Impella® Skills Video: Impella 5.5® with SmartAssist® Direct Aortic Insertion

This Impella skills video demonstrates direct aortic insertion of the Impella 5.5 with SmartAssist. The video is a simplified version of the technique, highlighting the primary steps of the procedure. Note that the vascular graft is not included in the Impella 5.5 with SmartAssist Set-up and Insertion Kit. Abiomed recommends using a Hemashield Platinum® or Vascutek Gelweave™ graft.

1. Confirm exit strategy of the Impella catheter from the chest prior to insertion.
2. Using the supplied sterile incision template, identify the location for the incision in the ascending aorta. It should be 7 cm above the aortic valve.
3. Place a side-biter clamp and make an incision no larger than 6 mm so that the front of the silicone plug does not advance through the incision into the aorta.
4. Attach a 10 mm x 20 cm Dacron vascular graft to the aorta using a standard end to side anastomosis.
5. Administer heparin to achieve ACT of at least 250 seconds.
6. When the anastomosis is complete, place a clamp at the distal end of the graft and then release the proximal clamp at the base of the graft.
7. Examine the suture line for leaks and re-clamp the graft at the base.
8. Load the 2 provided split silicone plugs onto the Impella catheter and push them up against the motor housing.
9. Prior to inserting the Impella catheter, lay the catheter out straight and remove any excess torque in the catheter and white connector cable.
10. Hold the catheter upright and visualize purge fluid at the base of the impeller.
11. With the graft clamped at the base, place the Impella 5.5 with SmartAssist into the open end of the graft up to the level of the rear plug. 
12. When the catheter is in position, secure a tourniquet around the rear silicone plug and tighten the tourniquet sufficiently to control bleeding while still allowing the catheter to slide through the plug.
13. Release the clamp and advance the Impella into the aorta.
14. If the patient is on cardiopulmonary bypass, allow the heart to fill by restricting the return flow to the bypass machine and reducing cardiopulmonary bypass flow to a minimum setting, as long as acceptable physiologic systemic flow is maintained.
15. As soon as the motor housing passes into the aorta, use a ligature to loosely secure the front silicone plug flush to the graft anastomosis. The silicone plug should be in the most proximal portion of the graft.
16. While the catheter is being advanced into the aorta, do not allow the front plug to advance beyond the base of the graft. 
17. Utilize TEE guidance to ensure that the aortic valve is open while advancing the Impella catheter across the aortic valve. To aid in passing the catheter through the aortic valve, apply slight pressure to the posterior aspect of the aortic valve to produce temporary aortic insufficiency.
18. Gently advance the catheter forward until the inlet area crosses the aortic valve. 
19. Position the catheter so that the distance between the Impella inlet and aortic valve measures approximately 5 cm.
20. After achieving correct and stable placement, position the front silicone plug as close as possible above the aorta.
21. Secure the front silicone plug to the graft using a penetrating suture ligature.
22. Clear the vascular graft of excess blood and advance the rear silicone plug to the front silicone plug.
23. Trim the graft to the desired length and secure the rear silicone plug using a penetrating suture ligature.
24. Close the chest according to the pre-case plan and secure the Impella catheter to the skin. 
     

Hemashield Platinum® is a registered mark of Getinge
Vascutek Gelweave™ is a trademark of Terumo Aortic