Use of Tissue Plasminogen Activator Alteplase for Suspected Impella Thrombosis

Abstract

Background Impella devices are being increasingly used to manage cardiogenic shock. The incidence of thrombosis and hemolysis in patients on Impella support increases with longer durations of use, and the management of Impella thrombosis remains ill‐defined. Methods In this case series, we describe our institutional use of tissue plasminogen activator (tPA) alteplase in the Impella purge solution (0.04 or 0.08 mg/ml tPA in sterile water) for management of suspected Impella thrombosis in five patients, each with a different clinical course, treatment, and outcome. Given the limited evidence on the diagnosis of Impella thrombosis, suspicion was driven by the presence of decreased purge flow rates, increased purge pressures, and markers of hemolysis such as elevated lactate dehydrogenase and hematuria. Outcomes In all cases, tPA administration resulted in resolution of low purge flow rates and high purge pressures. No major bleeding complications were directly associated with tPA. Two patients were bridged successfully to heart transplantation, two patients underwent left ventricular assist device implantation, and one patient died after withdrawal of care. Conclusion Based on our experience, tPA administration appears to be a viable and safe salvage option to delay or prevent device exchange in the setting of suspected Impella thrombosis.

Percutaneous thrombectomy of Impella‐associated iliac artery thrombosis using the FlowTriever system

“…This was treated with aspiration thrombectomy via the Pronto extraction catheter device with restoration of peripheral flow 11 . Succar et al reported 5 patients with suspected Impella thrombosis treated successfully with systemic tissue plasminogen activator (tPA) 12 . The patient in our case report developed right external iliac artery thrombosis just above the Impella sheath which had been kept in place for 3 days due to the patient's severe CS state.…”

“…11 Succar et al reported 5 patients with suspected Impella thrombosis treated successfully with systemic tissue plasminogen activator (tPA). 12 The patient in our case report developed right external iliac artery thrombosis just above the Impella sheath which had been kept in place for 3 days due to the patient's severe CS state. Despite multiple attempts to extract the thrombus via conventional approaches, only small fragments were retrieved.…”

Percutaneous Thrombectomy of Impella-Associated Iliac Artery Thrombosis Using the FlowTriever System

“…This was treated with aspiration thrombectomy via the Pronto extraction catheter device with restoration of peripheral flow (11) . Succar et al, reported 5 patients with suspected impella thrombosis treated successfully with systemic tissue plasminogen activator (tPA) (12) . The patient in our case report developed right external iliac artery thrombosis just above the Impella sheath which had been kept in place for three days due to the patient's severe CS state.…”

Effect of Atrioventricular Dyssynchrony on Impella Hemodynamics: Mechanism and Its Clinical Implications

“…Factors leading to low Impella or failing Impella output can lead to poor organ perfusion, thus increasing morbidity and mortality. There are many factors reported in the literature which can lead to low Impella output (Table 1) [26][27][28][29][30][31][32][33][34][35]. Since the Impella is volume-dependent, any cause of low LV volume such as hemorrhage or cardiac tamponade can lead to low or failing Impella output.…”

“…Rarely, device-related factors can be associated with failing Impella output, such as device dislodgement, fracture or damage of device element, device thrombosis, device detachment, major device malfunction, or pressure monitoring failure [26][27][28][29][30]. Acute thrombosis of Impella catheter can lead to a significant drop or no flow leading to hemodynamic instability [31,32]. Succar et al reported case series of five patients with suspected Impella thrombosis who were successfully treated with tissue plasminogen activa-tor (tPA) administration [32].…”