Strategies for Reducing Vascular and Bleeding Risk for Percutaneous Left Ventricular Assist Device-supported High-risk Percutaneous Coronary Intervention

Abstract

In patients at high risk for haemodynamic instability during percutaneous coronary intervention (PCI), practitioners are increasingly opting for prophylactic mechanical circulatory support, such as the Impella® heart pump (Abiomed, Danvers, MA, USA). Though Impellasupported high-risk PCI (HRPCI) ensures haemodynamic stability during the PCI procedure, access-related complication rates have varied significantly in published studies. Reported variability in complication rates relates to many factors, including anticoagulation practices, access and closure strategy, post-procedure care and variations in event definitions. This article aims to outline optimal strategies to minimize vascular and bleeding complications during Impella-supported HRPCI based on previously identified clinical, procedural and postprocedural risk factors. Practices to reduce complications include femoral skills training, standardized protocols to optimize access, closure, anticoagulation management and post-procedural care, as well as the application of techniques and technological advances. Protocols integrating these strategies to mitigate access-related bleeding and vascular complications for Impella-supported procedures can markedly limit vascular access risk as a barrier to appropriate large-bore mechanical circulatory support use in HRPCI.

La gestione infermieristica e la prevenzione delle complicanze nel paziente portatore di dispositivo di assistenza ventricolare Impella

“…25 Per continuare a ridurre il rischio di sanguinamento correlato all'accesso e l'insorgenza di complicanze vascolari nei pazienti supportati da pLVAD è necessario focalizzarsi su alcuni principi fondamentali. 26 Nei pazienti con dispositivo Impella le complicanze vascolari sono più frequenti nelle donne e nelle procedure eseguite in emergenza. 27 L'utilizzo del dispositivo Manta per la chiusura dell'arteria femorale dopo rimozione del dispositivo Impella risulta essere migliore rispetto alla compressione manuale.…”

“…28 Una complicanza frequente nei pazienti portatori di dispositivo Impella è il sanguinamento maggiore, che si manifesta in maniera più frequente in pazienti con fattori predisponenti. [23][24][25][26][27][28][29][30] L'ottimizzazione dell'angolo tra guaina e pelle è uno degli interventi utili per ridurre il rischio di sanguinamento. 31 Durante l'impianto, l'uso e l'espianto del dispositivo Impella, è necessario prestare estrema attenzione alla prevenzione di emorragie e complicanze dell'accesso vascolare.…”

From medical therapy to mechanical support: strategies for device selection and implantation techniques

“…For a safe femoral access, contemporary access techniques include a combination of fluoroscopy, femoral angiography, and US, with the latter as the most important factor in the setting of CS ( Figure 2 ). 36 Successful and safe large-bore femoral access is ensured by a single anterior wall puncture of the common femoral artery, avoiding areas of calcification and punctures that are too high (above the level of the inferior epigastric artery) or too low (superficial or profunda femoral artery; Figure 3 ). The FAUST RCT assessed US vs. fluoroscopic guidance for femoral access, which failed to show an overall difference in the success of common femoral artery cannulation (the primary endpoint).…”

“…Importantly, there is a significant learning curve for large-bore access, 36 and recent training recommendations for high-risk PCI highlight the importance of femoral access, closure, and complication management training, with a suggested 100 US-guided femoral access procedures and a minimum of 15 procedures with pVAD support during training. 43 …”

Mechanische Kreislaufunterstützung im Schock

“…Komplikationsmanagement ist ein zentraler Baustein für die erfolgreiche Therapie von Patienten mit mechanischen Unterstützungssystemen. Die wichtigsten Komplikationen der MCS-Systeme umfassen Blutungen, sowohl direkt an der Einstichstelle [103] als auch indirekt durch eine Device-induzierte Koagulopathie [104,105,106] und Thrombozytopenie [107]. Auch die zur Verhinderung von Thrombosen am MCS verabreichte Antikoagulation führt zu Blutungen [108,109].…”