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All Roads Lead to the Heart: A Case of Transulnar Approach for Coronary Catheterization in a Patient with Limited Access Routes

Introduction: In a time of increasing use of forearm arterial access in cardiac catheterization, the reported use of the ulnar artery remains low. However, in the patient population with heavy cardiovascular disease burden, it is not uncommon to have patients requiring either multiple catheterizations, future coronary bypass, or other additional procedures which may compromise arterial anatomy. Previously thought to require longer access time, several large meta analyses have shown comparable access time and failure rates to radial access.

Case presentation: We present a case of a 51-year-old male who underwent successful transulnar access for cardiac catheterization in the post-bypass setting with limited arterial access points. Presenting with an eight-month history of angina and positive stress test, he was found to have multivessel disease on initial catheterization. He underwent four vessel bypass using LIMA, RIMA, left radial artery, and left great saphenous vein. On post-op day two, he went into cardiac arrest requiring CPR and multiple vasopressors. He was subsequently placed on venoarterial ECMO with arterial access at his right femoral artery after failed access on his left femoral artery. With a new drop in ejection fraction, he returned to the lab for right and left catheterization. With recent failed L femoral access, ongoing use of R femoral artery for ECMO, harvest of L radial for bypass, and a failed Allen’s test on his R radial, the decision was made to use the R ulnar artery. Arterial access was successful, and PCI was performed on a severely stenotic lesion of the distal RCA. Ejection fraction returned to 55-60%, and he was weaned off ECMO.

Discussion: This case demonstrates opportunity for transulnar catheterization and reviews literature demonstrating comparable outcomes to radial access.


Krishnamurthy S, Furtney J and Badiye A

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