The Underrated Route: Trans-ulnar Access in the Era of Radial Dominance—A Case Series and Review of the Literature

Abstract This case series evaluates the feasibility, safety, and technical nuances of trans-ulnar artery access (TUA) as an alternative for diagnostic neurointerventional procedures when the trans-radial access (TRA) is limited by anatomical issues such as small vessel caliber or occlusion. It aims to demonstrate TUA's potential in reducing complications associated with traditional transfemoral access (TFA), including extended bed rest and increased bleeding risks, while facilitating quicker mobilization. Data from nine patients (mean age: 50.1 ± 14.2 years; six males, three females) who underwent diagnostic cerebral digital subtraction angiography via right TUA were analyzed retrospectively. Selection was based on ulnar artery diameter >1.4 mm (preprocedure mean: 1.43 ± 0.1 mm). Performed by an experienced neuroradiologist under ultrasound guidance, the procedures used the Seldinger technique with 4 to 5 Fr sheaths. Post-sheath insertion, an antispasmodic cocktail (200 μg nitroglycerin, 2.5 mg diltiazem, 2,500 IU heparin) was administered as used previously. Hemostasis involved radial compression devices, with 2-hour monitoring and 1-month follow-up via Doppler ultrasound and clinical examination. Indications for TUA included small radial caliber (six patients, 66%), occlusion (two patients, 22%), or failed TRA (one patient, 11.1%). All cases achieved technical success without major complications. The mean procedural time was 30.2 minutes. Single-puncture success occurred in six cases; mild spasm in two. The ulnar diameter remained stable post-procedure. TUA proves highly feasible and safe for diagnostic neuroangiography, offering advantages over TFA and TRA in selected patients, with reduced spasm incidence and easier navigation. However, challenges like operator inexperience and vessel size constraints highlight the need for caution. Future larger scale studies should explore broader neurointerventional applications to confirm these findings.