Strategies for safely closing large-bore access and managing vascular and bleeding complications are critical for achieving optimal patient outcomes with percutaneous mechanical circulatory support (pMCS). In this article the authors describe techniques for Impella removal with or without pre-closure and discuss how to prevent and manage complications associated with large-bore femoral access. 

Before discussing Impella pump removal, the authors emphasize the importance of ultrasound-guided vessel puncture and advanced imaging to ensure safe vascular access. They then describe in detail several pre- and/or post-closure techniques, including non-invasive and invasive strategies for removal of Impella pumps in the catheterization lab.

• Non-invasive strategies include manual compression and use of femoral compression devices such as FemoStop™ or CompressAR®
• Invasive strategies include suture-based vascular closure devices (VCD) such as Prostar® XL and ProGlide®, collagen-based VCD such as MANTA™, patch-based VCD such as PerQseal®, membrane-based VCD such as InSeal, surgical cut-down, and interventional strategies with peripheral balloon compression and/or covered stent implantation

These closure techniques can help preserve vessel patency and prevent vascular complications such as bleeding, retroperitoneal hemorrhage, vascular perforation, limb ischemia, and pseudoaneurysms. In patients who need to remain on MCS support after Protected PCI, dedicated large-bore closure devices such as MANTA, PerQseal, and InSeal, can address delayed hemostasis. The authors recommend angiography or ultrasound following access site closure with a VCD to rule out any residual bleeding and confirm vessel patency and distal limb perfusion.

After describing closure techniques, the authors discuss management of limb ischemia during Impella support, highlighting that removing Impella pump after PCI is associated with a reduced risk of limb ischemia. If, however, limb ischemia develops, management strategies include prompt removal of the Impella device and treatment before necrosis develops.

The article concludes with a discussion of procedural options for patient deterioration during Impella Protected PCI. The authors discuss MCS escalation and emphasize the importance of operators being familiar with endovascular bailout and complication management to optimize patient outcomes.