axillary approach for treatment of PAD

Percutaneous Insertion and Removal of Impella® Using the Axillary Artery for Treatment of Advanced Peripheral Artery Disease

Peripheral arterial disease (PAD), also referred to as hardening of the arteries, is a vascular disease that occurs in the arteries in the circulatory system. In PAD, the disease occurs in the arteries that carry oxygen and nutrient-rich blood from the heart to the arms and legs. For interventions that are aimed toward treating PAD or providing mechanical support, common femoral and brachial arteries are typical access sites for devices such as Impella® or intraaortic balloon pumps. Radial access does present its fair share of limitations, despite it becoming an increasingly popular access method among interventionalists. This synopsis of a recent article from the Journal of Invasive Cardiology provides a brief overview of the percutaneous insertion and removal of the Impella device using the axillary artery.

The technique for insertion and removal of the Impella device using the axillary artery (AA) is as follows:

  • The patient is placed in a supine position and the arm raised from the midline of the body at a 120-degree angle. Abducting the arm makes the AA available in the deltopectoral groove.
  • Fluoroscopy identifies the inferior border of the glenoid cavity. Following identification, a hemostat is placed in the medial of the glenoid cavity.
  • A 7 Fr sheath is then used for access and placement from a designated access point, typically the common femoral artery, and a catheter is advanced from the CFA to engage the subclavian artery.
  • Following localization of the artery by direct palpation, fluoroscopic subtraction imaging or baseline angiography is performed on the axillary, subclavian, and high brachial arteries. The usage of bony landmarks or ultrasound can also help identify the artery and neighboring nerve structures of the brachial plexus.
  • With the use of palpation, ultrasound, and fluoroscopic imaging, a micropuncture needle is used to access the second portion of the AA. This is usually accomplished following administration of a local anesthetic.
  • The placement of a 4 Fr micropuncture sheath is the next step. Access-site angiography follows to verify placement of the sheath at the best position within the AA.
  • Then, the interventionalist advances a 0.035” J-tip wire into the subclavian artery and exchanges the micropuncture sheath for a 6 Fr sheath.
  • Following advancement and exchange, the interventionalist deploys two ProGlide suture-mediated closure devices at the 10 o’clock and 2 o’clock positions.
  • Arteriotomy is dilated with a 9 Fr dilator before introducing the 13.5 Fr or 14 Fr Impella sheath over a stiff 0.035” wire.
  • A pigtail catheter is placed securely in the left ventricle using valve crossing techniques. The 0.018” Impella wire with a curve at the tip is advanced through the catheter. Then, the Impella device (2.5 or CP) is inserted through the sheath, and fluoroscopic imaging is used to advance the device into the left ventricle. Hemodynamic support is then used under standard protocol, and percutaneous coronary intervention (PCI) is performed from the CFA site.
  • After PCI has been performed, the Impella is removed. The passing of a 0.035” wire from the large-bore arteriotomy sheath and into the descending aorta follows.
  • A 3DRC guide catheter reengages the left subclavian artery from the 7 Fr CFA sheath. Then, the advancement of an exchange length 0.035” wire into the brachial artery and past the AA sheath is performed.
  • Using fluoroscopic guidance, the large-bore arteriotomy sheath is carefully withdrawn close to the AA large-bore arteriotomy access site. A 6 x 20 mm (or larger), 0.035”-compatible balloon is advanced over the 0.035” wire from the CFA. Inflation in the distal subclavian artery follows.
  • Complete removal of the Impella sheath can now occur, and the action of cinching and locking the deployed Perclose ProGlide sutures rounds out the pre-close technique.
  • The interventionalist can then deflate the balloon, using digital subtraction angiography through the wire-lumen of the balloon to verify zero leakage at the large-bore arteriotomy site.
  • The 0.035” wire and 3DRC guide catheter are then removed, and light pressure is applied to ensure hemostasis.

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