P50: Save leg: using contralateral femoral inflow for distal perfusion catheter placed for Impella CP

Abstract

Background: Leg ischemia is a possible complication of percutaneous left ventricular device (Impella CP TM) placement. To avoid leg ischemia in atrisk patients, a distal perfusion catheter (DPC) should be placed. The DPC can be connected to the wire-reaccess port of the Impella CP as an inflow to the DPC to perfuse the leg. However, the wire-reaccess port of the Impella was not designed to bypass arterial blood to the distal limb, but rather for wire passage. We introduced a passive distal perfusion system from the contralateral femoral artery to optimize blood flow to the distal limb. Methods: A 65 year-old female with dilated cardiomyopathy developed refractory ventricular tachycardia. She was taken to the catherization laboratory because of hemodynamic instability requiring high doses of vasopressors. By left heart catheterization, we noted normal coronary arteries with elevated left ventricular end-diastolic pressure (38 mm Hg) and a poor cardiac index. Thus, Impella CP was placed from the right groin to stabilize her hemodynamics. A DCP was placed on right distal femoral artery and connected to the wire-reaccess port of the Impella CP. The leg appeared perfused by DPC via reaccess port in the catherization laboratory; however, despite this as well as appropriate anticoagulation, the leg became ischemic (cold leg, low leg regional saturation) shortly after admission to the ICU, where a lack of flow in the DPC was confirmed. Results: An additional contralateral femoral arterial line was placed. The contralateral femoral arterial line was then connected to the DPC (figure), and the reaccess port of the Impella was capped. Shortly after placement of the new DPC system, the pulse was returned and leg saturation improved. Additionally, leg ischemia during Impella support did not reoccur. Conclusion: A DPC using the Impella CP reaccess port provided inadequate distal flow. When a DPC is indicated during femoral Impella CP use, the contralateral femoral artery should be chosen for inflow cannulation. Figure 1. Impella CP and distal perfusion catheter (DPC) in the right femoral artery. The arterial line in the left femoral artery is feeding DPC in the right femroal artery.