Successful Percutaneous Intervention for Left Ventricular Assist Device Graft Thrombosis
Presenter
Chetan Singh, M.D., ECU Health Medical Center, Greenville, NC
Chetan Singh, M.D., Ahmed Hassaan H Qavi, MD, Ateet Kosaraju, MD and Muhammad Umer Tariq, M.D., ECU Health Medical Center, Greenville, NC
Title
Successful Percutaneous Intervention for Left Ventricular Assist Device Graft Thrombosis
Introduction
Patients who develop left ventricular assist device (LVAD) outflow graft thrombosis, stenosis, or kinking can present to the hospital with progressive dyspnea, low flow alarms, and power spikes. Left unchecked, outflow graft compromise can progress to device failure.
Clinical Case
74-year-old male with history of hypertension, diabetes and nonischemic cardiomyopathy with HeartMate 3 LVAD implantation 3 years ago presented with dyspnea and fatigue. He was noted to have increasing frequency of low flow alarms on his LVAD. His right heart catheterization demonstrated normal right heart pressures. Given worsening dyspnea of unclear origin, he underwent CT angiography of his chest which showed thrombus resulting in moderate to severe narrowing of the arterial outflow graft from the LVAD. After discussion with Cardiothoracic Surgery, he underwent catheterization and angiography to evaluate and treat the outflow tract percutaneously. The right common femoral artery was accessed with a 6 French sheath. Using a Judkins Right 4.0 cm (JR4) catheter via the femoral sheath, the LVAD Dacryon graft was wired. The JR4 was then positioned at the outflow graft site, revealing a 10-mmHg gradient during angiography. Subsequent angiography indicated a clear tapering of the distal end of the outflow graft. At this juncture, the decision was made to perform a percutaneous intervention of the outflow graft. The right femoral 6 Fr sheath was upgraded to an 8 Fr, 90 cm destination sheath, which was advanced into the graft. Intravascular ultrasound (IVUS) revealed a 75% stenosis at the narrowest part of the graft, with a diameter of 10 mm. A 10.0 x 40 cm Mustang balloon was advanced over an Amplatz super stiff wire for balloon angioplasty. Following this, an 11 x 79 mm Gore® Viabahn® VBX Balloon Expandable stent was delivered and post-dilated with a 14 mm peripheral balloon, effectively shortening the stent. Repeat IVUS confirmed optimal stent expansion, and a subsequent gradient measurement showed no residual gradient. Patient did well post-procedurally with and had no further LVAD alarms. He was discharged on long-term clopidogrel. He continued to fare well at his six-month follow-up visit without evidence of outflow graft in-stent restenosis on repeat CT scan done for non-cardiac reasons.
Discussion
With the advent of endovascular techniques, minimally invasive interventions have become prominent tools in a clinician’s armamentarium to solve complex clinical problems. Following the implantation of a CF-LVAD, device complications would previously demand open-heart surgery through a re-operative field, but the advent of catheter-based therapies has provided an effective alternative that can be used for diagnosing and treating CF-LVAD complications in a minimally invasive manner.