The "two cut - monorail" technique, for the percutaneous removal of the Impella CP device, without preclose arterial access
Dimitrios Miserlis1, Maria Tecos2, Nitin Garg2, Jason N MacTaggart2, Mark Davies1, Timothy B Baxter2, Iraklis I Pipinos2
1University of Texas Health Science center at San Antonio, San Antonio, TX;2University of Nebraska Medical Center, Omaha, NE
BACKGROUND : The Impella heart pump (Abiomed Inc., Danvers, Massachusetts) is a percutaneous, catheter-based, ventricular support device. The device is placed across the aortic valve into the left ventricle and is used for hemodynamic support in the occasion of high risk percutaneous coronary interventions and for temporary treatment of cardiogenic shock. The Impella devices are frequently placed under urgent/emergent conditions without the time to preclose their 14 French access site. The current configuration of the Impella catheter does not allow placement of a wire through the device. This results in a need to remove the Impella, using open groin exploration and direct repair of the femoral access site which can be problematic in these critically ill patients.
METHODS: We describe an innovative method for the percutaneous removal of the Impella after it has been placed in a percutaneous fashion, without the use of the preclose technique. The concept is to utilize the hollow compartment of the Impella catheter shaft, to allow passage of a 0.035" wire in a "monorail fashion" through the catheter shaft into the patientís aorta. Over this wire, we can first remove the Impella device out of the arterial system and then place two Perclose ProGlide (Abbott Vascular, Santa Clara, Calif) devices to achieve closure and hemostasis of the arterial entry site. To achieve this, we pull three quarters of the Impella catheter out of the patient and create two small openings in the catheter wall approximately 30cm apart. The wire is then introduced through the first (proximal) opening and is advanced through the shaft of the catheter. The tip of the wire is placed just underneath the second (distal) opening. The catheter is then advanced in the aortoiliac segment of the patient. Once the distal opening reaches the level of the proximal common iliac artery the wire is pushed through the distal opening of the catheter into the patientís aorta. Wire access is thus established allowing safe removal of the Impella.RESULTS: The access site was successfully closed, hemostasis was achieved, and peripheral perfusion to the lower extremity was re-established. The duration of the operation was 1 hour and 12 minutes. The patient tolerated the procedure well without complications.CONCLUSIONS: Safe percutaneous removal of the Impella device and hemostasis of the groin access site can be achieved using this technique, under local anesthesia and without the need for an open operation. This totally percutaneous technique offers significant advantages over the current method of open femoral exposure and removal in these critically ill patients.
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