Abdominal Aortic Replacement On Impella Support
Nikita Singh, Lauren Story-Hefta, Mohammed Moursi
University of Arkansas for Medical Sciences (UAMS), Little Rock, AR
BACKGROUND: We report on a patient who underwent open aortic surgery and developed cardiogenic shock secondary to Takotsubo cardiomyopathy requiring Impella (Abiomed, Danvers, MA) support. The patient is a 47-year-old male smoker with hypertension and COPD who presented with an ischemic left lower extremity ABI of 0, a right lower extremity ABI of 0.85, and symptoms of chronic mesenteric ischemia. He was s/p an aortic endarterectomy 11 years prior. CTA revealed a thrombosed 2.7 cm left common iliac aneurysm, a thrombosed 5.6 cm left external iliac artery aneurysm, and an occluded right external iliac artery. He also had an occluded celiac artery, SMA and IMA.
METHODS: An aorto-bifemoral bypass, aorto-IMA bypass, and aorto-SMA bypass was attempted. After the initial dissection, he developed a STEMI and cardiac arrest. After ACLS, ROSC was achieved. An echocardiogram revealed an ejection fraction of 10%. His incisions were closed, and he was transported to the cardiac catheterization lab. Emergent catheterization revealed no acute coronary pathology. An Impella 3.5 was placed through his right axillary artery. Due to his need for greater support, this was replaced with an Impella 5.5 via an 8 mm PTFE conduit sewn onto his left subclavian artery. Overnight, he required P7 flow. A discussion was had between the Vascular Surgery, Intensivist, and Interventional Cardiology teams regarding proceeding with the high-risk surgery on Impella support versus the patient resuming his current limited lifestyle. The following day, an aorto-bifemoral bypass, aorto-SMA bypass, and aorto-IMA bypass was performed. His right forearm required fasciotomy for compartment syndrome. That night, he required takeback for abdominal bleeding. A repeat echocardiogram revealed an ejection fraction of 55%, and his Impella was weaned to P2 flow. The following day, his left subclavian conduit and Impella were removed, and his right forearm fasciotomy sites were closed. He was quickly weaned from pressers and was ultimately able to achieve limb salvage.
RESULTS: He was seen in clinic on post-op day 89 with no complications. His leg pain had resolved, he returned to work, and he was tolerating a regular diet.
CONCLUSION: Takotsubo is a unique reversible cardiomyopathy that is often precipitated by a stressful event. In rare cases, it can progress to cardiogenic shock, requiring external hemodynamic support such as an Impella. Given that the patient was symptomatic and that the entire dissection had been performed, we elected to proceed with completion of the procedure while on Impella support. Successful open aortic revascularization in a patient on Impella support is possible with the collaboration of a multidisciplinary team.
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