Ulnar Artery Access in Chronic Total Occlusion Percutaneous Coronary Intervention

Ulnar artery access may provide an alternative access route for chronic total occlusion percutaneous coronary intervention (CTO PCI), but data is limited.

To assess the utilization, patient characteristics, and in-hospital outcomes of ulnar artery access compared with radial access and non-ulnar access in patients undergoing CTO PCI.

We analyzed patients who underwent CTO PCI between 2012 and 2024 at 51 centers within the PROGRESS-CTO Registry. Patients were stratified by access: (1) no radial/ulnar, (2) radial without ulnar, and (3) ulnar. The primary endpoint was in-hospital major adverse cardiovascular events (MACE). Secondary endpoints included technical success. Multivariable logistic regression was used to identify independent predictors of outcomes.

Among 18,826 patients, 8844 (47.0%) had no radial/ulnar access, 9835 (52.2%) radial without ulnar, and 147 (0.8%) ulnar. Ulnar patients were younger (62.5 ± 10.4 vs. 64.0 ± 10.4 radial and ulnar, 65.1 ± 10.5 no radial/ulnar, p < 0.001) and had higher prevalence of prior PCI (73.6% vs. 59.3% and 64.0%, p < 0.001) and peripheral arterial disease (23.9% vs. 12.1% and 15.1%, p < 0.001). Lesion complexity was lower with ulnar access (J-CTO 2.19 ± 1.27 vs. 2.32 ± 1.27 radial and 2.47 ± 1.21 no radial/ulnar, p < 0.001). In-hospital outcomes were similar: MACE (2.7% ulnar vs. 1.8% radial vs. 2.0% no radial/ulnar, p = 0.315), technical success (83.7% vs. 87.3% vs. 87.2%, p = 0.425), and access complications (0.7% vs. 0.7% vs. 1.2%, p = 0.001). Logistic regression showed no independent association between ulnar access and MACE, technical success, or access-site complications.

In the largest series to date, ulnar access was used in 0.8% of CTO PCI with similar outcomes to radial and femoral access. Given its use in lower complexity cases, these findings are hypothesis-generating and warrant prospective evaluation.