D104-23 A Unique Use of Bilateral Carotid Embolic Protection Devices During Impella Removal With Device-associated Thrombus

Introduction The Impella device is widely used to provide temporary mechanical circulatory support for patients with cardiogenic shock. While effective, its use carries the risk of thrombus formation, particularly when anticoagulation must be suspended. Removal of a thrombus-laden device can precipitate systemic embolization, potentially leading to catastrophic cerebrovascular accidents (CVAs). Although protocols using purge solutions containing thrombolytics exist, there are no standardized guidelines on the use of embolic protection devices to mitigate the risk of embolization in patients requiring device removal. Here we present a case in which SpiderFX™ embolic protection devices were employed to mitigate the risk of cerebrovascular embolization during Impella device removal in a patient with a device-associated intraventricular thrombus, where thrombolytics were contraindicated. Case Presentation A 36-year-old male with no significant medical history presented with an anteroseptal ST-elevation myocardial infarction complicated by ventricular fibrillation arrest. Shortly after successful resuscitation and percutaneous coronary intervention to the proximal left anterior descending artery, the patient developed cardiogenic shock requiring Impella support. His course was complicated by substantial oropharyngeal bleeding, leading to a hemoglobin decrease from 17 to 9.5 g/dL over 48 hours, prompting the temporary suspension of systemic anticoagulation. A repeat echocardiogram revealed a new thrombus adherent to the Impella device near the inflow port (Figure 1). Given the ongoing bleeding, both systemic and catheter-directed thrombolysis were contraindicated. A multidisciplinary team collaborated to develop a neuroprotective strategy for Impella removal. SpiderFX filters were deployed in the distal cervical segments of both the right and left internal carotid arteries to provide cerebrovascular embolic protection. The Impella CP device was withdrawn under fluoroscopic guidance. Intraprocedural angiography demonstrated no evidence of thrombus capture or distal embolization. The filters were retrieved and the procedure concluded. Discussion This case illustrates an innovative, multidisciplinary approach to preventing cerebral embolization during the high-risk removal of an Impella device associated with intraventricular thrombus. The selective use of Spider embolic protection devices offered an alternative to thrombolytic therapy and minimized the risk of ischemic stroke during Impella removal in a patient with active bleeding. Conclusion The use of bilateral carotid Spider filters during Impella removal represents a unique and practical neuroprotective strategy when thrombolytics are contraindicated. This case highlights the importance of cross-specialty collaboration in managing complex patients requiring mechanical circulatory support and may inform future protocols for safer Impella retrieval in similar scenarios.