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

Figures

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  Figure 1. Common femoral artery and bifurcation into superficial and deep femoral artery. 3D reconstruction image from computed-tomography scan (CT-scan).

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  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.

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  Figure 3. DSA allow to puncture in the correct site of CFA avoiding bifurcation and other small vessels.

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  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.

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  Figure 5. (A). Skin incision on the groin. (B). Exposure of common femoral artery.

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  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.

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  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.

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  Figure 8. Decisional algorithm in setting of cardiogenic shock (CS) pre-PPCI and high risk-PCI. * Surgical cutdown.

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  Figure 9. Decisional algorithm in setting of cardiogenic shock (CS) post-PPCI. * Surgical cutdown.