Access and Closure Techniques with the Impella Left Ventricular Assist Device
- Volume 20 - Issue 4 - April 2012
- Posted on: 3/28/12
- 0 Comments
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The increase in large-bore access procedures is resulting in an increasing interest and experience with vascular closure devices.11 In settings in which the Impella is a supportive adjunct to the procedure and its removal is intended at the end of the procedure, a modified pre-close approach can be adopted. Very little prospective data on how best to select patients for vascular closure has been published, but the consensus opinion is that fluoroscopic guidance can help assist in planning vascular closure.12,13 Here again, non-invasive imaging, such as computed tomography (CT) angiography, may also enhance selection of patients for vascular closure. Applied methodically and systematically, a vascular closure approach has been reported to improve aid in hemostasis in endovascular aortic repair (EVAR).14,15 The choice of device dictates the strategy in terms of sequence of placement and number of devices to be placed.16 Choice of device depends largely on experience and the literature reports success with several devices, including the Prostar XL, Starclose, and Perclose (all from Abbott Vascular).17-19 The “pre-close” technique (our preferred technique) involves deploying two Perclose devices at the arteriotomy site prior to placing large caliber sheaths (Figure 1). An 18-gauge needle is used to cannulate the common femoral artery under fluoroscopy along its anterior aspect at the mid-level of the femoral head. An 0.035-inch wire is introduced into the vessel, then two 6 Fr Perclose Proglide devices are placed. The first device is placed at a 30°–45° angle and then deployed in the standard manner. The Perclose suture strands are extracted from the device and tagged with hemostatic forceps. Before complete removal of the first carrier device, the 0.035-inch guide wire is reinserted into the femoral artery via a marked monorail wire tube in the first device. A second Perclose device is then introduced at a 90˚ angle to the first device and deployed. The sutures are again secured with a hemostat. The guide wire is reinserted into the device and then sheaths can then be advanced into the femoral artery. At the end of the case, the sutures are cinched down after catheter removal in a sequential manner to close the arteriotomy.
A further measure of control can be gained in this setting, if there is already contralateral access, by placing a crossover sheath to provide the option of contralateral balloon tamponade in the event of failure of the closure elements. This is accomplished by using a diagnostic internal mammary catheter to cannulate, from the contralateral access, the ipsilateral common iliac artery that holds the large caliber sheath. A 0.035-inch hydrophilic wire is then advanced into the ipsilateral superficial femoral artery, and the diagnostic catheter is advanced over the wire beyond the larger caliber sheath. An 0.035 stiff wire (e.g., Amplatz, Cook Medical) wire is advanced through the diagnostic catheter, and then the catheter is removed. Over the stiff wire, a 6-7 Fr crossover sheath is advanced into the ipsilateral external iliac artery. A peripheral balloon (typically 6-8 mm in diameter) is then advanced to the arteriotomy and inflated to tamponade the site. Also, to decrease bleeding during large-caliber sheath removal, a peripheral balloon can be placed in the proximal iliac artery. It is inflated at a low pressure while the catheter is removed and the arteriotomy is closed with the Perclose sutures.19
Contralateral balloon tamponade closure can also be contemplated in a non pre-close setting to assist manual or surgical closure, and perhaps in the future, alternative device closure, though currently there is no percutaneous device able to take advantage of this in a non pre-close setting.
The Impella 5.0
The Impella 5.0 was originally designed for surgical insertion in the right femoral artery through a 3-cm incision. After hemostatic control is achieved with a purse-string suture, a 6 Fr all-purpose diagnostic catheter such as an Amplatz or a pigtail is advanced across the aortic valve under fluoroscopy. With fluoroscopic and/or transesophageal echocardiographic guidance, the Impella 5.0 LP pump can then be positioned across the aortic valve, using an 0.21-inch or a stiff 0.14-inch guidewire. Alternatively, an 8 mm or 10 mm Dacron graft can be anastomosed to the femoral artery in an end-to-side fashion.20