Insertion of the Axillary Impella 5.5

The authors present their technique for axillary Impella 5.5 insertion. The preferred incision was made through the deltopectoral groove, where the axillary artery is more superficial and easier to access. The pectoral muscles were traversed by spreading their fibers rather than dividing them, and two self-retaining retractors were used to optimize exposure.

To expose the axillary artery, the subclavian vein was mobilized caudally, and the artery was controlled proximally and distally with vessel loops. The patient was heparinized to achieve an activated clotting time (ACT) of approximately 250 seconds. The artery was then clamped proximally and distally, and an arteriotomy was performed using a #15 blade. A 10 mm vascular graft was prepared and anastomosed end-to-side to the artery using a continuous 5-0 Prolene suture. The clamps were subsequently removed, the artery was deaired, adequate backflow was confirmed, and hemostasis of the anastomosis was verified. The Impella introducer sheath was inserted into the graft and secured with two locking mechanisms. The sheath was then deaired through the side port using a syringe filled with heparinized saline.

Under fluoroscopic and transesophageal echocardiographic (TEE) guidance, the graft was wired using a KMP catheter loaded with a starter wire. Once transaortic valvular access was obtained, the starter wire was exchanged for the Impella guidewire, and the KMP catheter was removed. The Impella 5.5 device was deaired using the purge solution, loaded onto the guidewire, and advanced into the left ventricular cavity under fluoroscopic and TEE guidance. Once satisfactory positioning was confirmed, the guidewire was removed. The device was initiated at a performance level (P-level) of 2 and subsequently escalated according to the patient’s hemodynamic status.

The insertion process was finalized by removing the introducer sheath, trimming the graft to skin level, advancing the repositioning unit into the graft, and securing it with multiple silk ties. The yellow tab was removed to lock the device in place. The graft and device were secured to the skin with silk ties, and the wound was closed in multiple layers over the vessel loops to facilitate device removal at a later stage.

Disclosure

Drs. Tong, Soltesz, and Zaki are consultants for Johnson & Johnson MedTech Heart Recovery.

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