Experience equalizes transulnar and transradial approaches to heart procedures

SAN DIEGO – Surgical experience puts transulnar access on a par with transradial access for percutaneous coronary procedures, the randomized AJULAR trial showed.

The primary composite outcome of major adverse cardiac events or major vascular events during hospitalization was 14.6% for transulnar access and 14.4% for transradial access, meeting the noninferiority criteria.

“If used as a default strategy, [transulnar access] is noninferior to the transradial approach when performed by an experienced operator,” study author Dr. Rajendra Gokhroo reported at the annual meeting of the American College of Cardiology.

The use of radial artery cannulation is growing in the United States as an approach for coronary access because of obvious safety advantages over femoral access, but has its own limitations such as frequent vasospasm, small caliber, and unsuitability as a graft for coronary artery bypass grafting after cannulation.

Transulnar access is used by some as an alternative, but was found inferior to transradial access in the AURA of ARTEMIS study because of significantly more large hematomas and a high crossover rate in the transulnar group (Circ. Cardiovasc. Interv. 2013;6:252-261).

However, the study used inexperienced ulnar operators and attempted to cannulate even nearly absent ulnar arteries, said Dr. Gokhroo, a pioneer in ulnar intervention at Jawaharlal Nehru Medical College, Ajmer, India, and president of the Indian Society of Cardiology. Based on their observations, the risk of such events is threefold higher during the first 50 procedures, but is no longer statistically significant after 51-100 operations or after 100 operations.

For the prospective, single-center AJULAR (Ajmer Ulnar Artery) trial, all operators were required to have a minimum experience of 50 transulnar cannulations, and cannulation was attempted only if the ulnar artery was easily palpable and the anatomy favorable.

“Excessive calcification, tortuosity, and low-volume pulse were the additional features where the ulnar was avoided; otherwise no other patient characteristics or demographic features compelled us to avoid ulnar access,” Dr. Gokhroo said in an interview.

Inability to palpate the radial artery was also an exclusion criterion.

A total of 2,532 patients scheduled to undergo elective coronary angiography and ad hoc percutaneous transluminal coronary angioplasty were evenly randomized to transulnar access or transradial access. The mean age for the 1,270 ulnar patients was 67 years and 63 years for the 1,262 radial patients.

There were no significant differences in an intention-to-treat analysis between the transulnar and transradial groups with respect to the individual components of the primary outcome: major adverse cardiac events (2.9% vs. 3.2%), large hematoma (1% vs. 0.9%), or occlusion (6.1% vs. 6.6%), Dr. Gokhroo reported.

The secondary endpoints of crossover rate (4.4% vs. 3.8%) and vessel spasm (6.9% vs. 8.7%) were also similar.

“Our study definitely says that ulnar access is as good as radial access,” he said.

An analysis of 48 transradial crossover events revealed that, had ulnar cannulation been considered, the need for crossover to femoral artery access would have been reduced from 38 patients to 2 patients, with the remaining 10 patients accessed via the contralateral radial artery.

“If you have expertise in ulnar cannulation, 75% of femoral artery cannulations can be avoided,” Dr. Gokhroo said. “Transulnar cannulation is also an easy, safe, and comfortable procedure.”

Dr. Gokhroo and his associates said they had no relevant financial disclosures.

pwendling@frontlinemedcom.com

SAN DIEGO – Surgical experience puts transulnar access on a par with transradial access for percutaneous coronary procedures, the randomized AJULAR trial showed.

The primary composite outcome of major adverse cardiac events or major vascular events during hospitalization was 14.6% for transulnar access and 14.4% for transradial access, meeting the noninferiority criteria.

“If used as a default strategy, [transulnar access] is noninferior to the transradial approach when performed by an experienced operator,” study author Dr. Rajendra Gokhroo reported at the annual meeting of the American College of Cardiology.

The use of radial artery cannulation is growing in the United States as an approach for coronary access because of obvious safety advantages over femoral access, but has its own limitations such as frequent vasospasm, small caliber, and unsuitability as a graft for coronary artery bypass grafting after cannulation.

Transulnar access is used by some as an alternative, but was found inferior to transradial access in the AURA of ARTEMIS study because of significantly more large hematomas and a high crossover rate in the transulnar group (Circ. Cardiovasc. Interv. 2013;6:252-261).

However, the study used inexperienced ulnar operators and attempted to cannulate even nearly absent ulnar arteries, said Dr. Gokhroo, a pioneer in ulnar intervention at Jawaharlal Nehru Medical College, Ajmer, India, and president of the Indian Society of Cardiology. Based on their observations, the risk of such events is threefold higher during the first 50 procedures, but is no longer statistically significant after 51-100 operations or after 100 operations.

For the prospective, single-center AJULAR (Ajmer Ulnar Artery) trial, all operators were required to have a minimum experience of 50 transulnar cannulations, and cannulation was attempted only if the ulnar artery was easily palpable and the anatomy favorable.

“Excessive calcification, tortuosity, and low-volume pulse were the additional features where the ulnar was avoided; otherwise no other patient characteristics or demographic features compelled us to avoid ulnar access,” Dr. Gokhroo said in an interview.

Inability to palpate the radial artery was also an exclusion criterion.

A total of 2,532 patients scheduled to undergo elective coronary angiography and ad hoc percutaneous transluminal coronary angioplasty were evenly randomized to transulnar access or transradial access. The mean age for the 1,270 ulnar patients was 67 years and 63 years for the 1,262 radial patients.

There were no significant differences in an intention-to-treat analysis between the transulnar and transradial groups with respect to the individual components of the primary outcome: major adverse cardiac events (2.9% vs. 3.2%), large hematoma (1% vs. 0.9%), or occlusion (6.1% vs. 6.6%), Dr. Gokhroo reported.

The secondary endpoints of crossover rate (4.4% vs. 3.8%) and vessel spasm (6.9% vs. 8.7%) were also similar.

“Our study definitely says that ulnar access is as good as radial access,” he said.

An analysis of 48 transradial crossover events revealed that, had ulnar cannulation been considered, the need for crossover to femoral artery access would have been reduced from 38 patients to 2 patients, with the remaining 10 patients accessed via the contralateral radial artery.

“If you have expertise in ulnar cannulation, 75% of femoral artery cannulations can be avoided,” Dr. Gokhroo said. “Transulnar cannulation is also an easy, safe, and comfortable procedure.”

Dr. Gokhroo and his associates said they had no relevant financial disclosures.

pwendling@frontlinemedcom.com

SAN DIEGO – Surgical experience puts transulnar access on a par with transradial access for percutaneous coronary procedures, the randomized AJULAR trial showed.

The primary composite outcome of major adverse cardiac events or major vascular events during hospitalization was 14.6% for transulnar access and 14.4% for transradial access, meeting the noninferiority criteria.

“If used as a default strategy, [transulnar access] is noninferior to the transradial approach when performed by an experienced operator,” study author Dr. Rajendra Gokhroo reported at the annual meeting of the American College of Cardiology.

The use of radial artery cannulation is growing in the United States as an approach for coronary access because of obvious safety advantages over femoral access, but has its own limitations such as frequent vasospasm, small caliber, and unsuitability as a graft for coronary artery bypass grafting after cannulation.

Transulnar access is used by some as an alternative, but was found inferior to transradial access in the AURA of ARTEMIS study because of significantly more large hematomas and a high crossover rate in the transulnar group (Circ. Cardiovasc. Interv. 2013;6:252-261).

However, the study used inexperienced ulnar operators and attempted to cannulate even nearly absent ulnar arteries, said Dr. Gokhroo, a pioneer in ulnar intervention at Jawaharlal Nehru Medical College, Ajmer, India, and president of the Indian Society of Cardiology. Based on their observations, the risk of such events is threefold higher during the first 50 procedures, but is no longer statistically significant after 51-100 operations or after 100 operations.

For the prospective, single-center AJULAR (Ajmer Ulnar Artery) trial, all operators were required to have a minimum experience of 50 transulnar cannulations, and cannulation was attempted only if the ulnar artery was easily palpable and the anatomy favorable.

“Excessive calcification, tortuosity, and low-volume pulse were the additional features where the ulnar was avoided; otherwise no other patient characteristics or demographic features compelled us to avoid ulnar access,” Dr. Gokhroo said in an interview.

Inability to palpate the radial artery was also an exclusion criterion.

A total of 2,532 patients scheduled to undergo elective coronary angiography and ad hoc percutaneous transluminal coronary angioplasty were evenly randomized to transulnar access or transradial access. The mean age for the 1,270 ulnar patients was 67 years and 63 years for the 1,262 radial patients.

There were no significant differences in an intention-to-treat analysis between the transulnar and transradial groups with respect to the individual components of the primary outcome: major adverse cardiac events (2.9% vs. 3.2%), large hematoma (1% vs. 0.9%), or occlusion (6.1% vs. 6.6%), Dr. Gokhroo reported.

The secondary endpoints of crossover rate (4.4% vs. 3.8%) and vessel spasm (6.9% vs. 8.7%) were also similar.

“Our study definitely says that ulnar access is as good as radial access,” he said.

An analysis of 48 transradial crossover events revealed that, had ulnar cannulation been considered, the need for crossover to femoral artery access would have been reduced from 38 patients to 2 patients, with the remaining 10 patients accessed via the contralateral radial artery.

“If you have expertise in ulnar cannulation, 75% of femoral artery cannulations can be avoided,” Dr. Gokhroo said. “Transulnar cannulation is also an easy, safe, and comfortable procedure.”

Dr. Gokhroo and his associates said they had no relevant financial disclosures.

pwendling@frontlinemedcom.com