Utilization of Axillary Artery as Access for Mechanical Circulatory Support in Cardiogenic Shock Patients with Severe Occlusive Peripheral Arterial Disease

Background:
The common femoral artery is the access site of choice in the U.S. for large bore sheaths. Since coronary artery disease and peripheral arterial disease (PAD) are diseases of the same spectrum, it is not uncommon to encounter severely atherosclerotic femoral arteries that may hinder complex coronary interventions. We examined the feasibility of axillary artery as alternative access for mechanical circulatory support (MCS) in patients with prohibitive PAD.

Methods:
Records of all patients who required MCS via axillary artery access from December 2016 to September 2018 were examined. Demographics, clinical, procedural and outcomes data were collected on all patients.

Results:
A total of 48 patients (mean age 66±11 years, 83.3% men) were identified. This was due to severe PAD in the iliac and/or common femoral arteries preventing large bore sheath access. Of the 48 patients, 18 required PCI. Four patients received an Impella 2.5 and 40 patients received an Impella CP due to profound left ventricular dysfunction. Four patients presented with biventricular CS requiring concomitant placement of Impella RP for right ventricular support. Median device support time was 3 days (range 1-12 days). Twenty-two patients died before Impella was explanted due to refractory cardiogenic shock, multiorgan failure, or stroke. Four patients developed a hematoma at the axillary access site, 3 patients developed limb ischemia requiring bypass conduit and 2 patients developed axillary artery dissection. All 26 patients who survived to Impella explant were discharged from the hospital without major complication.

Conclusions:
Axillary artery could be considered a safe and viable alternative access for large bore sheaths in patients with prohibitive PAD.