Title
Novel Snare Guided Approach to Removal of an Impacted Impella
Introduction
Impella
® heart pumps provide hemodynamic support during percutaneous intervention and in patients with cardiogenic shock. Removal of the Impella
® can be complicated in critically ill patients with severe peripheral vascular disease. We present a case of a novel approach of snare guided removal of an impacted Impella
® when usual techniques failed.
Clinical Case
A 74-year-old female with history of poorly controlled type 2 diabetes, hypothyroidism, hypertension, and tobacco use disorder, presented with new onset congestive heart failure and NSTEMI. Transthoracic echocardiogram (TTE) revealed an ejection fraction of 15%. Left heart catheterization revealed distal left main artery disease (30%), 95% stenosis of the ostial left anterior descending artery, and mild to moderate disease elsewhere. Intravascular ultrasound of the left main revealed minimum luminal area (MLA) greater than 10 mm
2. The patient was brought in for Impella
® assisted intervention to the LAD. Interprocedurally, patient had a left main dissection extending to the ascending aorta, requiring emergent surgical repair and two vessel bypass grafting. The patient was weaned from mechanical circulatory support and referred for Impella
® removal on post-op day 5. The Impella
® was unable to be removed past the distal aorta at the common iliac artery bifurcation on initial attempts. A 10 x 40mm Mustang balloon in the distal aorta and 6 x 40 mm Mustang balloon in the left common iliac artery were used to dilate the respective arteries, allowing the Impella
® to be withdrawn just proximal to the left common iliac artery but not further. After further troubleshooting, the left brachial artery was accessed with a 6 French sheath. A 5 French Multipurpose A-2 catheter was inserted and used to snare the distal end of the Impella
® and straighten the support device. The snared Impella
® was subsequently able to be removed via the left femoral artery which was closed with Perclose sutures. Post-procedure angiography demonstrated moderate disease of the distal left common femoral artery with good posterior tibial pulses at conclusion of the case.
Discussion
Percutaneous left ventricular assist devices such as the Impella
® are often removed via surgical repair of the common femoral artery or percutaneously by applying pressure to achieve hemostasis at the access site. As large caliber sheaths are involved, severe peripheral vascular disease is a relative contraindication to using the femoral approach. Oftentimes patients are critically ill and surgical removal of the device is not tolerated or prohibited. We present a novel approach to effectively remove Impella
® devices in patients who are critically ill and with previously undiagnosed peripheral vascular disease by using a snare technique from a second arterial access. This avoids the need for open surgical removal and repair. It is important for interventionalists to acquire and recognize new knowledge and skills related to complex removal of Impella
® devices.