SCAI SHOCK 2018 A Team-Based Course On Cardiogenic Shock General Session # 2 Saturday, October 13, 2018 8:39 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, USA @chadialraies
None Disclosures
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
Ilio-femoral angiogram severe PAD
LM and plad disease
LM with left-to-right collaterals
RCA CTO and severe LV dysfunction
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
Hypotension Uptitration of norepinephrine and dopamine
Cardiac arrest
Ilio-femoral angiogram severe PAD
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;137:1258-64
Unfavorable Femoral Access Severe PAD Severe tortuosity
Alternative Access For Large Bore Sheath
Transcaval Axillary
Transcaval Pros Accommodate large bore sheaths Can take Impella 5.0 device Overcome severe iliac femoral PAD Overcome small iliac vessels
Transcaval Cons Technically challenging Ideally requires advanced imaging prior to the procedure Lack of dedicated closure device Increased risk of bleeding
Axillary Pros 6 mm diameter Easy to insert Faster insertion time Low bleeding risk Ambulation Emergent procedure Percutaneous solutions to complications Technically less challenging
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
Severe PAD and looking for alterative
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
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
Reasoning for Access Point Landmark Circumflex humeral Thoracoacromial 1. Compressible 2. Far from brachial plexus 3. Lower risk for pneumothorax Subscapular
Back to the case
Left axillary access (angiographic landmarks) Thoracoacromial Circumflex humeral Lateral thoracic Subscapular
Axillary access (angiographic landmarks)
Advancing sheath and Impella Advancing sheath over stiff 0.035-inch wire of choice (Lunderquist, Amplatz Super Stiff, Supra Core). Impella advanced over 0.018 wire under fluoroscopic guidance into the left ventricle
Severe LM disease EBU 3.5 7Fr ProWater wire to LAD
LM CSI atherectomy 1.25 Diamondback 360 Orbital Atherectomy over ViperWire
LM to LAD 3.5x38 DES
LAD and RI kissing
Final Fluoroscopy time: 33 min Contrast: Visipaque 200 ml
2 Days Later MAP (mmhg) 79 CO (L/min) 4.2 RAP/CVP (mmhg) 12 PASP (mmhg) 45 PADP (mmhg) 15 LVEDP (mmhg) 19
Conclusion Weaned off norepinephrine Lactate 1.8 Cr 1.8 Imeplla removed on day # 3 in the cath lab
Dry Closure Appropriately-sized (1:1) 7-10 X 40 mm balloon is used for dry closure The balloon is advanced over the 0.035-inch wire from the femoral sheath and inflated at low pressure (2-4 atmosphere)
Patient discharge to rehab on day # 6
Summary Access Hemodynamics (RHC,BP, LVEDP, CPO) Circulatory Support Coronary perfusion Minimize vasopressors & inotropes (Early) Escalation of MCS
Thank you @chadialraies alraies@hotmail.com