Ex‐vivo percutaneous bypass: Limb perfusion in the setting of occlusive large bore sheath

Abstract

Successful cardiac catheterization procedure begins with safe vascular access and ends with effective hemostasis after equipment removal. These new and advanced technologies in the cath lab require large‐bore arterial accesses. Large‐bore sheaths are associated with blood flow obstruction resulting in limb ischemia. In this case we present a 48‐year‐old woman was admitted NSTEMI and cardiogenic shock requiring mechanical circulatory support. Selective left common iliac angiography demonstrated obstructive flow at the level of the left CFA (access site). Therefore, ipsilateral bypass circuit was done. The current case illustrates the utility of a temporary ex‐vivo bypass circuit to preserve limb perfusion in the presence of an occlusive large bore sheath. The technique permits sufficient hemodynamic support while maintaining limb perfusion and can be used for any occlusive large bore sheath.

Vascular Access Management in Complex Percutaneous Coronary Interventions

“…18 Although it is possible to perfuse the affected leg without antegrade femoral access using internal contralateral femoralprofunda bypass, this technique is complex and requires expert peripheral vascular skills, time, and radiation. 19 For these reasons, it is usually only performed when the ipsilateral SFA is severely diseased or occluded. In most cases, leg perfusion involves obtaining antegrade femoral access.…”

“…Donor sheath options are multiple, resulting in many external bypass options: contralateral retrograde CFA resulting in the external contralateral femoro-femoral bypass technique(Supplementary Figure 3A); ipsilateral retrograde CFA large bore sheath resulting in the external ipsilateral femoro-femoral bypass technique (Supplementary Figure 3B); and ipsilateral retrograde radial artery access resulting in the external radial-femoral bypass technique or 'Lend a Hand' technique (Supplementary Figure 3C). 19,21 Large Bore Closure Dry Closure Some operators closing large bore arteriotimies advocate for dry closure of large bore sheaths through balloon occlusion of the ipsilateral external iliac artery via a secondary access point, minimizing bleeding and allowing time to optimize closure, improving clinical outcomes (Figure 4A-C). This is traditionally achieved by obtaining contralateral femoral or radial access and sheath placement to advance/inflate a 1:1 balloon sized to the iliac vessel at low pressure.…”