Impella® Skills Video: Impella 5.5® with SmartAssist® Insertion Using the Silicone Plug Technique

This Impella® skills video demonstrates insertion of the Impella 5.5® with SmartAssist® using the silicone plug technique. The video is a simplified version of the technique, highlighting the primary steps of the procedure.

1. Expose the axillary artery and apply vessel loops proximal and distal to the point of incision.
2. Make an incision between the vessel loops.
3. Attach a 10 mm x 20 cm woven Dacron vascular graft to the axillary artery using at least a 60-degree bevel to facilitate passage of the Impella into the graft.
4. Clamp the graft above the anastomosis.
5. Insert a 6Fr to 8Fr sheath into the graft and secure with heavy suture or umbilical tape to maintain hemostasis while making the wire exchange in the left ventricle.
6. Remove the clamp and insert a 4Fr to 5Fr diagnostic catheter—pigtail, AL1, or Multipurpose—into the sheath with a 0.035” guidewire and cross the aortic valve.
7. Remove the 0.035” guidewire and replace it with the provided 0.018” placement guidewire.
8. Form a curve or bend in the guidewire before advancing it into the apex of the left ventricle.
9. Remove the diagnostic catheter leaving the 0.018” guidewire in place.
10. Clamp the graft over the wire above the anastomosis to maintain hemostasis during insertion.
11. Remove the vascular sheath.
12. Attach one silicone plug to the distal portion of the Impella catheter shaft just proximal to the motor housing.
13. Prior to inserting the Impella over the wire, lay the catheter out straight and remove any excess torque in the catheter and white connector cable.
14. Hold the catheter upright and visualize purge fluid at the base of the impeller.
15. Load the Impella over the 0.018” guidewire, ensuring that the wire exits the inner radius of the catheter.
16. Fully advance the cannula, motor housing, and silicone plug into the graft.
17. Wrap heavy suture or umbilical tape around the graft and silicone plug ensuring that the catheter can still move within the silicone plug.
18. Ensure the 0.018” placement guidewire remains outside of the silicone plug.
19. Loosen the vessel loops or unclamp the graft.
20. Advance the Impella until the inlet crosses the aortic valve.
21. Remove the guidewire and press the START IMPELLA soft button on the console to initiate support.
22. Select P-2 to start the Impella and slowly increase the P-level to the desired amount of support.
23. After placement of the Impella, place a soft-jaw vascular clamp at the anastomosis.
24. Remove the silicone plug and trim the graft so that the skin can be closed over the graft.