Access & Closure, Clinical Research & Data, Insertion, AMI Cardiogenic Shock

Alternatives for Treating Emergent Cardiogenic Shock


Impella 5.0® Via Transcaval Access

Transcaval access can help meet the urgent clinical need for mechanical circulatory support (MCS) for some patients with cardiogenic shock. Adam Greenbaum, MD, describes results from a 10-patient experience in his recently published paper “Transcaval access for the emergency delivery of 5.0 liters per minute mechanical circulatory support in cardiogenic shock.”

Peripheral arterial disease, multiple pressors, and vasoconstriction can limit vascular access in patients with cardiogenic shock. Dr. Greenbaum and colleagues investigated whether transcaval access for the Impella 5.0® could reliably provide mechanical circulatory support to patients without the delays inherent in going to the operating room, assembling the operative team, and undergoing general anesthesia.

While transcaval access typically requires CT scanning, Dr. Greenbaum explains “over time we learned how to correlate those CTs with fluoroscopic views… because all we’re really looking for is a calcium-free window that’s on the right side of the aorta… and we can see calcium by fluoroscopy.”

While acknowledging the risks of emergently placing MCS via transcaval access under fluoroscopic guidance without the benefit of CT scanning, Dr. Greenbaum emphasizes, “in the case of cardiogenic shock, when you’re looking at a patient who’s potentially dying and dying rapidly, we thought that the risk was worth it in these patients to get higher magnitude support.” He also noted, “they’re often first diagnosed by a trip to the cath lab so they’re already on your table.”

Dr. Greenbaum believes that transcaval access can empower cardiologists to achieve faster access and provide patients with 5 to 6 extra liters of flow in a minimally invasive manner. “I think that once you’ve done a certain number of elective transcaval cases, either for valve replacement and/or for that matter, high-risk PCI, I think anyone could learn the technique to do it.”

Dr. Greenbaum discusses the results from his paper, which include 100% procedural success and 60% survival to discharge in patients with profound cardiogenic shock. He explains that while there were some vascular complications and bleeding, there was no leg ischemia, no venous thrombosis, and no DVTs or pulmonary emboli related to the large sheath being in the vein. “And the patients got their support relatively quickly and noninvasively.”

In his closing comments, Dr. Greenbaum notes, “I think transcaval access is here to stay… I think that it is no longer a last resort access method for instance, it is the first alternative access method at many centers because of its fully percutaneous, less invasive nature.”



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