‘radial First’ to ‘wrist First’: Transulnar Arterial Access for Diagnostic Cerebral Angiography and Neurovascular Intervention

Introduction: Extensive literature has demonstrated the safety of transradial artery access for coronary angiography, prompting an increasing number of neurointerventionalists to adopt the transradial approach for diagnostic cerebral angiography and neurovascular intervention. Still, factors such as variant or diminutive anatomy, vasospasm, or radial artery occlusion can preclude safe access to the radial artery. In such cases, transulnar access is an alternative route for arterial access.

Methods: Consecutive diagnostic and interventional neurovascular procedures completed solely via ulnar artery access over a 36-month period at a high-volume academic neurovascular center were retrospectively reviewed and analyzed. For transulnar access, (1) the wrist is supinated and slightly hyper-extended, (2) light pressure is used to palpate the artery, (3) ultrasound visualization is used to ensure protection of the ulnar nerve which runs parallel and medial, and (4) the artery is punctured with a 21-gauge needle approximately 1-3cm proximal to the pisiform bone.

Results: The ulnar artery was accessed for 50 procedures (39 diagnostic, 11 interventional) in 43 consecutive patients over a 36-month period. Interventions included pipeline flow diversions, coil embolizations, and stent placements. In all cases, the ulnar artery was chosen for cannulation because the ipsilateral radial artery proved unfavorable for the procedure in question. All procedures were successfully completed without need for conversion to femoral arterial access. There were no forearm hematomas, hand ischemia, or arm nerve damage in any patients.

Conclusion : Our experience suggests that transulnar artery access is a feasible and safe alternative for diagnostic cerebral angiography and neurovascular intervention. Given the lower rate of complications associated with transradial and transulnar arterial access when compared to literature using femoral access, this study further supports the shift of cerebral angiography and neurovascular intervention from a ‘radial first’ to a ‘wrist first’ approach.