Introduction

We present the case of a 49 year old female patient with severe cardiogenic shock. After insertion of an Impella CP microaxial pump (14 F) for ventricular unloading, she developed acute limb ischemia due to preexisting peripheral arterial disease with the clinical signs of pallor, pulselessness, perishing temperature of the right leg and livid toes.

Ultrasound diagnostics showed no blood flow in the right femoral superficial artery. The vessel was punctured ultrasound-guided distal to the Impella, and a usual 4F sheath normally used for coronary diagnostics was introduced via seldinger technique after confirmation of the intravascular position of the guiding wire. The bypass of the sheath was connected to a second 5F sheath in the femoral artery of the contralateral leg using a special double-male adapter for connecting both sheaths.
 
After opening both two-way taps, spontaneus blood flow was established via “autoperfusion” due to the present pressure gradient. A bed side angiogram then confirmed re-established blood flow. The clinical signs significantly improved up to no more imminent danger of limb loss. The Impella could be weaned and surgically removed after 5 days of cardiac recovery.

Figure 1: Ultrasound colour doppler image: A: no blood flow in right femoral superficial artery; B: preserved flow in profund artery
 

Figure 2: Placement of catheters: A: venous sheath (to be removed); B: arterial antegrade perfusion cannula in ischemic right patient leg; C: central venous line; D: double-male perfusion-adapter; E: Impella device (covered); F: retrograde arterial cannula („donor“)

Figure 3: Bed side angiogram (application of contrast agent via antegrade shunt): long segment stenosis and thrombus of the right femoral superficial artery, distinct collateral network



Figure 4: Flow scheme: A: arterial antegrade perfusion cannula in ischemic right patient leg; B: double-male perfusion-adapter; C: retrograde arterial cannula; blood flow from C to A via “autoperfusion” due to pressure gradient

Conclusions

The use of the described autoperfusion-technique may be considered in acute peripheral ischemia after Insertion of an Impella device, if device removal is not possible for hemodynamic reasons.