Comprehensive Prevention Strategy for Impella Access-Site Bleeding Using a Large-Bore Sheath and a Percutaneous Post-Closure Technique

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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00215. Epub July 25, 2024.

A 79-year-old man with the diagnosis of acute myocardial infarction complicating cardiogenic shock received Impella CP (Abiomed) insertion via a femoral approach. We punctured the common femoral artery under ultrasound guidance and performed iliofemoral angiography, revealing no significant stenosis (Figure A), then placed a 16-French (Fr) sheath. The Impella was implanted with its repositioning sheath fully enclosed inside the 16-Fr sheath (Figure B). We completed coronary revascularization under Impella support.

Two days later, the Impella was weaned with a post-closure technique using the Perclose (Abbott) at bedside per the following procedure. First, we removed the Impella, leaving the 16-Fr sheath in place. We verified the accurate sheath insertion point by ultrasound to optimize manual compression (Figure C, yellow arrow). Next, we cut the sheath-shaft to remove intra-sheath thrombi (Figure D) and directly punctured the remaining sheath-shaft to insert a guidewire (Figure E). While 1 operator was manually compressing, another removed the sheath (Figure F) and inserted the Perclose. The Perclose was properly positioned within the artery (Figure G) and deployed in the 10 o’clock direction (Figure H). The guidewire was reinserted, and the second Perclose was likewise deployed in the 2 o’clock direction (Figure I). Then, both knots were tightened (Figure J). We carefully confirmed no residual bleeds/dissection/occlusion by ultrasound. Finally, we removed the guidewire and trimmed the extra threads (Figure K). the patient experienced no vascular complications during hospitalization.

Although Impella access-site bleeding may worsen prognosis,¹ its prevention strategy remains unestablished. Our approach using a non-tapered 16-Fr sheath rarely causes blood leakage even if its position unexpectedly shifts. Furthermore, our ultrasound-guided post-closure hemostasis technique, which clears intra-sheath thrombi, may reduce vascular complications. This strategy could benefit bleeding-prone patients undergoing Impella support.

Affiliations and Disclosures

Masashi Yokoi, MD; Tsuyoshi Ito, MD; Junki Yamamoto, MD; Yoshihiro Seo, MD

From the Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: Written informed consent was obtained from the patient for the publication of their clinical information and any accompanying images.

Address for correspondence: Tsuyoshi Ito, MD, Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuhocho, Nagoya, Aichi, 4678601, Japan. Email: tuyosiito@gmail.com

Reference

1. Freund A, Jobs A, Lurz P, et al. Frequency and impact of bleeding on outcome in patients with cardiogenic shock. JACC Cardiovasc Interv. 2020;13(10):1182-1193. doi: 10.1016/j.jcin.2020.02.042