Access & Hemostasis

You Went Ulnar When Radial was Not Suitable. Now How Do You Close the Punctures?

Morton J. Kern, MD, with contributions from Samuel M. Butman, MD, Heart & Vascular Center of Northern Arizona, Cottonwood, Arizona; Lloyd W. Klein MD, Rush University, Chicago, Illinois; Gregory J. Dehmer, MD, Texas A&M College of Medicine, Temple, Texas; Ajay Kirtane, MD, Columbia University/New York-Presbyterian Hospital, New York City, New York; Neal Kleiman, MD, Houston Methodist, Weill Cornell Medical College, Houston, Texas; Bonnie H. Weiner, MD, University of Massachusetts, Worchester, Massachusetts; Barry Borlaug, MD, Mayo Clinic, Rochester, Minnesota; Paul Teirstein, MD, Scripps Clinic, La Jolla, California; Kirk Garrett, MD, Christiana Hospital System, Wilmington, Delaware.

Morton J. Kern, MD, with contributions from Samuel M. Butman, MD, Heart & Vascular Center of Northern Arizona, Cottonwood, Arizona; Lloyd W. Klein MD, Rush University, Chicago, Illinois; Gregory J. Dehmer, MD, Texas A&M College of Medicine, Temple, Texas; Ajay Kirtane, MD, Columbia University/New York-Presbyterian Hospital, New York City, New York; Neal Kleiman, MD, Houston Methodist, Weill Cornell Medical College, Houston, Texas; Bonnie H. Weiner, MD, University of Massachusetts, Worchester, Massachusetts; Barry Borlaug, MD, Mayo Clinic, Rochester, Minnesota; Paul Teirstein, MD, Scripps Clinic, La Jolla, California; Kirk Garrett, MD, Christiana Hospital System, Wilmington, Delaware.

You Went Ulnar When Radial was Not Suitable. Now How Do You Close the Punctures?
 
Having advocated the use of the ulnar artery when the radial artery is not suitable1, we did exactly what we talked about and placed an ulnar sheath using ultrasound guidance after encountering a radial loop on the left arm in a patient having prior coronary artery bypass graft surgery (CABG) with a left internal mammary artery (LIMA).2-5 The procedure was completed without difficulty and it was time to remove the sheaths. What we did not remember was that we should stagger the placement of the sheaths so that they are not at the same level on the wrist. How should we close 2 punctures which are parallel and at the same level with 1 compression band? 
 
Our solution was simple but untested. We placed a StatSeal Disc (Biolife) on the radial puncture and compressed the ulnar puncture with the TR Band (Terumo) (Figure 1). We felt some trepidation about possible insufficient pressure on the StatSeal and so placed a second TR Band in reverse position, but this was overkill. With a slightly cooler hand, we removed the second band. After an hour, pressure was released and slight bleeding at the ulnar but not radial puncture site was noted. Further pressure and later release resulted in successful sealing of both puncture sites with a warm hand.  
 
Based on this experience, I think planning for access site position when putting sheaths in both the radial and ulnar arteries is needed in order to place 2 TR Bands. Of course, you could do what we did as well. 
     — Morton Kern, MD 
 
References
  1. Kern M, Seto AH. Radial access failure: when should we go ulnar? Cath Lab Digest. 2016 Nov; 24(11). Available online at http://www.cathlabdigest.com/article/Radial-Access-Failure-When-Should-We-Go-Ulnar. Accessed September 18, 2017.
  2. Seto AH, Kern MJ. Transulnar catheterization: the road less traveled. Catheter Cardiovasc Interv. 2016 Apr; 87(5): 866-867.
  3. Gokhroo R, Bisht D, Padmanabhan D, et al. Feasibility of ulnar artery intervention (Ajmer ulnar artery intervention group study: AJULAR). Presented at American College of Cardiology Annual Session 2015.  Online at https://www.acc.org/education-and-meetings/image-and-slide-gallery/media-detail?id=108C7D837E47423685061D41FB7C5B80. Accessed September 18, 2017.
  4. Baumann F, Roberts JS. Real time intraprocedural ultrasound measurements of the radial and ulnar arteries in 565 consecutive patients undergoing cardiac catheterization and/or percutaneous coronary intervention via the wrist: understanding anatomy and anomalies may improve access success. J Interv Cardiol. 2015 Dec; 28(6): 574-582.
  5. Seto AH, Roberts JS, Abu-Fadel MS, et al. Real-time ultrasound guidance facilitates transradial access: RAUST (Radial Artery access with Ultrasound Trial). JACC Cardiovasc Interv. 2015 Feb; 8(2): 283-291.