Deployment of acute mechanical circulatory support devices via the axillary artery

ABSTRACT

Introduction: Use of acute mechanical circulatory support (MCS) devices for high-risk cardiac intervention, cardiogenic shock, and advanced heart failure is growing. Alternate vascular access options for these devices remains a clinical challenge. Building on experience from trans-aortic valve replacement procedures, the axillary artery is becoming a common access route for acute MCS and represents an important advance in the development of acute MCS technologies.

Areas covered: Authors review the clinical data and technical aspect of acute MCS deployment via the axillary artery. Axillary access is particularly useful for patients: 1) with severe peripheral vascular disease, 2) with hostile femoral access due to infection, indwelling endovascular devices, or obesity, and 3) to provide early mobility and ambulation. In this review, we discuss the deployment, technical issues and hemostasis regarding the use of intraaortic balloon pump, specifically, axillary intraaortic balloon pumps, trans-valvular left ventricular Impella pumps and arterial outflow of VA-ECMO.

Expert opinion: Vascular comorbidities or device design may limit the traditional iliofemoral access route for acute mechanical circulatory support devices. Large bore access for the deployment of these devices through the axillary artery is feasible and safe when appropriate vascular access and closure techniques are used.

KEYWORDS:

• Axillary artery
• acute mechanical circulatory support devices
• percutaneous axillary artery access
• intraaortic balloon pump
• impella
• veno-arterial extracorporeal membrane oxygenation

Article Highlights

• Acute mechanical circulatory support devices deployed via endovascular approaches are particularly well suited for patients with hemodynamic instability due to acute heart failure or cardiogenic shock that preclude their ability to undergo major cardiac surgery.

• Axillary access is particularly useful for patients: 1) with severe peripheral vascular disease, 2) with hostile femoral access due to infection, indwelling endovascular devices, or obesity, and 3) to provide early mobility and ambulation.

• Percutaneous IABP placement through the axillary artery provides extended hemodynamic support, reduces intra-cardiac filling pressures and affords the patient the opportunity of out-of-bed physical rehabilitation.

• Axillary deployment of the trans-valvular axial flow pumps (Impella 2.5 and CP) has been reported by several groups and is increasing in frequency as an alternate access option for high-risk PCI or cardiogenic shock; procedural success rates are high and rates of vascular complications are similar to those seen with a percutaneous femoral approach.

• Percutaneous axillary artery cannulation via the Seldinger technique by the experienced operator for deployment of VA-ECMO is found to be well tolerated, and periprocedural complications like brachial plexus injury, compartment or local wound infection are rare.

• An understanding of the anatomy of the axillary artery and surrounding structures is indispensable and the use of ultrasound guidance for percutaneous axillary arterial access is essential. Likewise, periprocedural hemostasis with suture mediated vascular closure devices remains the gold standard of vascular closure of the axillary artery and boasts the highest rate of hemostasis success.

Declaration of interest

N Kapur receives institutional research grants and speaker consulting honorarium from Abiomed, Boston Scientific, Abbott, Medtronic and Maquet. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Review Disclosure

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.