A case series: alternative access for refractory shock during cardiac arrest

Abstract

Background In patients with iliofemoral arterial disease, transcaval and percutaneous axillary artery access are safe alternatives for delivery of transcatheter aortic valve replacement for severe aortic stenosis. In the setting of cardiac arrest, arterial access is crucial for delivery of mechanical circulatory support devices such as an Impella CP® or cannulation for extracorporeal cardiopulmonary resuscitation (ECMO). We report the use of transcaval and axillary artery access in three cases of cardiac arrest in which the emergent placement of an Impella CP® (Abiomed, Danvers, MA, USA) or cannulation for ECMO was instrumental in resuscitation from refractory cardiac arrest. Case summary The first patient is a 59-year-old woman who developed ventricular fibrillation arrest after percutaneous intervention with emergent placement of a transcaval Impella CP®. In the second case, a 67-year-old man with coronary vasospasm developed cardiac arrest with an axillary artery Impella CP® placed. The third case highlights a 67-year-old man who developed cardiac arrest 1 day after unsuccessful chronic total occlusion repair requiring ECMO cannulation to his axillary artery. All three patients achieved spontaneous circulation after placement of assist devices. Discussion To our knowledge, a case report of transcaval or percutaneous axillary artery access for Impella CP® during cardiac arrest has not been published. While the long-term prognosis following cardiac arrest is poor, younger patients deserve every chance for survival with rapid cardiopulmonary support by alternative access if necessary. Advanced large bore alternative access techniques should be learned by all interventional operators.

Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association

“…However, percutaneous axillary techniques for a variety of large-bore access procedures are growing in use. 53 The placement of an arterial cannula in the femoral artery creates a risk for ipsilateral leg ischemia, which requires vigilant attention to lower-limb perfusion. Ipsilateral leg ischemia can be avoided by inserting an antegrade perfusion catheter (5F-8F) into the femoral artery distal to the arterial cannula that is connected to the arterial ECMO limb, allowing arterial flow down the leg.…”