Transcaval access for the emergency delivery of mechanical circulatory support in cardiogenic shock
Afana M, Altawil M, Basir M, Alqarqaz M, Alaswad K, Eng M, O'Neill WW, Lederman RJ, and Greenbaum AB. Transcaval access for the emergency delivery of mechanical circulatory support in cardiogenic shock. BMC Cardiovasc Disord 2019; 19(Suppl 1):A-11.
BMC Cardiovasc Disord
Background: Vascular access for the delivery of mechanical circulatory support (MCS) in patients with cardiogenic shock is often challenging due to peripheral arterial disease and vasoconstriction. Transcaval delivery of MCS may offer an alternative option. We describe the first series of patients in whom we implanted an Impella 5.0 device, without prior CT planning, through a percutaneous transcaval access route. Hypothesis: We hypothesize that transcaval access for the delivery of higher-flow MCS in cardiogenic shock is a feasible alternative in patients with peripheral arterial disease or profound shock needing increased support. Methods: Between December 2015 and June 2017, ten patients with progressive or refractory cardiogenic shock underwent transcaval Impella 5.0 implantation via a transcaval access. Demographic, clinical and procedural variables, along with in-hospital outcomes were collected. Results: All ten patients underwent emergency implantation of the 7mm diameter Impella 5.0L device via transcaval access, without prior CT-based planning. Six were women, with median age of 55.5 years (range, 29 - 69). Cardiogenic shock was attributed to idiopathic non-ischemic cardiomyopathy (n=4), myocarditis (n=2), ischemic cardiomyopathy (n=2), post-heart transplant rejection (n=1), and unknown etiology (n=1). Median duration of support was 92.1 hours (range, 21.2 - 165.4). Seven (70%) survived to device explant, with six (60%) surviving to transcaval access port closure and discharge. One transcaval sheath left in place for hemodynamic monitoring during a planned terminal wean in the setting of progressive clinical decline. Among survivors to discharge, five recovered heart function and one underwent left ventricular assist device as destination therapy. Conclusion: Transcaval access for the delivery of MCS is a feasible alternative for emergency non-surgical implantation of the Impella 5.0 device in patients with peripheral arterial disease or those with profound cardiogenic shock. This approach allows earlier institution and longer duration of higher-flow MCS, and may enable a bridge-torecovery or bridge-to-destination strategy.