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Review
. 2023 Feb 6;13(2):293.
doi: 10.3390/jpm13020293.

Management of Vascular Access in the Setting of Percutaneous Mechanical Circulatory Support (pMCS): Sheaths, Vascular Access and Closure Systems

Andrea Sardone  1 , Luca Franchin  1 , Diego Moniaci  2 , Salvatore Colangelo  1 , Francesco Colombo  1 , Giacomo Boccuzzi  1 , Mario Iannaccone  1
Affiliations
Review

Management of Vascular Access in the Setting of Percutaneous Mechanical Circulatory Support (pMCS): Sheaths, Vascular Access and Closure Systems

Andrea Sardone et al. J Pers Med. .

Abstract

The use of percutaneous mechanical circulatory support (pMCS), such as intra-aortic balloon pump, Impella, TandemHeart and VA-ECMO, in the setting of cardiogenic shock or in protect percutaneous coronary intervention (protect-PCI) is rapidly increasing in clinical practice. The major problem related to the use of pMCS is the management of all the device-related complications and of any vascular injury. MCS often requires large-bore access, if compared with common PCI, and for this reason the correct management of vascular access is a crucial point. The correct use of these devices in catheterization laboratories requires specific knowledge such as the correct evaluation of the vascular access performed, when possible, with advance imaging techniques in order to choose a percutaneous or a surgical approach. In addition to conventional transfemoral access, other types of access, such as transaxillary/subclavial access and the transcaval approach, have emerged over the years. These other approaches require advanced skills of the operators and a multidisciplinary team with dedicated physicians. Another important part of the management of vascular access is the closure systems used for hemostasis. Currently, two types of devices are typically used in the lab: suture-based or plug-based ones. In this review we want to describe all these aspects related to the management of vascular access in pMCS and describe, finally, a case report from our center's experience.

Keywords: cardiogenic shock; mechanical circulatory support; protect-PCI; vascular management.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Common femoral artery and bifurcation into superficial and deep femoral artery. 3D reconstruction image from computed-tomography scan (CT-scan).
Figure 2
Figure 2
Initial step to perform ultrasound-guided puncture. (A) Identify lower edge of femoral edge with fluoroscopy and a metal hemostat. (B) Write a sign in the skin with a marker in the correspondent point. (C) The probe positioned above the marked line.
Figure 3
Figure 3
DSA allow to puncture in the correct site of CFA avoiding bifurcation and other small vessels.
Figure 4
Figure 4
(A) 51-year-old man with history of: diabetes, chronic obstructive pulmonary desease (COPD), mild chronic kidney disease (GFR 56 mL/min) and peripheral artery disease (PAD) with previous percutaneous transluminal angioplasty (PTA) with stent implantation in the right external iliac artery, left iliac artery, left common femoral artery and subsequently aorto-bifemoral bypass surgery, referred to our center for HR-PCI A. Angiography evaluation after sheaths insertion. (B) Surgical cutdown with VA-ECMO cannulation and subsequently insertion of 7 Fr guiding sheats.
Figure 5
Figure 5
(A). Skin incision on the groin. (B). Exposure of common femoral artery.
Figure 6
Figure 6
(A). Vascular graft and common femoral artery anastomosis. (B). Tunnellization of vascular graft under the skin. (C). Insertion of Impella 5.0 sheath in the vascular graft.
Figure 7
Figure 7
(A). Surgical exposure of subclavian artery. (B). Insertion of Impella CP sheath under fluoroscopy guidance. (C). Placement of the sheath after tunnellization under the skin.
Figure 8
Figure 8
Decisional algorithm in setting of cardiogenic shock (CS) pre-PPCI and high risk-PCI. * Surgical cutdown.
Figure 9
Figure 9
Decisional algorithm in setting of cardiogenic shock (CS) post-PPCI. * Surgical cutdown.
See this image and copyright information in PMC

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