Temporary extracorporeal femoro-femoral crossover bypass to treat critical limb ischemia due to occlusive femoral transaortic microaxial left ventricular assist device – a novel technique and case series

S Richarz,E Mujagic,M Siegemund,B Bachofen,L Gürke,R D`Amico,T Döbele

doi:10.1093/bjs/znab202.060

Abstract

Abstract Objective The Impella transaortic microaxial left ventricular assist device (MLVAD) bears the risk of severe ipsilateral limb ischemia due to it´s percutaneous insertion through the common femoral artery (CFA). As long as the MLVAD is required for cardio-circulatory support, treatment options are limited. Therefore, we developed a temporary extracorporeal femoro-femoral crossover bypass to restore and maintain perfusion of the affected leg. Methods From October 2018, we treated all patients with severe limb ischemia due to the MLAVD with a femoro-femoral crossover bypass. For comparison, a consecutive cohort of patients undergoing placement of the MLAVD between January 2011 and July 2019 was identified. For those patients who experienced limb ischemia after Impella placement, data on age, gender, BMI and diabetes, underlying cardiac condition, duration of Impella pump in place, limb complications, limb salvage procedure, need for additional surgical procedure on the affected limb (e.g. fasciotomy) were recorded. The primary outcome is the feasibility and safety of our percutaneously established extracorporeal femoro-femoral crossover bypass. As secondary outcomes, we report overall 30 day mortality and limb salvage rates. Results Between January 2011 and July 2019, 25 of 245 (10.3%) patients developed a severe ipsilateral limb ischemia following the MLVAD placement. Until October 2018, 20 patients were treated conventionally (C-cohort) and since October 2018, five (consecutive) patients have been treated by an extracorporeal femoro-femoral cross over bypass (BP-Cohort). Following the BP-procedure, an immediate improvement of the perfusion was seen in all patients. The bypass remained in place during a median of 5 days. Limb salvage was documented in 100% of our patients and 30 days mortality was 60% in both groups. Conclusion This is the first case series reporting on this novel technique. We demonstrated that the percutaneous creation of an extracorporeal femoro-femoral crossover bypass is feasible, safe and effective and should therefore be promoted in the future.

Highlights

Background TheImpella transaortic microaxial left ventricular assist device (MLVAD) is a temporary circulatory support (TCS)
Limb salvage was documented in 100% of our patients and 30 days mortality was 60% in both groups. This is the first case series reporting on a novel technique of limb salvage in patients with severe limb ischemia due to an MLVAD
All consecutive patients undergoing placement of an Impella pump at Basel University Hospital between January 2011 and July 2019 were identified retrospectively using the intensive care unit electronic chart. For those patients who experienced limb ischemia after Impella placement, data on age, gender, BMI and diabetes, underlying cardiac condition, duration of Impella pump in place, limb complications, limb salvage procedure, need for additional surgical procedure on the affected limb and overall 30 day mortality were recorded from our electronic patient documentation program (ISMed)

Summary

Introduction

Impella transaortic microaxial left ventricular assist device (MLVAD) is a temporary circulatory support (TCS). The Impella transaortic microaxial left ventricular assist device (MLVAD) is a temporary circulatory support (TCS) device which maintains cardiac output in severely hemodynamically compromised patients. [3] While ongoing bleeding and hematoma formation are reported in up to 17.5% of cases, the risk of limb ischemia due to an occlusion of the iliac or femoral arteries by the device has been reported to occur in less than 4% of patients.[4,5,6,7] if it occurs, severe ischemia of the leg distal to the pump represents a potentially limb- or even life-threatening condition when left untreated, especially in patients suffering from cardio-circulatory failure. The femoral bifurcation is hardly accessible whithout removing the pump

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