How to Do It: Transbrachial Impella Placement to Facilitate Percutaneous Coronary Intervention.

A 64-year-old man with diffusely diseased iliofemoral vessels and an ejection fraction of 20% to 25% presented with a non-ST elevation myocardial infarction and proximal left anterior descending (LAD) and left circumflex (LCx) coronary artery disease, with a chronically occluded right coronary artery. The iliofemoral system was not suitable for Impella placement, and bilateral axillary arteries were heavily calcified. The proximal left brachial artery was chosen for placement of both an Impella CP (Abiomed, Danvers, MA, USA) and percutaneous coronary intervention (PCI) sheath through a graft sewn to the brachial artery in this single-access technique. A 6 mm graft was sewn to the brachial artery, through which the Impella CP was placed. The Impella CP sheath was then used to introduce a 7F sheath for PCI. Successful PCI with drug-eluting stents was carried out to the LAD and LCx arteries, the Impella was weaned and removed, and the graft was stapled. The patient was discharged without any access or PCI complications. This report demonstrates the feasibility of the single-access Impella technique through a brachial artery cutdown approach.

Initial experience with routine selective carotid arteriography by vascular surgeons.

We report the results of our first 2 years of experience with routine carotid angiography with an emphasis on technique and complications. We reviewed the hospital records, office charts, and prospective quality-assurance database records of 336 patients undergoing cerebrovascular arteriograms and collected data on the indications, complications, and technical aspects of the procedures. Indications for angiography included carotid stenosis in 331 (95%) patients, subclavian steal syndrome in 9 patients, vertebrobasilar insufficiency in 6 patients, and carotid body tumor in 2 patients. Selective catheterizations were performed on 654 common carotid arteries, 63 subclavian arteries, and 63 vertebral arteries. Both common carotid arteries were not selectively catheterized in 34 (9.8%) patients. Reasons for not selecting one or both common carotid arteries included physician choice to limit contrast administration in patients with renal insufficiency in 16 cases, proximal occlusion in 4 cases, proximal stenosis thought to be at risk of embolization if instrumented in 3 cases, imaging equipment malfunction in 2 cases, and in only 9 (2.6%) cases was selective carotid catheterization attempted but unsuccessful. There were no procedure-related deaths. Complications were documented in six (1.8%) patients, including cerebrovascular accident (CVA) in 1 (0.3%) patient. One hundred forty-two (41%) patients went on to carotid endarterectomy, and we performed 16 carotid bifurcation stents during the study period. Routine selective carotid angiography is a low-risk procedure that can be performed safely by vascular surgeons with catheter/guide wire skills.