Transaortic Placement of Percutaneous Mechanical Support Device via Partial Sternotomy: Feasible Option for Unsuitable Axillary Artery Access

Abstract

Acute decompensated refractory cardiogenic shock is an emergency in which the prompt instauration of mechanical circulatory support improves outcomes. The typical, initial approach for device delivery is via femoral vessels due to easy access and safety. If longer support is needed, the femoral access will severely impair the patient’s mobility and can also limit the amount of support given as the new-generation devices are too large for direct arterial insertion. Upper-body arterial conduits (UBACs) are used for the delivery of larger, percutaneous ventricular assist devices (pVADs). The Impella 5.5 (Abiomed, Danvers, MA, USA) is a pVAD that can be deployed through a UBAC by either axillary/subclavian access or a transaortic approach. The latter approach is typically used in cases of postcardiotomy shock, in which the ascending aorta is already exposed through a full sternotomy. However, in some cases, the axillary artery is not suitable due to size (<6 mm in diameter), and a smaller pVAD is delivered into the heart. To avoid providing suboptimal support, we present an alternative, minimally invasive approach in which the larger device is delivered through the ascending aorta. This article summarizes the details of this approach through a mini upper partial sternotomy and reviews the relevant technical considerations.

Perioperative Use of Impella 5.0/5.5 in High-Risk Coronary Artery Bypass Grafting

“…The Impella 5.0/5.5 can be implanted via the axillary or subclavian artery [15], innominate artery [16,17], and the ascending aorta (Figure 3) [18][19][20]. Since sternotomy is usually performed at the time of coronary artery bypass grafting, our favorite approach is through the ascending aorta.…”

A Historical Review of Mechanical Circulatory Support

“…The Impella 5.0 and 5.5 are larger microaxial pumps implanted through a conduit sutured to the axillary artery [42] or directly sutured to the aorta through a graft either through a full sternotomy or through partial upper one in cases of small axillary artery [43] and can provide flows, 5.0 and 5.5 l/min, respectively, like that of durable LVADs [44]. They also promote patient mobilization and therefore give patients the ability to participate in physical therapy.…”