Single Access During Impella® Hemodynamic Support

Matthew G. Whitbeck, MD, describes how the RAILWAY Sheathless Access System (Cordis)* can be used with the single access technique to expand treatment options to a broader range of patients, such as those with severe peripheral vascular disease and no axillary options. “It’s allowed us to provide treatment to a whole other group of patients.”

Dr. Whitbeck explains that he and his team frequently encounter patients with peripheral vascular disease of the iliacs where it is challenging to accommodate the 9 Fr cannula and the outer diameter of the 7 Fr, 45 cm destination sheath, as well as patients with tortuous iliacs through which Impella can be delivered but it is challenging to also deliver and manipulate a 7 Fr guide. In these types of patients procedures tend to be longer than a typical PCI, he notes, “so that means a longer risk of lack of perfusion to the limb. So, we were looking to give a little more room in the iliacs to continue having perfusion down to the leg. We were also looking for a particular technique that could overcome the lack of size of the iliac and help better deliver the guide.”

Dr. Whitbeck explains that he customizes the single access approach for each patient, and he describes cases in which this technique yielded good outcomes. "So, it’s another tool in our toolbox to use. It doesn’t have to be the default, but we want it available to operators in case they need it."

Dr. Whitbeck describes his experience using this Railway technique with an 8 Fr guide. “The outer diameter of an 8 Fr guide is still smaller than the outer diameter of the 7 Fr, hydrophilic 45 cm destination sheath, so the Railway does come in a 5, 6, and 7 Fr inner dilator. The distance between the inner diameter of the 8 Fr guide and the outer diameter of the Railway is minimal. So, it’s actually pretty easy to get it through the 14 Fr hub. And so that allows you to use an 8 Fr if you do so desire. You will come into some more resistance with an 8 Fr because you’re getting close to the outer diameter of the typical 7 Fr destination sheath, but it does give you access to larger rotational atherectomy burrs. We utilize it in high-risk CTOs that need hemodynamic support. You still only maintain two accesses: 8 Fr in the groin through the Impella® sheath and a 7 Fr in the left radial would be our most common strategy. So, it’s just added another dynamic.”

"I think it’s a very nice technique," he concludes. “The biggest thing to remember is the interaction with the 9 Fr cannula… I would just make it a rule that any time I need to adjust the guide, I’m holding some back tension on the Impella catheter.”

*RAILWAY is a filed for trademark of Cordis