Single Site Arterial Impella 5.5/ECMO (Ecpella) Cannulation for Refractory Shock

Abstract

<h3>Introduction</h3> We present a case of a single site arterial Impella 5.5 and ECMO access (Ecpella) for refractory cardiogenic shock. It represents a new solution to a difficult arterial access problem. The patient needed both left ventricular venting and venous arterial ECMO support. <h3>Case Report</h3> A 35-year-old male with non-ischemic cardiomyopathy, status post Heartmate 3 LVAD placement, presented with weight gain and lower extremity edema. There was concern for LVAD dysfunction secondary to poor output despite RPMs of 6200. A RHC demonstrated a CVP of 30, wedge pressure of 36, and an index of 1.8. The patient was not a transplant candidate secondary to morbid obesity and uncontrolled diabetes. The patient had a history of driveline infections and developed bacteremia. The patient progressed to septic and cardiogenic shock requiring multiple vasopressors and inotropes. Ultimately, the patient needed an LVAD exchange. However, with active bacteremia the new LVAD would likely become infected. The decision was made cannulate the patient for ECMO and to place an Impella 5.5 for left ventricular venting. The patient had venous cannulation via femoral vein. The femoral artery was very small, in profound vasospasm from massive pressors and not suitable size for cannulation. The patient underwent VA ECMO placement via a right axillary artery graft. The graft was split in a Y fashion to allow arterial Impella 5.5 access via the same site. Figure 1 demonstrates the Ecpella arrangement and the fluoroscopy demonstrates placement of the Impella. The patient's condition improved. The patient was able to wean off inotropes and vasopressors. <h3>Summary</h3> We present a case of single site arterial access for Impella 5.5 and arterial cannulation for VA ECMO and LV venting. The novel solution to use a single arterial access site can be used for patients with complex arterial access issues. In this case, the patient was being bridged to LVAD exchange.