INTERVENTIONAL CARDIOLOGY
Image in Cardiovascular Medicine
Cardiology Journal
2024, Vol. 31, No. 4, 643–644
DOI: 10.5603/cj.99067
Copyright © 2024 Via Medica
ISSN 1897–5593
eISSN 1898–018X
Impella-supported endovascular repair of thoracoabdominal aorta dissection
Arkadiusz Pietrasik1Aleksandra Gąsecka1
Michał Gawlik1Dawid Tomasik2Krzysztof Lamparski3Katarzyna Jama4Tomasz Jakimowicz4 11st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
22nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Poland
32nd Department of Clinical Radiology, Medical University of Warsaw, Poland
4Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Poland
Address for correspondence: Aleksandra Gąsecka, MD, PhD; 1st Chair and Department of Cardiology, Medical University
of Warsaw, ul. Banacha 1a, 02–097 Warsaw, Poland, tel: 22 599 19 51, e-mail: gaseckaa@gmail.com
Received: 22.01.2024 Accepted: 29.05.2024
This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.
Although Impella, as a percutaneous left ventricular (LV) assist device, is primarily indicated in high-risk percutaneous coronary interventions (HR-PCI) and cardiogenic shock (CS), emerging alternative indications are arising, i.e. fulminant myocarditis, transaortic valve implantation or ventricular tachyarrhythmia ablation.
In this case, a 47-year-old patient with Marfan syndrome and advanced chronic kidney disease was admitted for thoracoabdominal aorta dissection, extending from the aortic arch to the right iliac artery, with false lumen dilatation to 48 mm and persistent flow through multiple secondary entry tears (Fig. 1A, B).
Figure 1. A. Computed tomography of thoracoabdominal aorta dissection. The false and true lumens are indicated with thin and thick white arrows, respectively; B. 3D computed tomography reconstruction of the dissected thoracoabdominal aorta; C, D. 3D computed tomography reconstruction of the aorta after branched endovascular aneurysm repair operation with stentgraft implantation (white arrow); E. Impella device screen during the operation, showing decreased systolic blood pressure (67/35 mmHg) and mean arterial pressure (48 mmHg), but maintained cardiac power output (0.8 Watt)
The patient had a history of ascending aortic aneurysm treated with aortic root replacement, complicated with post-operative myocardial infarction and subsequent severe LV systolic dysfunction. He also suffered from thoracoabdominal aorta dissection, treated by thoracic endovascular stent-graft implantation (EVAR). Given the extremely high mortality risk (EuroScore II 32%), the HeartTeam opted for repeated EVAR with LV support. Impella CP pump (Abiomed, Danvers) was inserted through cutdown of the right axillary artery, allowing for a cardiac output of 7.9 L/min, with minimal noradrenaline infusion (Fig. 2E). A branched graft (E-nside TAAA, JOTEC) was implanted via left axillary and right inguinal access, overlapping with the previously implanted stent-graft (Zenith, Cook Medical) (Fig. 2C, 2D). Angiography revealed no endoleak and Impella was removed after approximately 4.5 hours. After a 2-day stay in the intensive care unit, the patient was discharged home on day 9.
The present report demonstrates the expansion of Impella use to EVAR, suggesting its potential role in any procedure requiring LV support to prevent hemodynamic compromise.
