primary approach for coronary interventions because it is cumbersome for the patients and for the operator.” However, they added as the transulnar approach was non-inferior to the transradial approach with regard to major access site complications and large haematomas, in selected patients, it could serve as a second-line arterial approach.


Hahalis explained the transulnar approach could only be used as a second-line arterial approach option if the operator had a patient with a good ulnar artery (ie. well palpable). He added that the potential reasons for using the ulnar artery as a second-line approach included the operator “wanting to protect the radial artery for possible harvesting if coronary bypass surgery appears likely based on patient’s symptoms and history as well as non-invasive test results; the radial artery exhibits weaker pulse; or, in the context of ipsilateral cross over after failed radial artey cannulation, the premise is that radial trauma should not be left behind.”

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