Review of the arm alternative arterial access sites for percutaneous interventions

Abstract

Percutaneous coronary interventions (PCI) traditionally rely on transradial access (TRA), but alternative arm vascular access sites are gaining importance due to the need to preserve radial arteries for future procedures and to overcome challenges like radial artery occlusion (RAO), tortuosity, or their small vessel size. Additionally, secondary or bailout options become critical when both radial and femoral access are not feasible. This review explores distal radial access (DRA), transulnar access (TUA), and transbrachial access (TBA) as alternatives. DRA offers reduced RAO rates, maintains antegrade blood flow in hand during both the procedure and hemostasis, and enhances patient comfort, but it requires ultrasound guidance for optimal success. TUA is particularly useful when the radial artery is unsuitable, though it may involve higher access site crossover and technical challenges. TBA, allowing for larger sheath sizes, is ideal for peripheral vascular disease cases but carries a higher risk of complications such as bleeding and nerve injury. These alternative access sites provide essential bailout options in complex scenarios, offering tailored solutions for cases where radial or femoral access is not viable. They enable operators to manage anatomical or procedural challenges while reducing vascular complications and improving patient outcomes. This article aims to extensively describe DRA, TUA, and TBA, addressing their benefits, challenges, and providing technical tips and tricks for successful use. Percutaneous repeat interventions will be necessary to perform alternative vascular access routes safely and effectively to ensure better outcomes and procedural success.