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No Panic in Hemodynamics: A "Single-Access" Axillary Impella-Assisted Balloon Aortic Valvuloplasty in Cardiogenic
Leo Kar Lok Lai1, Hussayn Alrayes1, Georgi Fram1
1Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, USA.
Insights
A novel approach using a single-access Impella device and balloon aortic valvuloplasty successfully treated a patient with severe aortic stenosis and cardiogenic shock when standard femoral access was not possible. This technique improved cardiac output and offers a viable alternative in complex cases.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Critical aortic stenosis (AS) with cardiogenic shock poses a significant management challenge.
- Occluded femoral vasculature can preclude standard transcatheter aortic valve replacement (TAVR) or balloon aortic valvuloplasty (BAV) approaches.
- Impella device support is crucial for maintaining hemodynamic stability in severe shock.
Purpose of the Study:
- To describe a successful single-access Impella-assisted balloon aortic valvuloplasty (BAV) in a patient with critical AS and cardiogenic shock due to occluded femoral arteries.
- To highlight the utility of pre-procedural intravascular ultrasound (IVUS) and a "dry-exchange" technique in this complex scenario.
Main Methods:
- A 68-year-old male with ischemic cardiomyopathy and critical AS presented with Society for Cardiovascular Angiography and Interventions (SCAI) stage D cardiogenic shock.
- Due to occluded bilateral femoral vasculature, a right axillary artery approach was chosen for Impella insertion.
- A single-access Impella-assisted BAV was performed using pre-IVUS guidance and a "dry-exchange" technique for repeated balloon inflations.
Main Results:
- The procedure successfully restored hemodynamic stability, improving the patient's cardiac index from 1.5 to 2.5 L/min/m2.
- The right axillary single-access approach was feasible and safe despite challenging anatomy.
- The "dry-exchange" technique facilitated repeated balloon inflations, maintaining device position and function.
Conclusions:
- Single-access Impella-assisted BAV via the axillary artery is a viable and effective alternative for patients with critical AS and cardiogenic shock when femoral access is contraindicated.
- Pre-procedural IVUS and the "dry-exchange" technique enhance the safety and efficacy of this complex interventional approach.
- This strategy can successfully maintain cardiac output during prolonged balloon inflations in high-risk patients.
Abstract:
A 68-year-old man with ischemic cardiomyopathy presented with critical aortic stenosis and Society for Cardiovascular Angiography and Interventions stage D cardiogenic shock. Because of occluded bilateral femoral vasculature, a right axillary single-access Impella balloon aortic valvuloplasty approach was successfully performed, improving the patient's cardiac index from 1.5 to 2.5 L/min/m2. This case highlights the use of pre-intravascular ultrasound imaging, the "dry-exchange" technique to enhance safety, and single-access Impella balloon aortic valvuloplasty to maintain cardiac output during repeated prolonged balloon inflations.
