I Was Too Late With Device Placement

Transcription

1 SCAI SHOCK 2018 A Team-Based Course On Cardiogenic Shock General Session # 2 Saturday, October 13, :39 8:51 AM Boston Park Plaza - Boston, MA I Was Too Late With Device Placement M Chadi Alraies, MD Wayne State University Detroit Medical Center Detroit, Michigan,

2 None Disclosures

3 62-year-old man with STEMI 62-year-old man with chest pressure PMHx: HTN, DM, PAD, smoking, CKD EKG ST depression in avr on EKG Troponin 1.2 ng/l BP on presentation 90/57 mmhg on dopamine drip Bedside echocardiogram EF 15-20% Cr 1.2 mg/dl

4 Ilio-femoral angiogram severe PAD

5 LM and plad disease

6 LM with left-to-right collaterals

7 RCA CTO and severe LV dysfunction

8 Hemodynamic on Dopamine and Norepi MAP (mmhg) 62 CI (L/min/m2) 1.4 CO (L/min) 2.8 RAP/CVP (mmhg) 19 PASP (mmhg) 53 PADP (mmhg) 32 LVEDP (mmhg) 34 CPO (W) 0.38

9 Hypotension Uptitration of norepinephrine and dopamine

10 Cardiac arrest

11 Ilio-femoral angiogram severe PAD

12 Prevalence of PAD in High Risk Patients More than one third of patients (35%) with severe aortic stenosis evaluated for TAVR had anatomic criteria unfavorable for transfemoral access. Small minimal luminal diameter Severe angulation of the iliac arteries Severe circumferential calcfiication Kurra V. J Thorac Cardiovasc Surg 2009;137:

13 Unfavorable Femoral Access Severe PAD Severe tortuosity

14 Alternative Access For Large Bore Sheath

15 Transcaval Axillary

16 Transcaval Pros Accommodate large bore sheaths Can take Impella 5.0 device Overcome severe iliac femoral PAD Overcome small iliac vessels

17 Transcaval Cons Technically challenging Ideally requires advanced imaging prior to the procedure Lack of dedicated closure device Increased risk of bleeding

18 Axillary Pros 6 mm diameter Easy to insert Faster insertion time Low bleeding risk Ambulation Emergent procedure Percutaneous solutions to complications Technically less challenging

19 Axillary Transcaval Cons Lack of dedicated equipment Lack of familiarity of the anatomy for most ICs Difficult room set up (left) Cannot use Impella 5.0 L without surgical cutdown

20 Severe PAD and looking for alterative

21 Anatomical Landmarks Anatomical landmark Familiar with AA segments Acromial Posterior circumflex humeral thoracoacromial 1 Subclavian Familiar with AA branches Access point 2 Superior thoracic Lateral to thoracoacromial Medial to the subscapular / circumflex humaral Medial to humeral head Anterior circumflex humeral Brachial 3 Teres major Pectoralis minor Lateral thoracic Subscapular

22 Anatomical and Angiographic Landmarks Angiographic landmark: lateral to the thoracoacromial artery and medial to the circumflex humeral / subscapular artery Thoracoacromial Costocervical Access point Subscapular Lateral thoracic Superior thoracic

23 Reasoning for Access Point Landmark Circumflex humeral Thoracoacromial 1. Compressible 2. Far from brachial plexus 3. Lower risk for pneumothorax Subscapular

24 Back to the case

25 Left axillary access (angiographic landmarks) Thoracoacromial Circumflex humeral Lateral thoracic Subscapular

26 Axillary access (angiographic landmarks)

27 Advancing sheath and Impella Advancing sheath over stiff inch wire of choice (Lunderquist, Amplatz Super Stiff, Supra Core). Impella advanced over wire under fluoroscopic guidance into the left ventricle

28 Severe LM disease EBU 3.5 7Fr ProWater wire to LAD

29 LM CSI atherectomy 1.25 Diamondback 360 Orbital Atherectomy over ViperWire

30 LM to LAD 3.5x38 DES

31 LAD and RI kissing

32 Final Fluoroscopy time: 33 min Contrast: Visipaque 200 ml

33 2 Days Later MAP (mmhg) 79 CO (L/min) 4.2 RAP/CVP (mmhg) 12 PASP (mmhg) 45 PADP (mmhg) 15 LVEDP (mmhg) 19

34 Conclusion Weaned off norepinephrine Lactate 1.8 Cr 1.8 Imeplla removed on day # 3 in the cath lab

35 Dry Closure Appropriately-sized (1:1) 7-10 X 40 mm balloon is used for dry closure The balloon is advanced over the inch wire from the femoral sheath and inflated at low pressure (2-4 atmosphere)

36 Patient discharge to rehab on day # 6

37 Summary Access Hemodynamics (RHC,BP, LVEDP, CPO) Circulatory Support Coronary perfusion Minimize vasopressors & inotropes (Early) Escalation of MCS

38 Thank