1. Alternative Approach Trans-Ulnar Approach Feasibility of Percutaneous Coronary Intervention Via Transulnar Artery Approach in Selected Patients with Coronary Heart Disease Xianghua Fu, MD, PhD et al Center of Interventional Cardiology, the 2 nd Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei,China

2. Alternative Approach Trans-Ulnar Approach Background  Advantages of transradial intervention : -earlier ambulation -earlier ambulation -less complications -less complications -shorter hospital stay and lower cost -shorter hospital stay and lower cost  Unfeasible for TRI(10-30%) : -anatomic variation -malformation -puncture trouble : spasm, tortuous, thin,calcification, etc. -puncture trouble : spasm, tortuous, thin,calcification, etc. -used for other purpose (graft, etc.) -used for other purpose (graft, etc.)

3. Alternative Approach Trans-Ulnar Approach Dr. Terashima et al (2000): 7/9 cases of ulnar artery for angiography How about PCI via ulnar artery access? Feasibility? Easy or difficult? Safety? Complication?

4. Alternative Approach Trans-Ulnar Approach Objective To explore the clinical feasibility of percutaneous coronary intervention via transulnar artery approach (TUI)To explore the clinical feasibility of percutaneous coronary intervention via transulnar artery approach (TUI)

5. Alternative Approach Trans-Ulnar Approach Enrolled Patients Total patients(2001-2003): 40 (Male 34;Female,6) from 482 PCI patients with CHD. Age : 41-79 years old Clinical diagnosis: –AMI(7-14d): 12 patients –OMI: 7 patients –UAP: 21 patients (Including 2 cases of restenosis after stent) All of them gave written informed consent approved by the academic committee of The 2 nd hospital of HBMU

6. Alternative Approach Trans-Ulnar Approach Reason of transulnar PCI Tortuous/thin radial artery or failured radial artery puncture : 30 patients Radial artery was used previously (angiography/PCI) : 8 patients Abnormality of radial artery : 2 patients

7. Alternative Approach Trans-Ulnar Approach Ulnar Artery v.s Radial Artery - Diameter: UA >RA - Allen’s test time: UA<RA, both sides positive - Pulsation: UA>RA - Puncture feeling: ulnar access may be easier.

8. Alternative Approach Trans-Ulnar Approach E cho/Doppler : diameter of ulnar artery is larger than that of radial artery, UA/RA Ratio is 1.35

9. Alternative Approach Trans-Ulnar Approach Devices  All same as with transradial PCI  21G （ 8# ） naked needle （ Cordis ， USA ）  0.019 inch hydrophilic guidewire （ Cordis ， USA ）  6F radial special sheath （ Cordis ， USA ）  4F angiograph catheter (Cordis, USA)  6F guiding catheter: -LCA ： XB-LAD3.5 EBU3.5 XB3.5 JL3.5 -RCA ： ART JR4.0 ZUMA

10. Alternative Approach Trans-Ulnar Approach Procedure  Puncture site: 3 cm up the right wrist with the most powerful pulsation of ulnar artery  Puncture angle: 45º along the axis of vessel  Prevention of ulnar artery spasm: nitroglycerin, verapamil, lidocaine and dilthiazem,or combinted dual agents by intra-sheath for some patients  Removal artery sheath: without ceasing heparin infusion  Management of puncture site: 6 hrs compression with gradual release of pressure  Ambulate immediately if patients condition permit

11. Alternative Approach Trans-Ulnar Approach TRU-PCI

12. Alternative Approach Trans-Ulnar Approach Clinical Outcome First time success rate for puncture : 87.5% (35 patients),the rest ( 5 patients) : 2-4 times Forty-eight lesions of 42 vessels were angioplasticied successfully The average procedure duration of manipulation : 56.6 min Ulnar artery hemodynamics (flow velocity, ulnar blood pressure) : no difference before and after the procedure One month follow-up : no significant difference before and after transulnar PCI

13. Alternative Approach Trans-Ulnar Approach Comparison of UA hemodynamic parameter before and after PCI operation 95.0±1.51 97.6±1.12 0.82±0.03 48.6±7.14 131±28/59 ±4 Post-PCI 95.5±1.70 99.1±1.83 0.80±0.05 51.4±7.03 136±33/60 ±5 Pre-PCI So 2 % Pao 2 (mmHg)RI Vs max (cm/s) UA BP UA BP(mmHg) UA: ulnar artery BP: blood pressure Vs: blood velosity RI: resistance index Pao 2 : oxygen pressure So 2 : oxygen saturation

14. Alternative Approach Trans-Ulnar Approach vessel comparison of UA and RA before and after PCI UA Allen`s time(s) RA Allen`s time (s) UA diameter (mm) RA diameter (mm) UA cross section area (mm 2 ) RA cross section area (mm 2 ) Pre- PCI 2.70±0.36* 4.68±0.5 2 3.26±0.22* 2.62±0.28 5.68±1.16* 4.08±1.33 Post - PCI 2.96±0.98 # 4.82±0.3 5 3.22±0.48 # 2.53±0.40 5.02±1.60 # 3.91±1.50 * p<0.05 UA vs RA before PCI # p<0.05 UA vs RA after PCI

15. Alternative Approach Trans-Ulnar Approach Complications -No serious complication -No ulnar nerve damage -No ulnar artery occlusion -No A-V fistula -No pseudoaneurism -Mild complications -Slight haematoma: 2 patients

16. Alternative Approach Trans-Ulnar Approach Summary 1. 1. PCI by ulnar artery approach has been successfully performed in forty patients with difficulty to perform TRI 2.Possible consideration for transulnar artery PCI: a.Transradial access PCI with difficulty but dual sides Allen’s test positive b.The pulsation of ulnar artery is stronger than that of radial artery c. The diameter of ulnar artery is larger than that of radial artery (≥2.5mm and ≥4.5mm 2 )

17. Alternative Approach Trans-Ulnar Approach Conclusions and Clinical Experience The outcome of our clinical practice demonstrated that transulnar PCI is practical, safe and beneficial for the patients with TRI difficulty, but more clinic practice will be need More patients to reach threshold for trans- forearm artery approach PCI More practice for skill performance