No Arterial Access? No Problem!
Presenter
Zaid Al Jebaje, MD, -, Detroit, MI
Zaid Al Jebaje, MD1, Babar B Basir, DO, FSCAI2, Gerald C. Koenig, MD, PhD, FSCAI2 and Pedro A Villablanca, M.D., FSCAI3, (1)-, Detroit, MI, (2)Henry Ford Health System, Detroit, MI, (3)Henry Ford Health System, Beverly Hills, MI
Title:
No arterial access?.. No problem!
Introduction:
The advancement of mechanical circulatory support has revolutionized the field of cardiogenic shock management and significantly impacted outcomes. However,vascular access complications, such as hemorrhage and limb ischemia, present a major limitation leading to increased patient morbidity and extending ICU length of stay. Achieving full mechanical support without arterial access may provide a solution to access-related issues.
Clinical Case:
We present a case of a 32-year-old female with a history of antiphospholipid syndrome and recent pregnancy who was transferred from an outside facility with acute decompensated heart failure and severely reduced left ventricular function, a working diagnosis of acute myocarditis vs peripartum cardiomyopathy. She was referred to our cardiac catheterization lab due to worsening hemodynamics and signs of end-organ hypoperfusion (rising lactate, creatinine, and LFTs levels) despite IV pressor support, there was also a concern for arterial thromboembolism in her lower extremities. An echocardiogram showed LVEF of 15% with global LV dysfunction and suspicion of LV apical thrombus. Invasive hemodynamics showed elevated biventricular filling pressures and depressed cardiac output/index. The decision to proceed with veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was made and bilateral common femoral arteries were evaluated using ultrasound but deemed too small to accommodate an ECMO arterial cannula. We then performed complete mechanical circulatory support with LA-VA ECMO using venous-only access with a 22Fr venous sheath into the left common femoral vein (CFV) and trans-septal approach, and a 19Fr arterial sheath placed into the right CFV with a trans-caval approach used for aortic cannulation. The patient tolerated the procedure well with immediately improved hemodynamics. Seven days later she successfully received orthotropic heart transplantation, and closure of the trans-caval access site was achieved with a covered stent. She currently follows in the advanced heart failure/transplant clinic in excellent condition. Discussion:
Patients with cardiogenic shock have increased systemic vascular resistance and often receive intravenous vasopressors as part of resuscitation measures, which make their peripheral arterial access challenging and increase the rate of access-related complications. A trans-septal approach provides means to unload both the left and right sides of the heart as a fenestrated 15 cm. segment of the cannula placed across the interatrial septum allows venting of both ventricles without the need for Impella placement, especially in cases of suspected or confirmed LV apical thrombus. A trans-caval approach allows cannulating the aorta using the common femoral vein, which is more compliant and can accommodate large-size sheaths. This approach leads to a lower rate of limb ischemia and arterial access bleeding complications. While becoming facile with the above techniques requires some degree of training and experience, we believe that it is within the scope of practice of interventionalists who perform mechanical circulatory support and care for patients with cardiogenic shock.