Advances in Vascular Post-Closure With Impella

Risk factors for percutaneous left ventricular assist device explant complications

INTRODUCTION

Percutaneous left ventricular assist device (pLVAD) explant remains nonstandardized with potential complications of bleeding and thrombosis. Explant settings include percutaneous techniques in the catheterization laboratory (CL), manually at bedside (MB), and surgically in the operating room (OR).

OBJECTIVE

Identify high-risk features for explant-related complications, including indication for support, setting, and technique.

METHODS

Postexplant bleeding and thrombosis/limb ischemia were identified following pLVAD removals over 2 years at a multicenter healthcare system.

RESULTS

Of 156 patients, bleeding (n = 26 [17%]) and thrombosis (n = 9 [6%]) occurred more often in patients with the peripheral arterial disease (PAD), female gender, anemia, and cardiogenic shock. OR explants had a higher combined endpoint (4/8 [50%]) versus CL (23/133 [17%], p < 0.05) driven by transfusion. There was no difference between OR versus MB (5/15 [33%], p = 0.66) or CL versus MB (p = 0.62). In shock patients, there was no difference between CL (7/30 [23%]) versus MB (5/15 [33%], p = 0.5) and OR (4/7 [57%], p = 0.16); or MB versus OR (p = 0.38). Average length of stay was significantly lower in the CL group versus MB and OR (3.6 ± 33.2 vs. 18.4 ± 10.9 vs. 28.1 ± 15.8 days, p < 0.0001). Preclosure in shock patients (5/25 [20%] vs. 11/27 [41%], p = 0.1383) and crossover balloon occlusion technique (9/44 [16%] vs. 25/112 [22%]; p = 1) were not associated with higher combined endpoints versus control.

CONCLUSION

Risk factors for pLVAD explant complications include PAD, female gender, and cardiogenic shock. There was no difference in complication rates between explant settings among cardiogenic shock patients, but shorter length of stay when performed in the CL. There was no difference in complication rates when using the crossover balloon occlusion technique.

Post-Closure Technique to Reduce Vascular Complications Related to Impella CP

BACKGROUND

Use of percutaneous mechanical circulatory support has grown exponentially. Vascular complications remain a growing concern and best practices for device removal do not exist. We describe a novel post-closure technique for the next generation Impella CP removal and immediate hemostasis.

METHODS

This study is a single center, retrospective, exploratory analysis of 11 consecutive patients receiving an Impella CP for either high-risk PCI or cardiogenic shock and then referred for post-closure compared to 20 patients receiving manual compression for Impella CP removal between 2017 and 2019.

RESULTS

Mean age range was 62.7-65.4 years and 50-65% male between groups. Average duration of Impella CP treatment ranged from 3.4 to 5.2 days. Patients referred for post-closure had significantly lower rates of all-cause adverse vascular events (0% versus 40%; n = 0/11 versus n = 8/20; p = 0.01). There was no significant difference in BARC 3 or greater bleeding, transfusion requirement, hospitalization duration or intensive care duration between removal strategies.

CONCLUSION

The novel post-closure technique may significantly reduce vascular complications associated with device removal and may improve clinical outcomes for these critically ill patients.

Post hoc closure of large bore vascular access using the MANTA closure device

Successful closure of large bore vascular access (≥12 Fr) is facilitated by the MANTA vascular closure device; however, it requires a critical first step of measuring "skin to arterial wall" depth of the access site using the depth locator before dilating the vessel above 8 Fr. It may be challenging at times to acquire the deployment depth at the onset of the procedure due to case urgency, delayed closure, or when large bore access is obtained at a different institution. We discuss a novel technique of measuring the deployment depth and successful delayed closure of large bore arterial access using the MANTA closure device.

The Rise of Endovascular Mechanical Circulatory Support Use for Cardiogenic Shock and High Risk Coronary Intervention: Considerations and Challenges

Introduction: Cardiogenic shock due to acute myocardial infarction and decompensated advanced heart failure remains a source of significant morbidity and mortality. Endovascular mechanical circulatory support devices including intra-aortic balloon pump (IABP), percutaneous left ventricular assist devices (Impella and Tandemheart pumps), and veno-arterial extracorporeal oxygenation (VA-ECMO) are utilized for a broadening range of indications.Areas covered: This narrative review explores the specific devices, their distinctive hemodynamic profiles, and practical considerations. Furthermore, reviewed are the trials evaluating device outcomes which have generated significant controversy within the field of heart failure and shock. New applications and future directions are discussed.Expert opinion: Use of endovascular mechanical circulatory support has increased over the last decade, though evidence supporting their use is lacking. Development of large-scale prospective registries and clinical classification systems will facilitate patient enrollment and inform trial design. Furthermore, expansion of indications for these devices is revolutionizing how the field of heart failure and cardiogenic shock thinks about hemodynamic support. The ability to tailor therapy to a patient's specific hemodynamic profile appears to be the future of cardiogenic shock management.

The science of safety: complications associated with the use of mechanical circulatory support in cardiogenic shock and best practices to maximize safety

Acute mechanical circulatory support (MCS) devices are widely used in cardiogenic shock (CS) despite a lack of high-quality clinical evidence to guide their use. Multiple devices exist across a spectrum from modest to complete support, and each is associated with unique risks. In this review, we summarize existing data on complications associated with the three most widely used acute MCS platforms: the intra-aortic balloon pump (IABP), Impella systems, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We review evidence from available randomized trials and highlight challenges comparing complication rates from case series and comparative observational studies where a lack of granular data precludes appropriate matching of patients by CS severity. We further offer a series of best practices to help shock practitioners minimize the risk of MCS-associated complications and ensure the best possible outcomes for patients.

Incidence and clinical outcomes of bleeding complications and acute limb ischemia in STEMI and cardiogenic shock

BACKGROUND

Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS-STEMI).

OBJECTIVE

We evaluated 10-year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS-STEMI.

METHODS

We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra-aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation.

RESULTS

Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS-STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in-hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in-hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs.

CONCLUSIONS

Bleeding and ALI are common complications associated with CS-STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS-STEMI.

Percutaneous Impella CP exchange with preservation of transfemoral access

In patients with cardiogenic shock, the global use of percutaneous mechanical circulatory support using the Impella CP device has increased with early data suggesting potential benefits over conservative management. In the current case report we describe a simple technique facilitating percutaneous Impella CP or RP exchange with preservation of transfemoral access, which does not require the use of a 0.035' wire. This technique allows for percutaneous sealing of the 14F arteriotomy using new closure devices avoiding the traditional cut-down.