Single-vessel access venoarterial extracorporeal membrane oxygenation and Impella technique for acute cardiogenic shock complicated by lung congestion

Abstract

The combination of the Impella and peripheral venoarterial extracorporeal membrane oxygenation (Ecmella) is a promising treatment for critically ill patients. We report a single-access Ecmella approach using the brachiocephalic artery. A 65-year-old woman with acute myocardial infarction involving the left main coronary artery underwent intra-aortic balloon pump and peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) placement. Given the progression of pulmonary congestion and lower limb ischaemia, and an axillary artery diameter of 4.9 mm, we decided to perform a single Ecmella approach. A Y-shaped 9-mm Dacron woven graft was anastomosed to the brachiocephalic artery through a reverse T-shaped partial sternotomy. The Impella 5.5 and arterial cannula of VA-ECMO were introduced through each graft. Six days after, VA-ECMO was removed. Sixty-two days after the surgery, the patient received durable left ventricle assist device implantation. In conclusion, haemodynamic support using a single-access Ecmella through brachiocephalic artery allows for managing patients with narrow peripheral arteries.

A combination therapy involving the Impella (Abiomed, MA, USA) and peripheral venoarterial extracorporeal membrane oxygenation (Ecmella) is promising for treating critically ill patients with severe cardiogenic shock [1, 2].

INTRODUCTION

A combination therapy involving the Impella (Abiomed, MA, USA) and peripheral venoarterial extracorporeal membrane oxygenation (Ecmella) is promising for treating critically ill patients with severe cardiogenic shock [1, 2]. However, there are cases where a narrow peripheral arterial diameter limits the insertion of adequately sized extracorporeal membrane oxygenation (ECMO) cannulas and the Impella, making it impossible to achieve sufficient circulatory support [3]. To overcome this situation, we report a method for single-access Ecmella via the brachiocephalic artery (BCA).

CASE

This study was performed in accordance with the Declaration of Helsinki and was approved by the institutional review board of the National Cerebral and Cardiovascular Center, Osaka, Japan (approval number: M30-026-5; approval date: 24 February 2022).

A 65-year-old woman suffered from left main acute myocardial infarction with cardiogenic shock. Initially, an intra-aortic balloon pump and peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) were inserted through right femoral artery and vein (16/20 Fr, 2.5 l/min), and she underwent percutaneous coronary intervention. The peak creatine kinase and creatine kinase-MB values were 14 469 and 807 U/l, respectively. We opted to perform a single-access Ecmella approach via the BCA because of the narrow diameter of 5.6 mm in the femoral artery and 4.9 mm in the axillary artery, coupled with lower limb ischaemia and a closed aortic valve with pulmonary congestion.

After applying reverse T-shaped partial upper sternotomy from the manubrium to the second intercostal body of the sternum, we administered an additional heparin to maintain an activated clotting time >300 s. The size of the BCA was 9 mm; therefore, we anastomosed a 9-mm Dacron woven graft to the BCA (Figure 1). The graft was modified into a Y shape. The Impella 5.5 was introduced through the main graft above the clavicle, while the other side of the graft was connected to the renewed VA-ECMO system (direct graft connect/25 Fr) (Video 1).

Figure 1:

Surgical procedure. Reverse T-shaped sternotomy was performed and the brachiocephalic artery was exposed (A). A 9-mm Dacron woven graft was anastomosed (B). A graft was modified into a Y shape (C). The Impella 5.5 was introduced through the main graft above the clavicle, while the other side of the graft was connected to venoarterial extracorporeal membrane oxygenation (D).

The VA-ECMO flow was initially set at 4.0 l/min and the Impella at P5 (2.5 l/min), making the total flow 6.5 l/min. The pulmonary artery wedge pressure decreased from 22 to 8 mmHg. On the 6th day, the ECMO was removed and the Impella 5.5 was set to P9. We aimed to wean off the Impella 5.5 following adequate rehabilitation, but the patient did not meet the criteria. On the 62nd day, we converted the Impella 5.5 to HeartMate3 (Abbot Park, IL, USA) through full medial sternotomy. After initiating cardiopulmonary bypass, we removed the Impella 5.5, and the graft was suture-closed near the anastomosis site. We detected mild to moderate central aortic valve regurgitation and performed a Park stitch. No cerebrovascular accidents or bleeding events occurred during Impella 5.5 support in the 6 months with the HeartMate3.

DISCUSSION

The single-access method, in which a Y-shaped artificial graft is placed in the axillary artery or BCA, can avoid femoral canulation-related complications [4, 5]. This BCA access is an alternative for patients with narrow EXTRA-thoracic vessels requiring the maximum Ecmella treatment. Although the BCA approach provides sufficient ECMO flow, it has the disadvantages of requiring partial sternotomy and the potential risk for causing cerebral infarction. Therefore, thoroughly assessing the arterial condition is essential. Additionally, because the Impella shaft is 3 mm and considering ECMO flow, a graft size of ≥9 mm is preferable for the single-access approach.

In conclusion, haemodynamic support using an Ecmella configuration with single BCA access allows for managing patients with heart failure without worrying about peripheral arterial complications or differential hypoxia.

FUNDING

No funds, grants or other support were received.

Conflict of interest: none declared.

DATA AVAILABILITY

The data underlying this article will be shared on reasonable request to the corresponding author.

Reviewer Information

Interdisciplinary CardioVascular and Thoracic Surgery thanks Evgenij V. Potapov, Sergio Pirola and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.