Background: Transcaval access (TCA) may enable fully percutaneous mechanical circulatory support (MCS) without the hazards of vascular complication in patients with heart failure that require left ventricular unloading.
Purpose: To review the safety, feasibility, and outcomes of using TCA to deliver Impella 5.0 MCS in patients with ischemic and non-ischemic systolic acute heart failure. Methods: This single center retrospective study included all patients that underwent TCA placement of a 5.0 Impella from June 2015 to January 2021. Demographic, clinical and procedural variables, and in-hospital outcomes were collected. The procedure was performed by electrifying a caval guidewire and advancing it into a pre-positioned aortic snare. After exchanging for a rigid guidewire, a 22 or 24Fr sheath was delivered into the aorta and then the Impella 5.0 was placed in the left ventricle through TCA sheaths.
Results: A total of 43 patients were included in the analysis. The average age was 56.9 years (interquartile range [IQR], 52-65.5), of which, 70%(n=30) were males. Fifteen patients had non-ischemic cardiomyopathy and 28 had ischemic cardiomyopathy. Baseline average left ventricular ejection fraction prior to implantation was 23.6% (IQR, 13.75-29.75). 86% of the patients were in category C-D of the SCAI classification schema for cardiogenic shock (CS), 39.5% required inotropes and 48.8% required pressors prior to the procedure; 54% had a prior MCS in place. Only 18.6% of the cases had prior CT imaging reviewed for planning. TCA was successful in all attempted patients and the MCS delivery was achieved in 100% of the cohort. The available hemodynamic parameters prior and after Impella 5.0 implantation via Table 1 TCA are summarized in table 1. From the total cohort, only 29 patients survived to explant device and TCA sheath. The explant was successful in all patients using nitinol occluders; two patients required a covered stent at the arteriotomy site due to right sided heart failure from residual fistula; no surgical repair was necessary. All residual fistulous tracks were graded as1 from Impella insertion/removal site was observed in 9.3%,which didn\u27t require further intervention. No vascular complication of the access site was observed with TCA. During hospitalization, 20.9% had VT/VF and 4.7% a PEA after implantation (all CS patients). 13.9% of the patients had AKI requiring hemodialysis and no stroke was observed in the entire group. The average length of stay for entire cohort was 16.3 days (IQR, 3.25-18.75).
Conclusions: Transcaval access of 5.0 Impella is safe and feasible under expert hands for patients where more conventional MCS devices do not provide enough support or have inadequate peripheral arterial access
