Axillary Implantation and Explantation of Impella 5.5® with SmartAssist® with Juan MacHannaford

With procedural video footage, Juan MacHannaford, MD, describes the implantation and explantation of the Impella 5.5® with SmartAssist® via the axillary artery. Dr. MacHannaford is section chief of cardiothoracic surgery and surgical director of heart transplantation and mechanical circulatory support at Medical City Heart and Spine Hospital in Dallas, Texas.

Dr. MacHannaford begins by showing how to access and prepare the axillary artery for insertion of the Impella 5.5. He explains that he performs all axillary implant procedures in a hybrid suite with a combination of fluoroscopy and transesophageal echocardiography (TEE).

After accessing the axillary artery, Dr. MacHannaford uses a vascular punch to do the arteriotomy for insertion of Impella 5.5. “That basically gives us a nice, open pathway for the device to go in and out easily,” he explains. “As far as choice of graft, you can either use a 10 or an 8. I almost exclusively use an 8 mm Vascutek® graft and when I bevel that you’re essentially making it a larger graft. So I find that using an 8 mm graft is a little bit better for hemostasis.”

Dr. MacHannaford explains how he creates a lateral insertion a few centimeters from the primary incision and tunnels the graft under the pectoralis major for a “straight shot into the artery.” Since he removes most devices in the ICU, he is then able to remove them through this small tunneling incision without opening the main procedural incision.

After the Impella 5.5. is inserted, Dr. MacHannaford tucks the entire graft back into the pocket he’s created, does a final transesophageal echocardiogram (TEE) to confirm Impella positions, and then secures it with sutures.

Dr. MacHannaford discusses anticoagulation, explaining that he typically uses sodium bicarbonate in the purge fluid and doesn’t start heparin for several hours or even the day after the procedure. “And once we do start heparin,” he states, “we maintain a PTT around 50 to 60 and we’ll keep that going until the moment of explant.”

Dr. MacHannaford typically removes the Impella 5.5 at the bedside. After anesthesizing the skin, he pulls the tucked graft out of the small lateral incision, cuts the sutures, and removes the device. He then staples and cuts the graft and tucks it back in before closing the incision with a few staples and covering with sterile dressing.

This material includes Dr. Juan MacHannaford's opinions and findings based on their own knowledge and experience. As with any medical treatment, individual results may vary and any steps described may not encompass the complete steps of the procedure. This is provided for informational purposes only and does not represent an endorsement of any particular physician and does not replace patient-surgeon consultations.