Letter to the Editor Interosseous artery collaterals and their support to ulno-palmar arch: A case report and a review of the literature Andrea Zuffi a, ⁎, Juan F. Iglesias a , Olivier Muller a , Pierfrancesco Agostoni b , Giuseppe Biondi Zoccai c , Eric Eeckhout a , Stephane Fournier a a University Hospital Center Vaudois (CHUV), Department of Cardiology, Lausanne, Switzerland b Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands c Sapienza University of Rome, Latina, Italy article info Article history: Received 3 June 2015 Accepted 20 June 2015 Available online 27 June 2015 A 65 year-old woman, with known hypertension, dyslipidemia, and positive family history of coronary artery disease and conservatively treated for an aorto-iliac occlusive disease, was admitted in September 2014 in our institution with angina (CCS 2) and a positive non-invasive test suggests myocardial ischemia in the inferior wall of the left ventri- cle. Diagnostic suspicion of a right coronary artery (RCA) restenosis in- dicated an invasive coronary artery assessment. Patient clinical history starts 7 months before with an acute anterior non-ST-segment Elevation Myocardial Infarction. Coronary angiogra- phy, performed through a right trans-radial access (TRA) evidenced a sub-occlusive mid-LAD stenosis and a significant stenosis on the RCA. The patient was successfully treated by a PCI on the proximal left ante- rior descending (LAD) with drug eluting stent (DES) implantation. After a short and uneventful hospitalization, she was discharged. One month later, the patient was readmitted to undergo a stage procedure on the RCA due to ventricular inferior wall ischemia evidence. Arterial pulse evaluation showed a probably iatrogenic right radial arterial occlusion (RAO). Therefore, in the context of the aorto-iliac occlusive disease, a left TRA was chosen. Coronary angiography confirmed the good result of the LAD stenting and the RCA stenosis was treated with PCI and Bare Metal Stent (BMS) implantation. The procedure was uneventful and the patient was discharged the following day. Prior to coronary artery angiography, during September 2014 hospi- talization, pulse examination was performed with a bilateral radial artery occlusion evidence. Despite a highly abnormal reverse modified Allen test which would have contraindicated a wrist access, the pulse- oxymetry evaluation (right thumb) recorded a C pattern [1] suggesting the presence of an efficient blood flow to ulno-palmar arch. We then International Journal of Cardiology 197 (2015) 280–281 ⁎ Corresponding author at: Service de cardiologie, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland. E-mail address: zuffiandrea@hotmail.com (A. Zuffi). chose a right trans-ulnar approach (TUA) with a 6 French ulnar sheath (Glidesheath, Terumo, Somerset, NJ) instead of a brachial access to per- form coronary angiography. We also performed a right forearm arteri- ography (Fig. 1), which demonstrated an efficient collateralization from interosseous anterior branch to distal radial artery. The access site was managed with verapamil 5 mg and heparin 5000 UI. The coro- nary angiography showed a sub-occlusive restenosis of the RCA treated with a DES. At the end of the procedure, the 6 French ulnar sheath was removed and the access site was compressed with a dedicated device (TR Band, Terumo, Somerset, NJ). The following day, the patient was discharged after a careful clinical examination including a duplex scan of the ulnar artery that demonstrated its patency. The use of TRA for cardiac catheterization and PCI has increased sub- stantially in recent years. Compared to trans-femoral access, TRA is re- lated to patients preference and comfort, low risk of vascular and bleeding complications and better clinical outcomes [2,3]. In TRA procedures, the risk of hand ischemia complication is still evaluated with the modified Allen Test (MAT). Although it has been shown to have a low specificity [4] and even if performances for hand collaterals arteries evaluation are significantly improved with the of Pletysmography (PL) and Oximetry (OX) association [1], MAT test util- ity still remains debated. However, TRA can be sometimes difficult or impossible to reach due to artery characteristics (atherosclerotic disease, reduced diameter due to repeated procedures) or anatomical variations (radial artery loops, tortuosity, hypoplasia, radial artery high origin). In the last ten years, several series of cases and two randomized controlled trials have shown TUA as a safe and effective alternative to TRA for diagnostic catheterization and PCI. Terashima et al. first re- ported TUA feasibility, performing 7 cases of left ulnar artery access for diagnostic coronary angiography [5]. Shortly after, among 5 pa- tients in which TUA was successfully performed, Dashkoff et al. re- ported 2 uneventful PCI [6]. In the two available randomized controlled trials comparing TRA and TUA, [7,8], no significant differences in efficacy and safety were no- ticed respectively at 30 and 60-day outcomes. TUA was related with high procedural success rate without significant vascular site complica- tions as compared with TRA. Nevertheless, in the AURA of ARTEMIS study, even after normalization for operator clustering, TUA showed a significant inferiority for the higher crossover rate. http://dx.doi.org/10.1016/j.ijcard.2015.06.083 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard