Radial-first to wrist-first: Transulnar arterial access for diagnostic cerebral angiography and neurovascular intervention

Purpose

Although transradial arterial access has been increasingly used in neurointerventional procedures, anatomical variations, vasospasm, or radial artery occlusion can preclude safe access to the radial artery. This study evaluates the feasibility and safety of transulnar artery access as an alternative route for diagnostic cerebral angiography and neurovascular interventions.

Materials and methods

A retrospective review was conducted at a high-volume academic neurovascular center. Consecutive diagnostic and interventional neurovascular procedures performed exclusively via transulnar artery access over a four-year period were reviewed and analyzed. Data collected included case type, arterial measurements (ulnar and radial), access choice rationale, and complications.

Results

A total of 161 procedures (111 diagnostic cerebral angiograms, 50 neurovascular interventions) were performed using transulnar access over a 5-year period. The mean patient age was 54.4 years, and 119 patients were female. Ulnar artery access was chosen due to an unfavorable ipsilateral radial artery or the need for a dedicated left vertebral artery injection. Interventions included pipeline flow diversion, aneurysm coiling (with and without adjunctive devices), tumor embolization, and balloon-assisted coiling. All ulnar artery access sites were closed with an inflatable band closure device. Additionally, no conversions to femoral access were required. There were minimal cases of forearm hematoma, hand ischemia, or arm nerve damage.

Conclusion

Transradial arterial access has demonstrated a lower rate of access site complications relative to the femoral approach. Our experience suggests that transulnar artery access is also a feasible and safe alternative for diagnostic cerebral angiography and neurovascular intervention. Given the lower complication rates associated with both transradial and transulnar access compared to femoral access in the existing literature, this study further supports shifting from a “radial-first” approach to a broader “wrist-first” approach in neurointerventional procedures.