Temporary extracorporeal femoro-femoral crossover bypass to treat critical limb ischemia due to occlusive femoral transaortic microaxial left ventricular assist device – A novel technique and case series

Abstract Background The Impella transaortic microaxial left ventricular assist device (MLVAD) is a temporary circulatory support (TCS). It's percutaneous insertion through the common femoral artery (CFA) bears the risk of severe ipsilateral limb ischemia. As long as the MLVAD is required for cardio - circulatory support, treatment options are limited. To approach this problem, we developed a temporary extracorporeal femoral - femoral crossover bypass to restore and maintain perfusion of the affected leg.The aim of this report is to introduce our novel technique and present results of a case series of accordingly treated patients.Methods From October 2018, we treated all patients with severe limb ischemia due to the MLAVD with a femoral - femoral crossover bypass and collected their data prospectively. For comparison, all consecutive patients undergoing placement of the MLAVD between January 2011 and July 2019 were identified retrospectively.The primary outcome of the study is the feasibility and safety of our percutaneously established extracorporeal femoral - femoral crossover bypass. As secondary endpoints, we report overall 30 - day mortality and limb salvage rates.Results Between January 2011 and July 2019, 25 of 245 (10.3%) patients developed a severe limb ischemia of the ipsilateral leg following the MLVAD placement.Until October 2018, 20 patients were treated conventionally (C - cohort) and since October 2018, five (consecutive) patients have been treated by an extracorporeal femoral - femoral cross over bypass (BP - Cohort).Following the BP - procedure, an immediate improvement of the perfusion of the affected limb was seen clinically and on Duplex ultrasound in all patients. 20% of the BP - cohort needed additional surgical salvage procedures compared to 25% of the C - Cohort. Limb salvage was documented in 100% of our patients and 30 days mortality was 60% in both groups.Conclusion This is the first case series reporting on a novel technique of limb salvage in patients with severe limb ischemia due to an MLVAD. We demonstrated that the percutaneous creation of an extracorporeal crossover bypass is feasible, safe and effective and should therefore be promoted.