27: Extra-Axial Distal Limb Perfusion for Impella associated Ischaemia in a Young Patient on ECPELLA Support

Background: Limb ischaemia is a recognised complication of femoral Impella placement, particularly when used in combination with VA-ECMO (ECPELLA configuration). The challenge is amplified in young patients with small-calibre vessels. We describe an innovative use of extra-axial distal perfusion with pharmacological adjuncts to salvage limb perfusion in a critically ill patient supported on ECPELLA. Case Summary: A 21-year-old female with poorly controlled hyperthyroidism presented in cardiogenic shock following two brief cardiac arrests. Echocardiography demonstrated severe biventricular dysfunction (EF 15%), consistent with thyrotoxic cardiomyopathy. Despite escalating inotropes, she remained in refractory shock and was initiated on VA-ECMO with Impella CP for left ventricular unloading (ECPELLA configuration). Soon after initiation, Near-infrared spectroscopy (NIRS) readings on the Impella limb fell to 22%, suggesting critical limb ischaemia. Owing to the small vessel size, a conventional distal perfusion cannula could not be placed, hence 4 Fr extra-axial cannula was inserted into the superficial femoral artery and connected to the arterial ECMO limb to re-establish antegrade flow. Intra arterial Glyceryl trinitrate and prostaglandin E1 infusions were used to augment microvascular circulation. Following this intervention, NIRS improved to 55%, with restoration of warmth and capillary refill. The patient’s cardiac function gradually recovered (EF 50% by day 10), and she was successfully decannulated from both ECMO and Impella without any residual limb deficit or tissue loss. Discussion: This case highlights a simple, effective and reproducible technique for managing Impella-associated limb ischaemia in ECPELLA patients where vessel calibre precludes standard distal perfusion. The addition of vasodilator therapy optimised distal flow and tissue oxygenation. Conclusion: An extra-axial 4 Fr distal perfusion strategy, combined with vasodilator infusions, offers a practical limb-saving option for small-vessel ECPELLA patients. Early NIRS-guided detection and proactive intervention are critical in preventing irreversible ischaemic complications in advanced mechanical circulatory support.