An innovative cervical approach for the insertion of a miniature microaxial flow ventricular assist device

Transinnominate Impella 5.5 device (Abiomed) insertion via limited cervical incision.

Central Message.

We describe a novel cervical approach for insertion of the Impella 5.5 ventricular assist device (Abiomed) in a pediatric patient awaiting heart retransplantation, avoiding any form of sternotomy.

The Impella 5.5 (I5.5) device (Abiomed) is a microaxial ventricular assist device that exhibits particular appeal for use in children.^1,2 Typically, the I5.5 device is delivered into the left ventricle after surgical exposure and sewing of a Hemashield graft (Woven double-velour polyester; Maquet) to either the axillary or subclavian artery.³ It is recommended that an artery measuring 5 mm is required to successfully deliver the I5.5 device. Often these vessels in children do not meet this criterion, resulting in limitation of the use of the I5.5 device in pediatric populations. The innominate artery, a much larger vessel, has been utilized for I5.5 device insertion to expand the utilization of this device in children.⁴ However, previously described transinnominate artery techniques require partial or full median sternotomy for vessel exposure. We present an innovative cervical approach to transinnominate I5.5 device insertion in an adolescent as a bridge to retransplantation to avoid a redo sternotomy. By institutional standard, this study did not meet requirements for institutional review board review because it is a case report involving data from 5 or fewer patients. Written informed consent for publication of study data was obtained from the patient.

Clinical Vignette

We present the case of a 17-year-old male patient with past medical history of restrictive cardiomyopathy who underwent orthotopic heart transplantation at age 12 years. He subsequently experienced multiple episodes of cellular rejection culminating in the development of severe cardiac allograft vasculopathy. This precipitated acute decompensated heart failure marked by severe biventricular dysfunction requiring aggressive inotropic support. He was re-evaluated and deemed an appropriate candidate for retransplantation. Given his deteriorated state of Interagency Registry for Mechanically Assisted Circulatory Support classification (level 2) a decision was made to place an I5.5 device as a bridge to cardiac retransplantation. The patient had a previous implant of the I5.5 device via axillary approach 2 months prior, with left ventricle recovery and subsequent explantation. This limited arterial options for a second implantation. As such, the innominate artery via a novel approach of a cervical incision was chosen.

Surgical Technique

An oblique incision was made from the sternal notch following the sternocleidomastoid muscle for approximately 3 cm in the right neck (Video 1). The sternocleidomastoid muscle was exposed and retracted laterally. The bifurcation of innominate artery was identified and then dissected proximally under the sternal notch to gain full exposure of the vessel. A vessel loop was used to encircle the innominate artery, elevating it to allow for a C-clamp to be placed (Figure 1, A). A longitudinal incision was then made into the innominate artery (7 mm by preoperative ultrasound measurement) and an 8 mm Hemashield graft was anastomosed (Figure 1, B). The graft was then tunneled subcutaneously through the skin exiting in the right neck (Figure 1, C). The I5.5 introducer sheath was positioned in the graft. Under fluoroscopic guidance, a 4 Fr Glidecath catheter (Terumo) and a 0.035 in Wholey wire (Medtronic) was used to position the catheter through the graft into the innominate artery and then into the left ventricle. The Wholey wire was then exchanged for a full-bodied 0.018 in wire, over which the I5.5 device was positioned with transesophageal echocardiographic and fluoroscopic guidance (Figure 1, D and E).

Figure 1.

Transinnominate artery Impella 5.5 (Abiomed) device insertion. A, Dissected innominate artery with distal control using vessel loop (right = sternal notch and left = innominate artery). B, Hemashield graft anastomosis to innominate artery. C, Subcutaneous tunneling of the Hemashield graft along right neck. D, Impella 5.5 device introduction via Hemashield graft through innominate artery. E, Completion of operation (A wound vacuum-assisted closure device was placed over a limited area of the cervical incision to aid in wound healing/infection prevention and a separate bandage inferior to the innominate insertion is from a previous Impella 5.5 device placement via axillary approach).

Postoperative Course

The patient was extubated within the first 36 hours postoperatively. His left ventricle was well supported on the I5.5 device at P-level 4 to 5 flow rates, whereas the right ventricle was supported with low-dose epinephrine and milrinone. Successful decompression of the left ventricle and resolution of pulmonary edema was observed by echocardiography and chest radiograph. He underwent 4 weeks of intensive rehabilitation that demonstrated stable positioning of the device, as evidenced by serial transthoracic echocardiograms, before successful heart retransplantation.

Comments

In our review of the literature, this is the first report describing a cervical incision for transinnominate artery I5.5 device insertion. This approach provides numerous important advantages. It is less invasive and does not require any form of sternotomy. Furthermore, it avoids a redo sternotomy to access the innominate artery in those patients who have had previous cardiac surgery. Additionally, catheter manipulation through an axillary artery approach can be challenging, in part because of a limited ability to torque catheters due to multiple turns during the course to the left ventricle. A cervical incision transinnominate artery approach allows for a relatively straight path to the left ventricle with sufficient support for catheter directability. This approach provides the opportunity to utilize the innominate artery, a much larger vessel than the axillary artery, potentially increasing I5.5 ventricular assist device candidacy for pediatric patients.

Supplementary Data

Video 1

Surgical technique exhibiting limited cervical incision, innominate artery dissection, Hemashield graft anastomosis, subcutaneous tunneling of the Hemashield graft, and securing the Impella 5.5 (Abiomed) device introducer sheath. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00012-3/fulltext.