Impella® Skills Video: Insertion Steps for the Impella CP® with SmartAssist®

This Impella® Skills video demonstrates the insertion steps for the Impella CP® with SmartAssist® heart pump. 

1. Obtain access to the femoral artery.

2. Insert a 5–8 Fr introducer over the 0.035 guidewire (provided) to pre-dilate the vessel.

3. Remove the 5–8 Fr introducer over the 0.035 guidewire.

4. After removal of the 5 -8 Fr sheath, place two Preclose sutures at 10 o’clock and 2 o’clock positions within the femoral artery, which results in pre-dilation of the arteriotomy to 10F.

5. Sequentially insert and remove the 12 Fr dilator or insert the peel-away 14F Impella introducer with dilator directly. Flush the peel-away sheath side arm with normal saline. The dilator may be left in place with intermittent flushing until systemic anticoagulation is delivered. When an ACT greater than or equal to 250 seconds is achieved, remove the dilator

6. Heparin, bivalirudin, or argatroban, are systemic anticoagulation options and should be used per institutional protocol.

7. Once the 14 Fr peel-away sheath is in place, assess distal limb patency using angiography, distal pulse palpation, ultrasound, or infrared tissue oximetry. If there is poor limb perfusion, consider placement of an antegrade perfusion sheath, prior to leaving the procedural suite.

8. Prior to catheter insertion, flush the introducer.

9. Insert a diagnostic catheter (Abiomed recommends a 6 Fr AL1 or Multipurpose without side holes or 4–5 Fr pigtail with or without side holes) over a 0.035 inch diagnostic guidewire into the introducer and advance it into the left ventricle.

10. Remove the 0.035 inch diagnostic guidewire, leaving the diagnostic catheter in the ventricle. Form a curve or bend on the end of the 0.018 inch, 260 cm placement guidewire, following the instructions and heeding the precautions described in the sidebar box.

11. Advance the placement guidewire into the apex of the left ventricle.

12. Remove the diagnostic catheter

13. Insert the placement guidewire into the red EasyGuide lumen at the tip of the pigtail

    a. Advance the guidewire until it exits the red lumen near the label

    b. Remove the EasyGuide lumen by gently pulling the label in line with the catheter shaft while holding the Impella® Catheter

    c. If you suspect that a portion of the red lumen remains in the catheter, do NOT use the Impella Catheter. Measure red lumen length using catheter markings (intact length is between 21.5 cm and 22.5 cm).

    d. Skip to step 14 if the catheter is successfully backloaded on the guidewire.

    To backload the catheter without the EasyGuide lumen

14. Wet the cannula with sterile water and backload the catheter onto the placement guidewire. One or two people can load the catheter on the guidewire.

    One-person technique

    a. Advance the guidewire into the Impella Catheter and stabilize the cannula between the fingers. This prevents pinching of the inlet area. The guidewire must exit the outlet area on the inner radius of the cannula and align with the straight black line on the catheter. The cannula can be hyperextended as necessary to ensure the guidewire exits on the inner radius of the cannula.

    Two-person technique

    b. The scrub assistant can help stabilize the catheter by holding the catheter proximal to the motor. This will allow the implanting physician to visualize the inner radius. The guidewire must exit the outlet area on the inner radius of the cannula and align with the straight black line on the catheter. The physician can focus on advancing the guidewire and, if the cannula needs to be hyperextended, the scrub assistant is available to assist.

15. Advance the catheter through the hemostatic valve into the femoral artery and along the placement guidewire and across the aortic valve using a fixed-wire technique. Follow the catheter under fluoroscopy as it is advanced across the aortic valve, positioning the inlet area of the catheter 3.5 cm below the aortic valve annulus and in the middle of the ventricular chamber, free from the mitral valve chordae. Be careful not to coil the guidewire in the left ventricle.

16. Remove the placement guidewire.

17. Confirm position with fluoroscopy and confirm that an aortic waveform is displayed on the Automated Impella Controller.