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Abdominal aortic aneurysm surgery with mechanical support using the Impella^® microaxial blood pump

^a Department of Cardiovascular Surgery B (Pr Jegaden), Hôpital Cardiovasculaire et Pneumologique Louis Pradel, Université Claude Bernard, Inserm U886, 28, avenue du doyen Lépine, 69677, Bron Cedex, France
^b Department of Anesthesia (Pr Lehot), Claude Bernard University, Louis Pradel Hospital, Bron, France

Received 6 December 2007; received in revised form 30 January 2008; accepted 31 January 2008

*Corresponding author. Tel.: +33 (0) 4 72 35 75 29; fax: +33 (0) 4 72 35 75 32.

E-mail address: fadi.farhat{at}chu-lyon.fr (F. Farhat).

	Abstract

Top Abstract 1. Case 2. Discussion References

 
A 50-year-old man with an end-stage cardiac failure was referred to our institution for pre-transplantation assessment. An infrarenal aortic aneurysm (diameter 45 mm) was discovered and progressed (up to 59 mm) over a two-month period. Decision to perform aneurysmectomy with the support of an Impella^® Recover LP50 microaxial blood pump was decided regarding the rapid evolution of the disease. The patient had uneventful cardiac-wise during surgery and postoperative period.

Key Words: Aortic surgery; Impella; Microaxial; Assist device

	1. Case

Top Abstract 1. Case 2. Discussion References

 
A 50-year-old man was referred to our institution for an end-stage cardiac failure. Medical history was marked by smoking, alcohol addiction and dyslipidemia. The patient presented three years before myocardial infarcts due to proximal left anterior descending (LAD) artery occlusion. Coronary angiogram revealed multiple vessels stenosis and viability MRI large necrotic anterior and inferior wall segment, with a low left ventricular ejection fraction (LVEF: 18%). A systematic implantation of an internal cardiac defibrillator was performed through the left subclavian vein and the patient was planned for an orthotopic cardiac transplantation.

A systematic body scan showed an infrarenal aortic aneurysm measuring 59 mm, starting immediately below the renal arteries (without proximal neck) and extending to the iliac bifurcation. The patient explained that the aneurysm was known for one year, with a recent CT-scan performed two months before showing a diameter of 45 mm. After multidisciplinary discussion, he was scheduled for abdominal aortic surgery with the coverage of an Impella LP50^TM microaxial blood pump.

After general anaesthesia, the patient was placed in supine position with a pillow under his kidneys. Arterial monitoring as well as central venous access were performed before surgery. The first step of the procedure was to insert the microaxial pump. A right subclavian incision was made and the subclavian artery exposed. Fifty IU/kg of intravenous heparin was given, then an 8 mm Dacron^TM tube was sutured end-to-side to the artery to allow the introduction of the pump. A guide wire was placed into the left ventricle under fluoroscopy guidance, then the Impella LP50^TM was inserted into the Dacron^TM graft and an occluding plug around the 9Fr driving cable was tied to prevent blood loss during the implantation manoeuvres. The plug allowed the guide wire and the driving cable to slide easily. The pump was pushed towards the ascending aorta and then crossed the aortic valve and its correct positioning was checked using fluoroscopy. After removal of the guide wire, the pump was started to reach progressively a flow of 4.5 l/min.

At that moment, a transverse laparotomy was performed and the infrarenal abdominal aorta exposed. It was clamped using a solid body clamp below the renal arteries and opened until the iliac bifurcation. Both iliac arteries were occluded in an endoluminal manner with two 14Fr Foley^TM catheters. A 22 mm Dacron tube (Laboratoires Perouse Implants, Ivry, France) was used to replace the infrarenal aorta. During the suture of the tube, the patient presented a ventricular fibrillation spontaneously resolutive after 20 s. During that period, haemodynamic status remained stable as the pump was delivering a 4 l/min flow. At the end of the distal anastomosis, the proximal aortic clamp was removed after proper de-airing and haemostasis checked (total clamping time 22 min). A Redon catheter was inserted into the retroperitoneal space before the abdomen was closed in a standard manner. The pump was progressively stopped without any inotropic support and removed out of the subclavian artery into the Dacron^TM tube. The prosthesis was cut off, then tied 1 cm close to the anastomosis with the subclavian artery, and the subclavian incision was closed.

The patient was extubated 2 h after admittance into the recovery room. Troponin I at 24 h was 0.04 IU/ml. On postoperative day (POD) 5, the patient presented with sustained hyperthermia. Blood cultures revealed methicilline sensible Staphylococcus aureus. The central venous access, still present at that time, was removed and examined, showing the presence of the same micro-organism. A double antibiotherapy (methycilline and gentamycine) was immediately started. Unfortunately, evolution was marked on POD 10 by a septic thrombophlebitis of the right internal jugular vein. The patient underwent thrombectomy of the jugular vein under general anaesthesia, using a Fogarty^TM catheter. A transoesophageal echography (TEE) was performed during the same procedure to eliminate a concomitant endocarditis. Further evolution was uneventful and the patient was discharged home on POD 21.

	2. Discussion

Top Abstract 1. Case 2. Discussion References

 
Chronic heart failure continues to represent a challenge in patients who have to undergo associated surgeries, such as digestive, orthopaedic or abdominal aortic approaches. As a ventricular unloading catheter, the Impella^® Recover^® microaxial pump is appropriate for temporary circulatory assistance in severe left ventricle (LV) dysfunctions. Impella^® Recover^® LP50 has been designed for Seldinger technique implantation through femoral artery under local anaesthesia [1]. The device is simple to insert and does not require systemic anti-coagulation. According to the duration of the support, its indications are bridge to recovery, bridge to bridge in a too ill patient for conventional implantable LVADs, and bridge to transplantation when short waiting time is considered [1, 2]. When correctly positioned into the LV, it allows an optimal flow reaching up to 5 l/min. In the case of this patient, the Impella^® Recover^® LP50 seemed seductive since LVEF was poor, rendering the abdominal aortic replacement very risky. Yet, the implantation of the micro axial pump using a Seldinger technique was impossible in this case. For this reason, we decided to use the right axillary approach. We have recently described this technique for long-term implantations, to allow the patients rehabilitation before weaning [3]. In the present case, the postoperative course was free from cardiac failure and we didn't note any perioperative myocardial infarct. Yet, the thrombophlebitis of the internal jugular vein is an uncommon complication but the secondary course was satisfactory.

In our opinion, the Impella^® Recover^® LP50 could represent an interesting weapon in the armamentarium of the cardiovascular surgeons in comparable situations.

	References

Top Abstract 1. Case 2. Discussion References

 

1. La Rocca GM, Shimbo D, Rodriguez CJ, Stewart A, Naka Y, Weinberger J, Homma S, Pizzarello R. The Impella Recover LP 5.0 left ventricular assist device: a bridge to coronary artery bypass grafting and cardiac transplantation. J Am Soc Echocardiogr 2006;19:468, e5–7.
2. Garatti A, Colombo T, Russo C, Lanfranconi M, Milazzo F, Catena E, Bruschi G, Frigerio M, Vitali E. Different applications for left ventricular mechanical support with the Impella Recover 100 microaxial blood pump. J Heart Lung Transpl 2005;24:481–485.[CrossRef][Medline]
3. Sassard T, Scalabre A, Bonnefoy E, Sanchez I, Farhat F, Jegaden O. The right axillary artery approach for the Impella Recover LP 5.0 microaxial pump. Ann Thorac Surg, in press.

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