CathMasters by CardioNerds

Epizódok

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  10. Crisis Control — Bailout Management for Failed Percutaneous Axillary Artery Closure with Dr. Rajiv Tayal 02.08.2026 6p

  CathMasters hosts Dr. Amit Goyal, Dr. Li Pang, and Dr. Nazli Okumus discuss bailout management for failed percutaneous axillary artery closure with expert Dr. Raj Tayal. Building on the Data-to-Delivery and Proctor Playbook episodes, this Crisis Control episode walks through a scenario of wide-open extravasation after Perclose failure during right axillary access TAVR. The team covers a stepwise escalation algorithm — from repeat Perclose deployment and serial balloon tamponade with protamine reversal, to hybrid closure with AngioSeal, to covered stent placement with the Viabahn endoprosthesis — and discusses when to call vascular surgery. This episode translates the 2022 SCAI Position Statement bailout recommendations into a practical, cath-lab-ready crisis management framework. CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls As long as wire access is maintained across the arteriotomy, the operator retains full bailout capability — the working wire going through the arteriotomy allows for repeat vascular closure device attempt, including Perclose and/or AngioSeal (hybrid closure), while the safety wire positioned in the axillary artery from the secondary access allows for balloon tamponade and/or covered stent deployment. Losing wire access is the true crisis. If both Perclose sutures fail (snapped or cut), the “post-closure” rescue technique involves reinserting a large sheath, placing two 0.035″ wires side-by-side, removing the sheath, then inserting two 8F sheaths side-by-side for sequential Perclose deployment — maintaining wire access through the second sheath throughout. A 6Fr sheath will accommodate 5-7 mm Viabahn covered stents while a 7Fr sheath will accommodate up to a 9mm Viabahn covered stent. When deploying a covered stent from the radial artery without a destination sheath, use vascular markers on the screen to mark the bleeding site, lock the table position, and deploy based on those landmarks — retrograde contrast injection from the radial opacifies the vessel poorly compared to antegrade femoral injection. Covered stent placement in the 2nd segment of the axillary artery has minimal long-term sequelae — there are no critical branches that, if covered, would cause significant ischemia. Covering the lateral thoracic artery is acceptable; the subscapular artery is less desirable but tolerable. Avoid occluding the suprascapular artery (1st segment). Notes 1. Initial Assessment: Extravasation After Perclose Failure Bleeding is the most common complication of transaxillary access. Risk increases with larger sheaths, patient age, longer dwell time, tortuosity, urgency, and anticoagulation status. Hemostasis failure can lead to bleeding into the axillary space with possible brachial plexus compression and permanent nerve injury. As the axillary artery is extrathoracic, hemothorax should not occur if vessel puncture was in the correct location. The critical first question after failed closure: do you still have wire access through the arteriotomy and a safety wire in the artery? If yes, the full spectrum of bailout options remains available. 2. Stepwise Escalation Algorithm for Failed Closure The following algorithm represents a synthesis of the SCAI Position Statement recommendations and Dr. Tayal’s practical approach: Step 1 — Repeat Perclose: If one suture snapped but wire access is maintained, deploy an additional Perclose. This maintains wire access and allows interval assessment. If improvement is seen, proceed with observation. Step 2 — Serial balloon tamponade: Advance the tamponade balloon to the arteriotomy site (not proximal to it), inflate at 4–6 atm with simultaneous external manual compression × 5 minutes → deflate → angiogram. Repeat for a second 5-minute cycle if needed. Step 3 — Protamine reversal + balloon tamponade: Administer protamine, then repeat balloon tamponade × 5 minutes with external pressure. Thrombosis risk from protamine in an 8–10 mm axillary artery is low compared to coronary-sized vessels. Step 4 — Hybrid closure (AngioSeal): If bleeding is minimal and appears to be tract oozing between sutures, deploy an AngioSeal collagen plug. Although this sacrifices wire access through the axillary arteriotomy, the 0.018″ safety wire from the secondary femoral/radial access provides continued bailout capability. Step 5 — Covered stent: If bleeding persists after multiple tamponade cycles, proceed to covered stent deployment (see below). Step 6 — Surgical repair: Reserved for scenarios where covered stent is not feasible or effective (see below). 3. Post-Closure Rescue Technique (Both Percloses Failed) If both sutures are lost (snapped, cut, or pulled through), reinsert a large sheath (12–14F) to tamponade the arteriotomy. Place two 0.035″ wires through the sheath. Remove the sheath with both wires in place. Insert two 8F sheaths side-by-side, one over each wire. Deploy Perclose sequentially through one sheath while maintaining wire access through the other. If post-closure Perclose also fails, pivot to AngioSeal or covered stent via the second sheath. 4. Covered Stent Selection and Deployment Viabahn (W. L. Gore & Associates, Inc.) is the preferred covered stent for axillary artery bailout due to superior apposition and crush resistance in this mobile location. Self-expanding covered stents conform to the artery’s shape and adapt to the dynamic environment of the shoulder. Sizing: oversize by ≥1 mm relative to the artery diameter. For most patients (average axillary artery 6–6.5 mm), a 7 or 8 mm Viabahn covers the majority of cases. A 9 mm is rarely needed. Sheath compatibility: Viabahn 5–8 mm requires a 6–7F delivery system. Delivery route: Radial artery: A standard 6–7F slender sheath accommodates Viabahn up to 8 mm. However, visualization is limited (retrograde injection opacifies poorly). Use vascular markers on the screen to mark the bleeding site, lock the table, and deploy based on landmarks. The SCAI Position Statement recommends a long sheath from the radial approach, as passage of balloons and stents can induce spasm and entrapment. Femoral artery: Preferred for the first 5–10 cases — allows antegrade contrast injection with superior visualization and accommodates larger sheaths/devices. A 7–8F long (90–110 cm) sheath is recommended. Brachial artery: Avoid if possible; reserve for cases requiring stent sizes >8 mm when femoral access is unavailable. Length: Use a 50 mm stent and err on the side of extra length. Attempting to be too precise with a short stent risks needing additional stents proximally or distally. Post-dilation: Avoid if possible — post-dilating a self-expanding stent beyond its intended diameter causes foreshortening. Oversizing at initial deployment is preferable. Branch vessel considerations: In the 2nd segment, covering the lateral thoracic artery is acceptable. The subscapular artery (3rd segment) is less desirable to cover. The suprascapular artery (1st segment) should not be occluded. The vertebral and internal mammary arteries (subclavian) must be avoided, but these are normally far proximal from the access site in the 2nd axillary artery segment. Long-term outcomes: Covered stents in the axillary artery are well-tolerated with minimal long-term sequelae. The PAXA Registry reported secondary closure success in 98% of patients after adjunctive endovascular procedures (including 37 covered stents), with 100% axillary artery patency on follow-up CTA in the Al Adas et al. series. 5. When Covered Stent Is Not Feasible or Effective — Surgical Bailout Covered stent may be infeasible when: (1) the delivery system cannot be advanced (severe tortuosity, spasm), (2) the injury is too proximal (1st segment near the thoracic outlet), or (3) a mechanical complication prevents device extraction (e.g., partially deployed balloon-expandable TAVR valve trapped in the artery as referenced in the podcast episode). In the case described by Dr. Tayal, a balloon-expandable TAVR valve balloon ruptured on annular calcium, leaving a partially inflated valve that could not be fully deployed or withdrawn. The team pulled the device back into the axillary artery, inflated a proximal balloon to control bleeding, and a vascular surgeon performed a cutdown, extracted the device, placed a conduit, and the TAVR was completed successfully through the same artery. Key principle: if the arteriotomy is in the 2nd segment, proximal vascular control can be achieved endovascularly (balloon tamponade), buying time for surgical involvement without catastrophic hemorrhage. Direct surgical repair is preferable in some cases to avoid the risks of stent grafts (side branch occlusion, restenosis, thrombosis, infection, reduced mobility). In most cases, the arteriotomy can be repaired primarily unless there is significant atherosclerotic disease or vessel wall disruption, in which case patch angioplasty or interposition graft may be required. 6. Proactive Measures to Minimize Crisis Notify vascular surgery before the procedure — share the plan, data, and bailout strategy. Collegial pre-procedural communication prevents adversarial dynamics if complications arise. Have Viabahn stents (7 mm and 8 mm) in the room, not in a remote storage location. Experienced operators should achieve a <2–3% failure rate requiring covered stent or surgical conversion. The PAXA Registry reported a 1.5% open conversion rate, and the Al Adas et al. series reported a 6.9% covered stent rate (trending down to 4% in the late cohort with experience). Vascular complications from percutaneous transaxillary access, while reported at higher rates than transfemoral (up to 17% major vascular), do not appear to influence clinical outcomes when managed with proper endovascular techniques and materials. References Seto AH, Estep JD, Tayal R, et al. SCAI position statement on best practices for percutaneous axillary arterial access and training. J Soc Cardiovasc Angiogr Interv. 2022;1(3):100041. doi:10.1016/j.jscai.2022.100041 ⭐ Key Reference Sherwood M, Allen KB, Dahle TG, et al. SCAI expert consensus statement on alternative access for transcatheter aortic valve replacement. J Soc Cardiovasc Angiogr Interv. 2025;4(3 Part A):102514. doi:10.1016/j.jscai.2024.102514 ⭐ Key Reference Feistritzer HJ, Dumpies O, Rosseel L, et al. Alternative access for TAVR: a state-of-the-art review and practical guide. JACC Cardiovasc Interv. 2025;18(19):2309-2325. doi:10.1016/j.jcin.2025.08.029 ⭐ Key Reference Bertoglio L, Conradi L, Howard DPJ, et al. Percutaneous transaxillary access for endovascular aortic procedures in the multicenter international PAXA Registry. J Vasc Surg. 2022;75(3):868-876.e3. doi:10.1016/j.jvs.2021.08.089 ⭐ Key Reference Al Adas Z, Uceda D, Mazur A, et al. Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures. J Vasc Surg. 2024;79(3):487-496. doi:10.1016/j.jvs.2023.10.048 Koziarz A, Kennedy SA, Awad El-Karim G, et al. Vascular closure devices for axillary artery access: a systematic review and meta-analysis. J Endovasc Ther. 2024;31(5):763-771. doi:10.1177/15266028221147451 Southmayd G, Hoque A, Kaki A, Tayal R, Rab ST. Percutaneous large-bore axillary access is a safe alternative to surgical approach: a systematic review. Catheter Cardiovasc Interv. 2020;96(7):1481-1488. doi:10.1002/ccd.29273 Chung CJ, Kaneko T, Tayal R, Dahle TG, McCabe JM. Percutaneous versus surgical transaxillary access for transcatheter aortic valve replacement: a propensity-matched analysis of the US experience. EuroIntervention. 2022;17(18):1514-1522. doi:10.4244/EIJ-D-21-00549 Palmerini T, Saia F, Kim WK, et al. Vascular access in patients with peripheral arterial disease undergoing TAVR: the Hostile Registry. JACC Cardiovasc Interv. 2023;16(4):396-411. doi:10.1016/j.jcin.2022.12.009 Lederman RJ, Babaliaros VC, Lisko JC, et al. Transcaval versus transaxillary TAVR in contemporary practice: a propensity-weighted analysis. JACC Cardiovasc Interv. 2022;15(9):965-975. doi:10.1016/j.jcin.2022.03.014 Mach M, Okutucu S, Kerbel T, et al. Vascular complications in TAVR: incidence, clinical impact, and management. J Clin Med. 2021;10(21):5046. doi:10.3390/jcm10215046 Xenos ES, Freeman M, Stevens S, et al. Covered stents for injuries of subclavian and axillary arteries. J Vasc Surg. 2003;38(3):451-454. doi:10.1016/S0741-5214(03)00553-7 Schäfer U, Ho Y, Frerker C, et al. Direct percutaneous access technique for transaxillary transcatheter aortic valve implantation: “the Hamburg Sankt Georg approach.” JACC Cardiovasc Interv. 2012;5(5):477-486. doi:10.1016/j.jcin.2011.11.014 Bertoglio L, Mascia D, Cambiaghi T, et al. Percutaneous axillary artery access for fenestrated and branched thoracoabdominal endovascular repair. J Vasc Surg. 2018;68(1):34-40. doi:10.1016/j.jvs.2017.10.076 Gleason TG, Schindler JT, Hagberg RC, et al. Subclavian/axillary access for self-expanding transcatheter aortic valve replacement renders equivalent outcomes as transfemoral. Ann Thorac Surg. 2018;105(2):477-483. doi:10.1016/j.athoracsur.2017.07.017 Ali N, Cunnington MS, Muir D, et al. Transcatheter aortic valve implantation via percutaneous axillary access — a UK registry. Catheter Cardiovasc Interv. 2026;107(4):997-1004. doi:10.1002/ccd.70435 Ooms JF, Van Mieghem NM. Completely percutaneous transaxillary aortic valve implantation under local anesthesia: a minimalist alternative access approach. JACC Cardiovasc Interv. 2019;12(1):e1-e2. doi:10.1016/j.jcin.2018.10.041 Sequeira A, Abreo K. The structure and function of endovascular stents: a primer for the interventional nephrologist. Semin Dial. 2014;27(3):272-282. doi:10.1111/sdi.12225 Chopra A, Modrall JG, Knowles M, et al. Uncertain patency of covered stents placed for traumatic axillosubclavian artery injury. J Am Coll Surg. 2016;223(1):34-41. doi:10.1016/j.jamcollsurg.2016.03.023 DuBose JJ, Rajani R, Gilani R, et al. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury. 2012;43(11):1785-1792. doi:10.1016/j.injury.2012.08.028 Feldman DN, Armstrong EJ, Aronow HD, et al. SCAI consensus guidelines for device selection in femoral-popliteal arterial interventions. Catheter Cardiovasc Interv. 2018;92(1):E165-E174. doi:10.1002/ccd.27635
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  9. Proctor Playbook — Percutaneous Transaxillary Access and Closure: State-of-the-Art Technique with Dr. Rajiv Tayal 10.07.2026 15p

  CathMasters Drs. Amit Goyal, Li Pang, and Dr. Nazli Okumus, discuss state-of-the-art percutaneous axillary arterial access and closure with expert proctor Dr. Raj Tayal. Using a simulated case of Impella-supported high-risk PCI in a patient with severe bilateral iliofemoral PAD, the team walks through a step-by-step proctor playbook: pre-procedural CTA planning, laterality selection, room and arm setup, axillary artery anatomy, ultrasound-guided access technique, safety wire strategy, pre-closure with suture-mediated vascular closure devices, dry closure with balloon tamponade, and a bailout algorithm for failed hemostasis. This episode translates the 2022 SCAI Position Statement on Best Practices for Percutaneous Axillary Arterial Access into actionable, cath-lab-ready technique. Episode 8 reviews the evidence base for this technique in the “Data-to-Delivery” discussion and Episode 10 will tackle vascular complication management with transaxillary access in the “Crisis Control” discussion. CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls Target the second segment of the axillary artery (posterior to pectoralis minor) — it is extrathoracic, has no critical branches in its course, is compressible against the chest wall, and carries the lowest risk of brachial plexus injury because no cord passes anterior to it. Arm abduction to 90° lengthens the second segment, brings the artery more superficially, and allows the operator to remain parallel to the vessel — reducing the tendency to splay the artery and cause occult bleeding beneath the pectoralis muscle. The axillary artery has a thicker elastic lamina and a thinner muscular lamina than the femoral artery, making it more susceptible to “pull-through” injury with excessive VCD suture tension. Dr. Tayal recommends placing the Perclose sutures at 11-and-1 o’clock (or parallel with both at 12 o’clock) rather than the traditional 10-and-2 o’clock to reduce the risk of iatrogenic stenosis. Use an 0.018″ safety wire (not 0.014″) — it provides sufficient support to deliver a Viabahn-covered stent if needed, and during dry closure, a 0.035″ balloon can be advanced over it, allowing a completion angiogram through a Tuohy-Borst valve without removing the wire. Dry closure bailout algorithm: inflate → 5 min hold with external pressure → deflate and angiogram → repeat if needed → give protamine and repeat → if still bleeding, proceed to covered stent or hybrid closure (AngioSeal). Always have Viabahn stents in the room, not elsewhere! Notes 1. Pre-Procedural Planning: CTA Checklist and Screening CTA is the gold standard for pre-procedural planning. Key assessments include: minimum luminal diameter (generally≥6 mm), calcification burden and distribution, tortuosity, aneurysmal disease, and relationship to branches (vertebral artery, IMA, lateral thoracic, subscapular). Per the SCAI Position Statement, absolute contraindications include a prior covered stent or surgical repair that renders the artery unsuitable for percutaneous access. Relative contraindications include vessel calcification, stenosis, tortuosity, aneurysmal dilatation, or prior dissection. When CTA is unavailable (e.g., AKI, emergent cases), ultrasound assessment of the axillary artery, with or without angiography, via an ipsilateral radial or femoral approach using a JR4 or 3DRC catheter, is a reasonable alternative. The axillary artery is infrequently affected by atherosclerosis (~2%), with disease most commonly located at the subclavian ostium. Note: CT scans are typically performed with the arms above the head, which can make vessels appear more tortuous or foreshortened than they are when the arms are abducted to 90° during the procedure. 2. Laterality Selection: Left vs. Right Left axillary access is generally preferred for TAVR due to more favorable delivery angles to the aortic valve (especially in older patients with type II/III aortic arches), avoidance of the brachiocephalic artery, and preservation of the innominate artery for cerebral embolic protection if needed. Right axillary access offers a simpler room setup (no need to flip screens or add a prep table) and may be reasonable in younger patients (type I arch) or for specific TAVR valve alignments. Stroke risk with transaxillary access is consistently elevated (~6–8%) regardless of laterality, valve type, or surgical vs. percutaneous approach. The Hostile Registry reported right-sided stroke rates nearly double those of left-sided (6.3% vs. 3.7%), though this did not reach statistical significance. Left-sided access increases operator radiation exposure. A left-sided pacemaker is not an absolute contraindication, but it may physically limit access; a shallow needle angle often allows successful placement. A patent LIMA graft is a relative contraindication — the degree of obstruction depends on vessel diameter at the IMA bifurcation compared with the planned sheath’s outer diameter. 3. Room Setup and Arm Positioning Arm abduction to 90° in a radial arm board is recommended. This lengthens the second segment of the axillary artery, brings it more superficial/anterior, and allows the operator to stay parallel with the vessel. Keeping the arm at the patient’s side (as in femoral access) creates a tendency to pull devices downward, splaying the artery and causing occult bleeding beneath the pectoralis muscle, which tracks down, along the lateral rib cage and may not be readily evident. For left-sided access, move monitors to the head of the bed or foot of the patient (similar to pacemaker implant setup). For right-sided access, standard room configuration can be maintained. 4. Equipment Checklist Stiff micropuncture kit Ultrasound with linear probe and sterile cover Two Perclose devices (ProGlide or ProStyle) 0.018″ wire (steelcore preferred; avoid V-18 due to risk of branch perforation with its high tip load; Dr. Tayal recommends avoiding 0.014″ wires due to insufficient support for covered stent delivery although some operators may prefer this) Pre-designated dry closure balloon: 8–10 × 40 mm compliant balloon (shorter balloons  risk missing the arteriotomy) Viabahn covered stents should be in the room — know the required sizes and sheath compatibility 6F and 8F sheaths, JR4 or 3DR diagnostic catheter, stiff exchange-length 0.035″ wire for sheath insertion. 5. Sedation Conscious sedation is the preferred approach for experienced operators and is standard at high-volume centers (including European practice). General anesthesia may be considered for early-experience cases or when a proctor is teaching. Experienced operators (≥10 cases) can achieve large-bore sheath insertion and Impella deployment in 7–10 minutes, comparable to transfemoral access times. 6. Axillary Artery Anatomy — Target Zone The axillary artery is divided into three segments relative to the pectoralis minor muscle: 1st segment (medial to pec minor): branch — superior thoracic artery 2nd segment (posterior to pec minor): branches — thoracoacromial artery, lateral thoracic artery 3rd segment (lateral to pec minor): branches — subscapular artery, anterior and posterior circumflex humeral arteries The 2nd segment is the recommended target for percutaneous access per the SCAI Position Statement, due to its extrathoracic location, absence of critical branches in the access path, compressibility against the chest wall, and decreased risk of brachial plexus injury (no cord passes anterior to this segment). Angiographic landmarks for the access zone: puncture between the lateral thoracic artery (first branch going straight caudally off the axillary artery outside the rib cage) and the subscapular artery (identifiable by its proximity to the circumflex humeral arteries near the humeral head). Staying between these two branches places the operator in the 2nd segment in ~95% of cases. The axillary artery typically measures 6–7 mm in diameter (range 5–8 mm). 7. Safety Wire Strategy For the first 5–10 cases, femoral access is strongly recommended as the source for the safety wire. Advance a JR4 or 3DR catheter to engage the subclavian, take a baseline angiogram, then advance an 0.018″ wire through the axillary artery. The 0.018″ wire in the artery serves dual purposes: (1) facilitates ultrasound-guided access by distinguishing artery from vein (important in patients with significant TR, where the vein may appear pulsatile and larger than the artery), and (2) provides a rail for bailout balloon/stent delivery. Wire entrapment risk: the 0.018″ wire can become entrapped in Perclose sutures. To mitigate this, pull back the 0.018″ wire before deploying pre-closure devices, then re-advance it after pre-closure through an 8F sheath. Critical: wire the 0.018″ past the arteriotomy site before inserting the large-bore sheath and maintain this wire in place — attempting to wire beyond the sheath after insertion risks dissection. During the procedure, the 0.018″ wire can remain alongside the coronary guide catheter in the femoral sheath (e.g., 0.018″ wire + 7F guide through an 8F sheath). Some oozing will occur but is not clinically significant. 8. Ultrasound-Guided Puncture Technique Use ultrasound to identify the brachial plexus (appears as a “ball of grapes” proximally; cords separate as the probe moves laterally — no cord anterior to the 2nd segment). Mark the skin: (1) where the 0.018″ wire is in the artery, (2) planned skin entry point, and (3) planned arteriotomy site (marked with an “X”). There should be a larger gap between skin entry and arteriotomy than expected based on a shallow angle of approach. Angle of approach: shallower than femoral access (~45°), generally ~30° for percutaneous transaxillary acces. A steep angle is a common beginner error — it makes the needle tip visible on ultrasound but creates a suboptimal arteriotomy. If the needle tip is hard to visualize, inject lidocaine as you advance to identify the needle position in subcutaneous tissue. Stay within the deltopectoral groove — if the vessel is deeper than ~5 cm, the puncture is likely too low on the anterior chest wall. Roadmap angiography is a useful backup tool but not routinely necessary for experienced operators. 9. Pre-Closure and Large-Bore Sheath Insertion After micropuncture access, insert a 6F sheath → pull back the 0.018″ wire → deploy two Perclose devices → upsize to 8F sheath → re-advance 0.018″ wire → advance JR4 over a 0.035″ J-wire into the ascending aorta → exchange for a stiff wire → insert large-bore sheath. Tissue dissection: make a small nick, then use a Kelly/hemostat to bluntly dissect through the pectoralis muscle before advancing the Perclose. Watch the device go in during early cases — it can kink at the “elbow.” Perclose orientation in the axillary artery: place sutures at 11-and-1 o’clock or parallel at 12 o’clock rather than the traditional 10-and-2 o’clock used in the femoral artery. The axillary artery has more elastic lamina and less muscular lamina than the femoral, so aggressive suture tension at wide angles increases the risk of iatrogenic stenosis and “pull-through.” 10. Closure Device Selection Perclose (suture-mediated VCD) is the device recommended by the SCAI Position Statement — it permits rewiring and maintenance of access if the device fails. Both ProGlide and ProStyle are acceptable. Collagen-plug devices (AngioSeal, Mynx, MANTA) do not allow preservation of access if they fail. Hybrid closure (1 Perclose at 12 o’clock + 1 AngioSeal) is an advanced technique described by Dr. Tayal for experienced operators but is not recommended for early-experience cases given the greater risk of perclose failure with transaxillary access. VCD technical success in the axillary artery is ~85% overall, with a significant inverse relationship between sheath size and success (OR 0.87 per 1F increase). 11. Dry Closure Choreography and Bailout Algorithm From the femoral artery, advance a compliant balloon (8–10 × 40 mm, sized 1.0–1.1:1 to the artery) over the 0.035″ wire to a position proximal to the large-bore sheath tip, ideally distal to the vertebral artery. Step-by-step: Inflate balloon to 2–4 atm → achieve endovascular hemostasis Walk the large-bore sheath out over the 0.035″ wire Pull and cinch the non-locking Perclose sutures Deflate balloon, pull back, and perform completion angiogram (can use Tuohy-Borst through the 0.035″ balloon catheter with the 0.018″ wire still in place) Obtain a DSA in a slightly caudal angulation to evaluate the underside of the vessel Bailout algorithm for persistent extravasation: Advance balloon to the arteriotomy site → inflate 2–4 atm + external manual pressure × 5 minutes → deflate → angiogram If still bleeding: repeat balloon tamponade × 5 minutes If still bleeding: administer protamine → repeat balloon tamponade × 5 minutes If still bleeding: proceed to covered stent (Viabahn preferred for superior apposition and crush resistance) or hybrid closure with AngioSeal Per the SCAI Position Statement, in cases of bleeding/extravasation, the balloon can be inflated at the arteriotomy site at 4–6 atm for 15–20 minutes with simultaneous manual compression and anticoagulation reversal. Alternative Access for TAVR: A State-of-the-Art Review and Practical Guide. JACC Cardiovasc Interv. October 12, 2025.  Topography of the axillary artery. Topography and Anatomical Variations of the Axillary Artery. Biomed Res Int. August 18, 2020. References Seto AH, Estep JD, Tayal R, et al. SCAI position statement on best practices for percutaneous axillary arterial access and training. J Soc Cardiovasc Angiogr Interv. 2022;1(3):100041. doi:10.1016/j.jscai.2022.100041 ⭐ Key Reference Sherwood M, Allen KB, Dahle TG, et al. SCAI expert consensus statement on alternative access for transcatheter aortic valve replacement. J Soc Cardiovasc Angiogr Interv. 2025;4(3 Part A):102514. doi:10.1016/j.jscai.2024.102514 ⭐ Key Reference Feistritzer HJ, Dumpies O, Rosseel L, et al. Alternative access for TAVR: a state-of-the-art review and practical guide. JACC Cardiovasc Interv. 2025;18(19):2309-2325. doi:10.1016/j.jcin.2025.08.029 ⭐ Key Reference Koziarz A, Kennedy SA, Awad El-Karim G, et al. Vascular closure devices for axillary artery access: a systematic review and meta-analysis. J Endovasc Ther. 2024;31(5):763-771. doi:10.1177/15266028221147451 Al Adas Z, Uceda D, Mazur A, et al. Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures. J Vasc Surg. 2024;79(3):487-496. doi:10.1016/j.jvs.2023.10.048 Schäfer U, Ho Y, Frerker C, et al. Direct percutaneous access technique for transaxillary transcatheter aortic valve implantation: “the Hamburg Sankt Georg approach.” JACC Cardiovasc Interv. 2012;5(5):477-486. doi:10.1016/j.jcin.2011.11.014 Palmerini T, Saia F, Kim WK, et al. Vascular access in patients with peripheral arterial disease undergoing TAVR: the Hostile Registry. JACC Cardiovasc Interv. 2023;16(4):396-411. doi:10.1016/j.jcin.2022.12.009 Lederman RJ, Babaliaros VC, Lisko JC, et al. Transcaval versus transaxillary TAVR in contemporary practice: a propensity-weighted analysis. JACC Cardiovasc Interv. 2022;15(9):965-975. doi:10.1016/j.jcin.2022.03.014 Kirker E, Korngold E, Hodson RW, et al. Transcarotid versus subclavian/axillary access for transcatheter aortic valve replacement with SAPIEN 3. Ann Thorac Surg. 2020;110(6):1900-1906. doi:10.1016/j.athoracsur.2020.06.105 van Wiechen MP, Tchétché D, Ooms JF, et al. Suture- or plug-based large-bore arteriotomy closure: a pilot randomized controlled trial. JACC Cardiovasc Interv. 2021;14(2):149-157. doi:10.1016/j.jcin.2020.09.052 Damluji AA, Tehrani B, Sinha SS, et al. Position statement on vascular access safety for percutaneous devices in AMI complicated by cardiogenic shock. JACC Cardiovasc Interv. 2022;15(20):2003-2019. doi:10.1016/j.jcin.2022.08.040 Yang K, Lee H, Choi IJ, et al. Topography and anatomical variations of the axillary artery. Biomed Res Int. 2020;2020:4657876. doi:10.1155/2020/4657876 Harris E, Warner CJ, Hnath JC, Sternbach Y, Darling RC. Percutaneous axillary artery access for endovascular interventions. J Vasc Surg. 2018;68(2):466-471. doi:10.1016/j.jvs.2017.12.062 Southmayd G, Hoque A, Kaki A, Tayal R, Rab ST. Percutaneous large-bore axillary access is a safe alternative to surgical approach: a systematic review. Catheter Cardiovasc Interv. 2020;96(7):1481-1488. doi:10.1002/ccd.29273 Chung CJ, Kaneko T, Tayal R, Dahle TG, McCabe JM. Percutaneous versus surgical transaxillary access for transcatheter aortic valve replacement: a propensity-matched analysis of the US experience. EuroIntervention. 2022;17(18):1514-1522. doi:10.4244/EIJ-D-21-00549 Vegas A, Wells B, Braum P, et al. Guidelines for performing ultrasound-guided vascular cannulation: recommendations of the American Society of Echocardiography. J Am Soc Echocardiogr. 2025;38(2):57-91. doi:10.1016/j.echo.2024.12.004 Flumignan RL, Trevisani VF, Lopes RD, et al. Ultrasound guidance for arterial (other than femoral) catheterisation in adults. Cochrane Database Syst Rev. 2021;10:CD013585. doi:10.1002/14651858.CD013585.pub2 Ooms JF, Van Mieghem NM. Completely percutaneous transaxillary aortic valve implantation under local anesthesia: a minimalist alternative access approach. JACC Cardiovasc Interv. 2019;12(1):e1-e2. doi:10.1016/j.jcin.2018.10.041 Bertoglio L, Conradi L, Howard DPJ, et al. Percutaneous transaxillary access for endovascular aortic procedures in the multicenter international PAXA Registry. J Vasc Surg. 2022;75(3):868-876.e3. doi:10.1016/j.jvs.2021.08.089 Gleason TG, Schindler JT, Hagberg RC, et al. Subclavian/axillary access for self-expanding transcatheter aortic valve replacement renders equivalent outcomes as transfemoral. Ann Thorac Surg. 2018;105(2):477-483. doi:10.1016/j.athoracsur.2017.07.017 Ali N, Cunnington MS, Muir D, et al. Transcatheter aortic valve implantation via percutaneous axillary access — a UK registry. Catheter Cardiovasc Interv. 2026;107(4):997-1004. doi:10.1002/ccd.70435 Fanaroff AC, Manandhar P, Holmes DR, et al. Peripheral artery disease and transcatheter aortic valve replacement outcomes: a report from the STS/ACC TVT Registry. Circ Cardiovasc Interv. 2017;10(10):e005456. doi:10.1161/CIRCINTERVENTIONS.117.005456
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  8.  Data to Delivery: Percutaneous Transaxillary Arterial Access and Closure with Dr. Rajiv Tayal 06.07.2026 31p

  CathMasters hosts Dr. Amit Goyal, Dr. Li Pang, and Dr. Nazli Okumus discuss the evidence base for percutaneous transaxillary large-bore arterial access and closure with expert faculty Dr. Rajiv Tayal. Approximately 5% of US TAVR cases require alternative access despite lower-profile devices, and with expanding indications for TAVR and mechanical circulatory support (MCS), the absolute number of patients needing non-femoral large-bore access is rising. This “Data to Delivery” episode reviews the comparative outcomes of transaxillary access for TAVR and MCS, the stroke signal and laterality debate, vascular complications of percutaneous versus surgical approaches, brachial plexus injury risk, dwell-time considerations for axillary MCS, and the learning curve for this technique.  CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls The second segment of the axillary artery is the preferred access site because it is devoid of brachial plexus elements on its anterior surface, is accessible to surgical bailout, and is distant enough from the chest cavity to minimize pneumo/hemothorax risk — a transpectoral approach through pectoralis minor under ultrasound guidance targets this segment (SCAI Position Statement, Seto et al. 2022). “Bidirectional control is the fundamental principle of large-bore alternative access.” Maintain a bailout wire (from the ipsilateral radial or femoral artery) in addition to the wire through the large-bore sheath. This enables proximal balloon tamponade (“dry closure”) and rapid covered stent deployment if catastrophic bleeding occurs. Stroke is the Achilles’ heel of transaxillary TAVR — rates are consistently 6–8% across registries (TVT Registry, Hostile Registry, ACCESS study) and appear independent of valve type, laterality, surgical vs. percutaneous approach, or center experience. The 2025 SCAI Consensus Statement notes that other extrathoracic access techniques (transcarotid, transcaval) should be favored over transaxillary when stroke risk is a primary concern. More vascular complications ≠ more bleeding with percutaneous access. The TVT Registry propensity match showed percutaneous transaxillary access had double the major vascular complications vs. surgical cutdown (3.0% vs. 1.5%), but Southmayd’s systematic review found dramatically less major bleeding with percutaneous access (2.7% vs. 18%). This paradox is partly definitional: covered stent placement counts as a vascular complication in percutaneous series but conduit/graft use does not in surgical series. Axillary Impella enables early ambulation and device stability — the ARMS Registry (102 patients, 10 centers) demonstrated feasibility with complication rates comparable to transfemoral Impella. Devices have been maintained for >14 days percutaneously, though prolonged dwell times increase thrombus risk and may warrant higher ACT targets. After removing the peel-away sheath, the repositioning sheath downsizes to 9F at the tip — leaving the peel-away sheath in place risks a 5–6F gap that promotes thrombus formation and embolization. Notes 1. Why Transaxillary Access Matters Now Approximately 25% of TAVR patients have peripheral arterial disease (PAD), and the 2025 SCAI Expert Consensus Statement reports that 4.7% of US TAVR cases require alternative (non-femoral) access despite lower-profile delivery systems. With TAVR expanding into lower-risk populations and MCS use increasing (high-risk PCI, cardiogenic shock), the absolute demand for non-femoral large-bore access is growing. Transaxillary access is versatile: it can be performed percutaneously under conscious sedation without general anesthesia or OR activation, and can be deployed emergently (e.g., cardiogenic shock) or electively. The 2025 SCAI Consensus Statement notes that transaxillary access may carry a higher risk for neurologic complications and recommends that other extrathoracic techniques be favored when feasible. 2. Outcomes: Transaxillary vs. Transfemoral TAVR Propensity-matched studies show comparable 30-day and 1-year mortality between transaxillary and transfemoral TAVR (Gleason et al., CoreValve trial; Dahle et al., TVT Registry; Kindzelski et al., Cleveland Clinic series). Procedural success rates for transaxillary TAVR are high (91–100% across observational studies). The transaxillary approach has emerged as the most common alternative to transfemoral access, surpassing transapical and transaortic routes, which carry higher mortality and bleeding rates. 3. The Stroke Signal Stroke rates with transaxillary TAVR are consistently elevated at 6–8% across multiple registries: TVT Registry (Dahle et al.): 6.1% at 30 days with SAPIEN 3 CoreValve Extreme Risk Pivotal Trial: 7.5% Hostile Registry (Palmerini et al.): 5.9% for transalternative access (92% transaxillary) ACCESS Study: 8.0% overall (4.0% debilitating) The 2025 SCAI Consensus concludes that elevated stroke rates appear to be a “class effect” of transaxillary access, independent of valve selection, laterality, surgical vs. percutaneous approach, or center experience. Proposed mechanisms include: (a) sheath-to-artery ratio effects in a smaller vessel (~6.2 mm average diameter vs. ~8.5 mm for femoral); (b) atherosclerotic embolization during catheter exchanges; (c) right-sided access crossing the innominate artery with inline flow to the right carotid; (d) vertebral artery flow interruption by the large-bore sheath. Laterality: In the Hostile Registry, right transaxillary stroke was 6.3% vs. 3.7% left, but this difference was not statistically significant (HR 1.14; 95% CI 0.37–3.57; p = 0.82). The ACCESS study similarly found no significant difference by laterality. Left-sided access is generally preferred when feasible, as the sheath may create a partial “embolic shield” across the brachiocephalic artery. Compared with transcarotid and transcaval access, transaxillary access has consistently higher stroke rates in propensity-matched analyses. Lederman et al. reported a five-fold reduction in stroke/TIA with transcaval vs. transaxillary access (2.9% vs. 13.2%). 4. Vascular Complications: Percutaneous vs. Surgical Cutdown TVT Registry propensity match (Chung et al., 2022; n = 4,219): Percutaneous transaxillary access had higher major vascular complications (3.0% vs. 1.5%; p = 0.02) but similar life-threatening bleeding (0.3% vs. 0.1%; p = 0.31) compared with surgical cutdown. Percutaneous access was associated with less ICU utilization and more use of conscious sedation. Southmayd et al. systematic review (2020): Percutaneous large-bore axillary access had dramatically less major bleeding than surgical cutdown (2.7% vs. 18%). The apparent paradox (more vascular complications but less bleeding) is partly definitional: covered stent placement is classified as a vascular complication in percutaneous series, whereas conduit/graft use in surgical cutdown is not. Dry closure is the key hemostasis strategy: deploy Perclose devices, and if there is residual bleeding, inflate a balloon proximal to the arteriotomy for tamponade while deploying a covered stent (Viabahn preferred for superior apposition and crush resistance). Covered stent patency in non-diseased axillary arteries is excellent long-term. The axillary artery has a rich collateral network (subscapular contributories); vascular surgery data suggest that ligation of the artery in the appropriate segment does not cause significant upper extremity ischemia. 5. Other Complications: Brachial Plexus Injury, Pneumo/Hemothorax Brachial plexus injury was historically the most feared complication (rates as high as 15–20% in the 1970s–80s) when access was obtained in the third segment of the artery (armpit, arm abducted, palpation-guided). The neurovascular bundle is enclosed in a fascial sheath with the artery and vein in this segment, making hematoma-related nerve compression common. Modern transpectoral access to the second segment under ultrasound guidance has dramatically reduced this risk. The anterior surface of the second segment is devoid of brachial plexus elements. In the ARMS Registry, 3 of 102 patients (2.9%) had brachial plexus symptoms (all C8 tingling), all occurring after multiple days of support. The Cleveland Clinic series (Kindzelski et al.) reported zero brachial plexus injuries. Pneumo/hemothorax risk increases with access too proximal (first segment), which approaches the thoracic cavity. The second segment is preferred in part because it is more readily accessible for surgical bailout than the first segment. 6. Transaxillary Mechanical Circulatory Support (MCS) The ARMS Registry (McCabe, Kaki, Tayal et al., 2021): 102 patients across 10 US centers underwent percutaneous axillary Impella CP placement. Successful implantation in 98%. Median device dwell time was 2 days (range 0–35 days). Procedural complications included 10 bleeding events and 1 stroke. Covered stent use was 17%, decreasing with operator experience. Duration of support was independently associated with a 1.1% increased odds of vascular complication per day. Indications for axillary MCS over femoral include: prohibitive iliofemoral PAD, anticipated need for support >24–48 hours, desire for early patient ambulation, and cardiogenic shock patients who may need escalation of support. Dwell-time considerations: Devices have been maintained percutaneously for >14 days (up to 30+ days in some cases). Prolonged dwell increases thrombus risk around the access site; higher ACT targets than transfemoral are recommended. Brachial plexus symptoms may increase slightly with prolonged dwell, likely from local inflammation or nuanced bleeding. Device stability: Axillary Impella tends to be more stable with less need for repositioning compared with femoral. Fixation technique: Foley locks to cross-hatch the cable across the patient’s chest with the controller positioned near the umbilicus. Repositioning sheath: After removing the peel-away sheath (outer diameter ~17F for Impella CP), the repositioning sheath is 9F at the tip, increasing to 11–12F proximally. Leaving the peel-away sheath in place creates a 5–6F gap that promotes thrombus formation with risk of cerebral or distal embolization. Strategies to manage the downsized arteriotomy include: pulling down on the non-locking Perclose suture to snug the arteriotomy, circumferential injection of lidocaine with epinephrine to pucker the tissue, and figure-of-eight suture if needed. 7. Learning Curve and Training Al Adas et al. (2024): Prospective study of 146 patients undergoing percutaneous axillary access for complex endovascular aortic repair (FBEVAR). Covered stent rate was 6.9% overall, with a trend toward improvement (10% early cohort → 4% late cohort) and a significant negative correlation between cumulative complication rate and cumulative experience. Perclose device proficiency itself has a learning curve: data suggest ~45 cases for a vascular surgeon to achieve <5% failure rate; large-bore access increases this further. Across the US, even for large-bore femoral access without PAD, an average of 2.5 Perclose devices are used per case. SCAI recommends learning percutaneous axillary access through proctorship for at least the first 2–3 procedures, with operators prepared for bailout strategies. Training pathways include cadaveric courses for fellows transitioning to practice. No formal case-volume requirements have been established. The technique is transferable from basic femoral access skills and requires facility with ultrasound-guided access, micropuncture technique, and dry closure principles. 8. Axillary Artery Anatomy: Key Points The axillary artery is divided into three segments by the pectoralis minor muscle. Average diameter is approximately 6.2 mm (vs. ~8.5 mm for the femoral artery). Only 1–2% of patients have significant atherosclerotic disease in the axillary artery, even among those with severe iliofemoral PAD. First segment (medial to pectoralis minor): Larger, more superficial, but proximity to the thoracic cavity increases pneumo/hemothorax risk. Difficult for surgical bailout. Second segment (behind pectoralis minor): Preferred access site. Anterior surface is free of brachial plexus elements. Accessible for surgical repair. Compressible against the chest wall. Third segment (lateral to pectoralis minor): Smallest portion. Surrounded by brachial plexus cords and enclosed in a fascial sheath with the artery and vein. Historical access site associated with high rates of nerve injury. 9. Is Transaxillary Access a Niche Skill or an Expanding Platform? Currently somewhat niche, but applications are expanding beyond TAVR to include: high-risk PCI with Impella support, cardiogenic shock with prolonged MCS, complex peripheral interventions (aortoiliac CTOs), EVAR/FBEVAR, and potentially ECMO. The technique evolved from small-bore peripheral interventions (6–8F) for aortoiliac CTOs, then graduated to intra-aortic balloon pumps, Impella CP, and eventually large-bore TAVR sheaths. Operators comfortable with axillary access gain a versatile platform applicable across multiple clinical scenarios, analogous to how comfort with tibial or popliteal access expands the peripheral interventionalist’s toolkit. References ⭐ Seto AH, Estep JD, Tayal R, et al. SCAI position statement on best practices for percutaneous axillary arterial access and training. J Soc Cardiovasc Angiogr Interv. 2022;1(3):100041. doi:10.1016/j.jscai.2022.100041. Link ⭐ Sherwood M, Allen KB, Dahle TG, et al. SCAI expert consensus statement on alternative access for transcatheter aortic valve replacement. J Soc Cardiovasc Angiogr Interv. 2025;4(3 Part A):102514. doi:10.1016/j.jscai.2024.102514. Link ⭐ Feistritzer HJ, Dumpies O, Rosseel L, et al. Alternative access for TAVR: a state-of-the-art review and practical guide. JACC Cardiovasc Interv. 2025;18(19):2309-2325. doi:10.1016/j.jcin.2025.08.029. Link ⭐ Chung CJ, Kaneko T, Tayal R, Dahle TG, McCabe JM. Percutaneous versus surgical transaxillary access for transcatheter aortic valve replacement: a propensity-matched analysis of the US experience. EuroIntervention. 2022;17(18):1514-1522. doi:10.4244/EIJ-D-21-00549. Link ⭐ Southmayd G, Hoque A, Kaki A, Tayal R, Rab ST. Percutaneous large-bore axillary access is a safe alternative to surgical approach: a systematic review. Catheter Cardiovasc Interv. 2020;96(7):1481-1488. doi:10.1002/ccd.29273. Link ⭐ McCabe JM, Kaki AA, Pinto DS, et al. Percutaneous axillary access for placement of microaxial ventricular support devices: the Axillary Access Registry to Monitor Safety (ARMS). Circ Cardiovasc Interv. 2021;14(1):e009351. doi:10.1161/CIRCINTERVENTIONS.120.009351. Link ⭐ Palmerini T, Saia F, Kim WK, et al. Vascular access in patients with peripheral arterial disease undergoing TAVR: the Hostile Registry. JACC Cardiovasc Interv. 2023;16(4):396-411. doi:10.1016/j.jcin.2022.12.009. Link ⭐ Lederman RJ, Babaliaros VC, Lisko JC, et al. Transcaval versus transaxillary TAVR in contemporary practice: a propensity-weighted analysis. JACC Cardiovasc Interv. 2022;15(9):965-975. doi:10.1016/j.jcin.2022.03.014. Link Al Adas Z, Uceda D, Mazur A, et al. Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures. J Vasc Surg. 2024;79(3):487-496. doi:10.1016/j.jvs.2023.10.048. Link Gleason TG, Schindler JT, Hagberg RC, et al. Subclavian/axillary access for self-expanding transcatheter aortic valve replacement renders equivalent outcomes as transfemoral. Ann Thorac Surg. 2018;105(2):477-483. doi:10.1016/j.athoracsur.2017.07.017. Link ⭐ Dahle TG, Kaneko T, McCabe JM. Outcomes following subclavian and axillary artery access for transcatheter aortic valve replacement: Society of the Thoracic Surgeons/American College of Cardiology TVT Registry report. JACC Cardiovasc Interv. 2019;12(7):662-672. doi:10.1016/j.jcin.2019.01.227. Link Kindzelski B, Mick SL, Krishnaswamy A, et al. Evolution of alternative-access transcatheter aortic valve replacement. Ann Thorac Surg. 2021;112(6):1904-1911. doi:10.1016/j.athoracsur.2020.12.043. Link Ali N, Cunnington MS, Muir D, et al. Transcatheter aortic valve implantation via percutaneous axillary access — a UK registry. Catheter Cardiovasc Interv. 2026;107(4):997-1004. doi:10.1002/ccd.70435. Link Kaneko T, Hirji SA, Yazdchi F, et al. Association between peripheral versus central access for alternative access transcatheter aortic valve replacement and mortality and stroke. Circ Cardiovasc Interv. 2022;15(9):e011694. doi:10.1161/CIRCINTERVENTIONS.121.011694. Link Koziarz A, Kennedy SA, Awad El-Karim G, et al. Vascular closure devices for axillary artery access: a systematic review and meta-analysis. J Endovasc Ther. 2024;31(5):763-771. doi:10.1177/15266028221147451. Link Fanaroff AC, Manandhar P, Holmes DR, et al. Peripheral artery disease and transcatheter aortic valve replacement outcomes: a report from the STS/ACC Transcatheter Therapy Registry. Circ Cardiovasc Interv. 2017;10(10):e005456. doi:10.1161/CIRCINTERVENTIONS.117.005456. Link Kaki A, Blank N, Alraies MC, et al. Axillary artery access for mechanical circulatory support devices in patients with prohibitive peripheral arterial disease presenting with cardiogenic shock. Am J Cardiol. 2019;123(10):1715-1720. doi:10.1016/j.amjcard.2019.02.038. Link Kajy M, Laktineh A, Blank N, et al. Deploying mechanical circulatory support via the axillary artery in cardiogenic shock and high-risk percutaneous coronary intervention. Am J Cardiol. 2020;128:127-133. doi:10.1016/j.amjcard.2020.04.055. Link Ooms JF, Van Mieghem NM. Completely percutaneous transaxillary aortic valve implantation under local anesthesia: a minimalist alternative access approach. JACC Cardiovasc Interv. 2019;12(1):e1-e2. doi:10.1016/j.jcin.2018.10.041. Link Schäfer U, Ho Y, Frerker C, et al. Direct percutaneous access technique for transaxillary transcatheter aortic valve implantation: “the Hamburg Sankt Georg approach.” JACC Cardiovasc Interv. 2012;5(5):477-486. doi:10.1016/j.jcin.2011.11.014. Link Bertoglio L, Conradi L, Howard DPJ, et al. Percutaneous transaxillary access for endovascular aortic procedures in the multicenter international PAXA Registry. J Vasc Surg. 2022;75(3):868-876.e3. doi:10.1016/j.jvs.2021.08.089. Link Schultz J, Duval S, Shaffer A, et al. Axillary or subclavian Impella 5.0 support in cardiogenic shock: a systematic review and meta-analysis. ASAIO J. 2022;68(2):e29-e32. doi:10.1097/MAT.0000000000001637. Link Bansal A, Kalra A, Kumar A, et al. Outcomes of combined transcatheter aortic valve replacement and peripheral vascular intervention in the United States. JACC Cardiovasc Interv. 2021;14(23):2572-2580. doi:10.1016/j.jcin.2021.08.024. Link
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  7. ACS Guidelines Question #2 with Dr. Michelle O’Donoghue 03.07.2026 5p

  This episode is part of our comprehensive Decipher the Guidelines Series covering the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes.  The following question refers to Section 5.2.1 of the 2025 ACS Guidelines. The question is asked by Thomas Jefferson medical student and CardioNerds Academy Intern Dr. Grace Qiu, answered first by Henry Ford Interventional cardiology fellow and member of the CardioNerds Interventional Cardiology Council Dr. Li Pang, and then by expert faculty Dr. Michelle O’Donoghue. Dr. O’Donoghue is a cardiologist, senior investigator with the TIMI Study Group, and Associate Professor of Medicine at Harvard Medical School who holds the McGillycuddy-Logue Endowed Chair in Cardiology at Brigham and Women’s Hospital. She was the Vice Chair of the Writing Committee for the 2025 ACS Guidelines. Question Answer QuestionAnswer A 63-year-old woman presented to the emergency room for chest pain. She described having exertional chest pain for the past two months and had an episode of severe pain after dinner 3 days ago. She went to bed and slept it off.  She told her children today at a family gathering, and was immediately brought to the ED by her daughter. She has a history of hypertension and hyperlipidemia. She was asymptomatic and normotensive in the ED. Labs show a down-trending troponin and an elevated NT-proBNP but are otherwise unremarkable. Her ECG showed Q waves with ST elevation in V2-V4. She was treated with aspirin and heparin drip, and taken to the cath lab. Coronary angiogram showed complete proximal LAD occlusion with right-to-left collaterals, without significant residual disease elsewhere. She remains asymptomatic and is stable, both hemodynamically and electrically.What is the next best step with regard to reperfusion and anti-thrombotic management? A Proceed with primary PCI to LAD  B Medical management with aspirin and enoxaparin  C Medical management with aspirin and clopidogrel D Medical management with aspirin and ticagrelor Explanation The Correct answer is DIn patients who are stable with STEMI and have a totally occluded infarct-related artery >24 hours after symptom onset and are without evidence of ongoing ischemia, acute severe HF, or life-threatening arrhythmia, PPCI should not be performed due to lack of benefit. (Class 3, LOE B-R)The benefit of PPCI begins to diminish after >12 hours from symptom onset, but there appears to be continued benefit through approximately 24 hours. In stable asymptomatic patients with an occluded artery >48 hours after symptom onset, routine PCI has not been shown to be beneficial in the absence of ongoing ischemia. The relative utility of routine PCI for asymptomatic patients with STEMI between 24 and 48 hours from symptom onset is less rigorously tested.PCI is not recommended for an occluded infarct-related artery if the patient is asymptomatic and has a completed infarct. MACE outcomes were similar in those with an occluded infarct-related artery who underwent medical therapy versus those who underwent PCI 3 to 28 days after an MI (Occluded Artery Trial [OAT]), and results were no different at 7-year follow-up. Similar findings were noted in the DECOPI (Desobstruction Coronaire en Post-Infarctus) trial, which enrolled patients with an occluded artery and Q waves on the ECG presenting 2 to 15 days after symptom onset.However, coronary revascularization should be considered for patients with late presentations with continued signs and symptoms of ischemia, including cardiogenic shock, acute severe HF, persistent angina, and life-threatening arrhythmias.  Main Takeaway In patients who are stable with STEMI who have a totally occluded infarct-related artery >24 hours after symptom onset and are without evidence of ongoing ischemia, acute severe HF, or life-threatening arrhythmia, PPCI should not be performed due to lack of benefit. Guideline Loc. Section 5.2.1 
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  6. AngioClub: A Multimodality Approach to Recalcitrant In-Stent Restenosis 29.06.2026 41p

  CathMasters (Drs. Amit Goyal, Daniel Ambinder, Nazli Okumus, and Salman Allana) discuss a challenging case of recalcitrant focal in-stent restenosis (ISR) within two layers of stent in a right coronary artery. The panel walks through a systematic approach to ISR: guide selection and access strategy; the role of intracoronary imaging in classifying ISR using the Waksman mechanistic classification; and a stepwise lesion-modification algorithm using cutting balloons, excimer laser coronary atherectomy (ELCA), and intravascular lithotripsy (IVL). The discussion concludes with the contemporary role of drug-coated balloons (DCB) versus vascular brachytherapy (VBT), and when to consider rotational atherectomy (RA) for stent ablation in refractory cases. CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Media Coronary Angiography OCT – First Run OCT – Second Run Final Angiography Pearls Always image before you intervene. Intravascular imaging (OCT or IVUS) is essential for classifying ISR using the Waksman mechanistic classification (Type I: mechanical; Type II: biologic; Type III: mixed; Type IV: CTO; Type V: multilayer) because the mechanism dictates the treatment strategy. “Watermelon seeding” does not equal neointimal hyperplasia. While balloon slippage is classically associated with neointimal hyperplasia, it also occurs with calcified lesions that resist expansion. Do not assume the mechanism without imaging. ELCA with contrast is not the same as ELCA with saline. Contrast infusion amplifies the photomechanical effect by generating cavitating microbubbles producing shockwaves equivalent to ~100 atm, enabling ablation of calcified neoatherosclerosis — but at the cost of increased risk of no-reflow and dissection. Use saline for predominantly biologic (NIH) lesions; consider adding contrast when calcium is present. Recalcitrant ISR often requires multimodality lesion preparation. A single tool rarely suffices for Waksman Type III (mixed) ISR. In this case, cutting balloon addressed tissue disruption, ELCA ablated neointimal hyperplasia, and IVL cracked the calcified neoatherosclerosis — each targeting a different component of the disease. Know your shelf and know your off-ramp. Not every lab has every tool. If adequate lesion modification cannot be achieved, have a plan to refer to a center with additional capabilities (e.g., brachytherapy, rotational atherectomy for stent ablation) rather than leaving a suboptimal result. Notes How should ISR be classified, and why does it matter? The Waksman ISR Classification is an imaging-based mechanistic classification that guides treatment. It identifies 5 types: Type I — mechanical (IA: underexpansion; IB: stent fracture); Type II — biologic (IIA: neointimal hyperplasia; IIB: noncalcified neoatherosclerosis; IIC: calcified neoatherosclerosis); Type III — mixed mechanical and biologic; Type IV — chronic total occlusion; Type V — multilayer (>2 stent layers). OCT is preferred over IVUS for characterizing the neointimal tissue (NIH vs. neoatherosclerosis vs. calcium), though IVUS provides complementary information on stent expansion and persistent calcium. In this case, OCT revealed Waksman Type III ISR: a combination of neointimal hyperplasia and calcified neoatherosclerosis within two layers of stent that were reasonably well expanded — meaning both biologic and mechanical components required treatment. What is the stepwise approach to lesion modification in recalcitrant ISR? Steps will vary based on lesion characteristics, operator experience, and availability of cath lab devices. The following is specific to the case discussed in this podcast. Step 1 — Noncompliant (NC) balloon: Start with a small NC balloon (2.0–2.5 mm) to predilate and create a path for imaging catheters. This also provides initial diagnostic information about lesion compliance. Step 2 — Cutting/scoring balloon: If the NC balloon watermelon seeds or fails to expand, use a cutting balloon (e.g., Wolverine) or scoring balloon (e.g., AngioSculpt, ScoreFlex) to anchor and disrupt tissue. Sizing strategies vary by operator: One-to-one sizing at nominal to moderate pressures (12–14 atm) Undersizing by 0.5 mm and going to higher pressures (up to 18–20 atm) with slow inflation/deflation Step 3 — Atheroablative therapy (ELCA or RA): If persistent waist remains after cutting balloon + NC: ELCA is preferred for predominantly biologic (NIH) ISR. For the 1.4 mm catheter, max settings are 60 mJ/mm² fluence and 40 Hz repetition rate. Advance slowly at 0.5–1 mm/sec. Use saline flush for NIH; 50/50 contrast/saline for calcified neoatherosclerosis. RA is preferred for calcified neoatherosclerosis or underexpanded stents. Start with a 1.5-mm burr at 160,000–180,000 RPM for calcific disease (treat as de novo). For underexpanded stents, longer runs at 200,000–220,000 RPM may be needed — advance very slowly to avoid burr entrapment. Step 4 — Intravascular lithotripsy (IVL): Size 1:1 to the reference vessel. IVL is particularly effective for calcium behind stent struts, causing underexpansion. A meta-analysis of 354 patients showed an 88.7% strategy success rate for IVL in stent underexpansion. IVL may be less effective for calcified neoatherosclerosis (calcium within the stent lumen) compared to peri-stent calcium. Step 5 — High-pressure NC or OPN balloon: After calcium modification, follow with aggressive NC balloon postdilation. OPN (ultra-high-pressure) balloons are an option, but are bulky and may be difficult to deliver. What is the role of ELCA in ISR, and how does contrast flush change the game? ELCA produces monochromatic UV light (308 nm wavelength) that ablates tissue via three mechanisms: photochemical (direct molecular bond disruption), photothermal (heat generation), and photomechanical (acoustic shockwave from vapor bubble formation). Contrast flush amplifies the photomechanical effect by generating cavitating microbubbles that produce shockwaves equivalent to ~100 atm, enabling disruption of calcified tissue that saline-only ELCA cannot address. Available catheter sizes: 0.9, 1.4, 1.7, and 2.0 mm. For ISR, 1.4 mm is typically the starting size. The 0.9 mm catheter is reserved for very tight or balloon-uncrossable lesions. Catheter size should not exceed two-thirds of the vessel diameter. The ROLLER COASTR trial (171 patients) randomized patients with calcified coronary stenosis to RA, IVL, or ELCA. IVL was noninferior to RA for stent expansion, but ELCA narrowly failed to meet the noninferiority margin versus RA in the intention-to-treat analysis — suggesting that for heavily calcified de novo lesions, RA and IVL may be superior to ELCA. However, for ISR specifically, ELCA combined with DCB may offer advantages. The ELDISR trial (110 patients) randomized patients with ISR to ELCA + balloon angioplasty vs. balloon angioplasty alone and showed benefits with ELCA. Smaller studies have shown ELCA + DCB yields lower TLR than DCB alone (~10% vs. 20% at 1 year). DCB vs. brachytherapy — what is the contemporary approach to antiproliferative therapy in ISR? Drug-coated balloons (DCB): The AGENT IDE trial randomized ~600 patients with coronary ISR to paclitaxel-coated balloon (Agent DCB) vs. uncoated balloon. DCB significantly reduced 12-month target lesion failure (TLF), driven by lower ischemia-driven TLR and target-vessel MI. Notably, zero cases of stent thrombosis occurred in the DCB arm vs. 6 cases (3.2%) in the control arm. Approximately 60% of enrolled patients had single-layer ISR, so the applicability to multilayer ISR was initially uncertain. A subsequent subgroup analysis showed consistent DCB benefit in both single-layer and multilayer ISR, with particularly striking absolute risk reduction in the multilayer cohort (TLF ~24% vs. ~40%). Vascular brachytherapy (VBT): Remains a viable option, particularly for recurrent ISR after DCB failure. TLR rates with brachytherapy are approximately 29–30% at 2 years in single-center series. Logistical challenges include the need for a radiation source, radiation oncologist, and radiation physicist in the lab, making it an elective/scheduled procedure. Contemporary practice: DCB is increasingly used as first-line antiproliferative therapy for ISR, given ease of use and strong trial data. VBT is reserved as a backup for recurrent ISR after DCB failure. No high-quality randomized data directly compare DCB to VBT. The longest available DCB is 30 mm, so diffuse ISR lesions exceeding this length may favor VBT.  ELCA + DCB combination: Emerging data suggest that combining ELCA with DCB may be superior to DCB alone, particularly for debulking neointimal tissue before drug delivery. This combination is supported by the ELDISR trial and smaller observational studies. When and how to use rotational atherectomy for ISR and stent ablation RA ablates both neointimal tissue and metallic stent struts via differential cutting (preferentially ablating hard, inelastic material). For calcified neoatherosclerosis: treat similarly to de novo calcified disease. Start with a 1.5 mm burr at 160,000–180,000 RPM. For underexpanded/dog-boning stents refractory to other modalities, prolonged RA runs at 200,000–220,000 RPM may be required. Advance very slowly to minimize the risk of burr entrapment. May need to upsize to 1.75 or 2.0 mm burr. The ROSTER trial (200 patients, BMS-ISR) showed RA reduced TLR vs. balloon angioplasty at 12 months (32% vs. 45%). The ARTIST trial (298 patients) showed no benefit — likely because stent underexpansion was not excluded by IVUS, and RA is less effective for radial expansion of an underexpanded stent without calcium. After RA for stent ablation, consider DCB rather than adding a third stent layer. The threshold for implanting a third stent layer should be very high. Practical tips for guide selection and access in complex ISR Femoral access is preferred for complex RCA ISR in post-CABG patients to maximize guide support. A 7-French system is recommended to accommodate larger devices (ELCA, IVL, RA). AL 1.0 or AL 0.75 guides provide excellent support for the RCA. Longer sheaths (e.g., 45 cm) provide additional backup support. A GuideLiner may be needed for device delivery in long, fully stented segments. Wire choice is critical: use a supportive wire for device delivery, but be cautious about distal wire perforation in small, diseased branches. References ★ Klein LW, Nathan S, Maehara A, et al. SCAI Expert Consensus Statement on Management of In-Stent Restenosis and Stent Thrombosis. J Soc Cardiovasc Angiogr Interv. 2023;2(5):101048. https://doi.org/10.1016/j.jscai.2023.101048 ★ Giustino G, Colombo A, Camaj A, et al. Coronary In-Stent Restenosis: JACC State-of-the-Art Review. J Am Coll Cardiol. 2022;80(4):348-372. https://doi.org/10.1016/j.jacc.2022.05.017 ★ Yeh RW, Shlofmitz R, Moses J, et al. Paclitaxel-Coated Balloon vs Uncoated Balloon for Coronary In-Stent Restenosis: The AGENT IDE Randomized Clinical Trial. JAMA. 2024;331(13):1098-1107. https://doi.org/10.1001/jama.2024.3107 ★ Kirtane AJ, Shlofmitz R, Moses J, et al. Paclitaxel-Coated Balloon for the Treatment of Multilayer In-Stent Restenosis: AGENT IDE Subgroup Analysis. J Am Coll Cardiol. 2025;86(7). https://doi.org/10.1016/j.jacc.2025.05.xxx ★ Ng P, Maehara A, Kirtane AJ, et al. Management of Coronary Stent Underexpansion. J Am Coll Cardiol. 2025;85(7):713-731. https://doi.org/10.1016/j.jacc.2024.12.003 ★ Riley RF, Patel MP, Abbott JD, et al. SCAI Expert Consensus Statement on the Management of Calcified Coronary Lesions. J Soc Cardiovasc Angiogr Interv. 2024;3(2):101259. https://doi.org/10.1016/j.jscai.2023.101259 Jurado-Román A, Gómez-Menchero A, Rivero-Santana B, et al. Rotational Atherectomy, Lithotripsy, or Laser for Calcified Coronary Stenosis: The ROLLER COASTR-EPIC22 Trial. JACC Cardiovasc Interv. 2025;18(5):573-584. https://doi.org/10.1016/j.jcin.2024.12.025 He P, Chen H, Yang J, et al. Debulking With Excimer Laser Coronary Angioplasty Versus Balloon Angioplasty in Patients With In-Stent Restenosis (ELDISR Study): A Randomized Controlled Trial. Lasers Surg Med. 2025;57(4):e70007. https://doi.org/10.1002/lsm.70007 He P, Chen H, Yang J, et al. Excimer Laser Coronary Angioplasty Combined With Drug-Coated Balloon in the Treatment of In-Stent Restenosis. Lasers Surg Med. 2024;56(6):567-576. https://doi.org/10.1002/lsm.23797 Maqsood MH, Zhang RS, Rawal N, et al. Drug-Eluting Stent, Drug-Coated Balloon, or Plain Old Balloon Angioplasty for In-Stent Coronary Restenosis: Insights From a Mixed Treatment Comparison Meta-Analysis of Randomized Trials. Circ Cardiovasc Interv. 2025;18(11):e014671. https://doi.org/10.1161/CIRCINTERVENTIONS.124.014671 Siontis GC, Stefanini GG, Mavridis D, et al. Percutaneous Coronary Interventional Strategies for Treatment of In-Stent Restenosis: A Network Meta-Analysis. Lancet. 2015;386(9994):655-664. https://doi.org/10.1016/S0140-6736(15)60657-2 Caminiti R, Vetta G, Parlavecchio A, et al. A Systematic Review and Meta-Analysis Including 354 Patients From 13 Studies of Intravascular Lithotripsy for the Treatment of Underexpanded Coronary Stents. Am J Cardiol. 2023;205:291-298. https://doi.org/10.1016/j.amjcard.2023.07.148 Farhat H, Kuzemczak M, Durel N, et al. Rotational Atherectomy Versus Intravascular Lithotripsy for Calcified In-Stent Restenosis: A Single-Center Study With 1-Year Follow-Up. Am J Cardiol. 2023;205:83-89. https://doi.org/10.1016/j.amjcard.2023.07.155 Sharma SK, Kini A, Mehran R, et al. Randomized Trial of Rotational Atherectomy Versus Balloon Angioplasty for Diffuse In-Stent Restenosis (ROSTER). Am Heart J. 2004;147(1):16-22. https://doi.org/10.1016/j.ahj.2003.07.013 Alfonso F, Byrne RA, Rivero F, Kastrati A. Current Treatment of In-Stent Restenosis. J Am Coll Cardiol. 2014;63(24):2659-2673. https://doi.org/10.1016/j.jacc.2014.02.545 Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. J Am Coll Cardiol. 2022;79(2):e21-e129. https://doi.org/10.1016/j.jacc.2021.09.006 Tomey MI, Kini AS, Sharma SK. Current Status of Rotational Atherectomy. JACC Cardiovasc Interv. 2014;7(4):345-353. https://doi.org/10.1016/j.jcin.2013.12.196 Yasumura K, Koshy AN, Vengrenyuk Y, et al. Predictors of Suboptimal Lumen Expansion Following Intravascular Lithotripsy for Coronary In-Stent Restenosis. JACC Cardiovasc Interv. 2024;17(2):225-237. https://doi.org/10.1016/j.jcin.2023.10.048
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  5. ACS Guidelines Question #1 with Dr. Sunil Rao 25.06.2026 9p

  The following question refers to Section 7.1 of the 2025 ACS Guidelines. The question is asked by Thomas Jefferson medical student and CardioNerds Academy Intern Dr. Grace Qiu, answered first by University of Michigan fellow and CardioNerds FIT Ambassador Dr. Kayla Secrest, and then by expert faculty Dr. Sunil Rao. Dr. Rao is an interventional cardiologist, Professor of Medicine at NYU Grossman School of Medicine, Deputy Director of the Leon H. Charney Division of Cardiology, and the Director of Interventional Cardiology for the NYU Langone Health System. He is the Editor-in-Chief for Circulation Cardiovascular Interventions and was the Chair of the Writing Committee for the 2025 ACS Guidelines. This episode is part of our comprehensive Decipher the Guidelines Series covering the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes. Question #1 A 68-year-old man with a history of hypertension, hyperlipidemia, stage III chronic kidney disease, and prior tobacco use presents to a local emergency department with reports of chest pain while raking leaves at home. Upon arrival, he is hemodynamically stable with a heart rate of 86 beats per minute and a blood pressure of 133/85 mmHg. His EKG reveals ST elevations in the septal and anterior leads (V1-V4). He is given 324mg of aspirin and is promptly evaluated by the interventional cardiology team, who elects to take him emergently to the catheterization lab. Upon arrival to the catheterization lab, the nurse asks the interventional fellow which access sites they should prep for this case? How should the interventional fellow respond? A Right radial artery only B Radial + bilateral femoral C Bilateral femoral only Click to Reveal Answer Explanation The correct answer is B. Radial and bilateral femoralRadial artery access is the preferred vascular access site for coronary angiography and PCI in patients with ACS. Transradial access has been shown to reduce mortality, bleeding, and vascular complications compared with transfemoral access (Class I, LOE A). Radial access also allows earlier ambulation and is associated with greater patient comfort.Although the right radial artery is the most widely studied upper-extremity access site, alternative sites such as the ulnar and distal radial arteries have demonstrated similar outcomes.However, the radial artery may be required as a bypass conduit for CABG. In institutions where the radial artery is routinely used for surgical grafting, this potential future use should be considered when selecting vascular access.In addition, transfemoral access—preferably performed with ultrasound guidance—should be considered in patients in whom temporary mechanical circulatory support (MCS) is anticipated or in those for whom radial access is not feasible due to anatomical or technical constraints. Prepping bilateral groins in addition to the radial artery provides a backup strategy for urgent MCS placement or for transition to femoral access should radial access fail.For these reasons, prepping both the radial artery and bilateral groins is the most appropriate response.Radial-only preparation is incorrect because, although radial access is preferred, patients with STEMI may still require emergent MCS or alternative access if the radial artery is unsuitable. Preparing only the wrist without backup femoral access may delay care should hemodynamic instability occur.Femoral-only preparation is incorrect because transradial access provides superior outcomes in ACS, including significant reductions in all-cause mortality, major bleeding, and vascular complications. RCTs and meta-analyses, including MATRIX (which showed lower MACE and net adverse clinical events with radial access) and SAFARI-STEMI (which showed no difference in mortality but was underpowered)—support radial as first-line access when feasible. Main Takeaway For patients with ACS undergoing PCI, radial access is strongly preferred to reduce mortality, bleeding, and vascular complications. Guideline Loc. Section 7.1
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  4. Data to Delivery: CHIP-BCIS3 — Microaxial Flow Pump Support for High-Risk Complex PCI with Dr. Saraschandra Vallabhajosyula 21.06.2026 36p

  CathMasters host Dr. Li Pang, member of the CardioNerds Interventional Cardiology Council, and expert faculty Dr. Saraschandra Vallabhajosyula discuss the landmark CHIP-BCIS3 trial (Controlled Trial of High-Risk Coronary Intervention with Percutaneous Left Ventricular Unloading), published in the New England Journal of Medicine in 2026.  Using a representative case of an 84-year-old man with ischemic cardiomyopathy (LVEF 25%), NSTEMI, and severe multivessel calcified coronary artery disease requiring left main bifurcation PCI and calcium modification in a left-dominant coronary system, the episode walks through the background evidence gap, trial design, key results, limitations, and practical implications for interventional cardiologists managing complex high-risk indicated PCI (CHIP). The discussion contextualizes CHIP-BCIS3 within the broader landscape of mechanical circulatory support trials, including BCIS-1, PROTECT II, DanGer Shock, and the upcoming PROTECT IV. CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls CHIP-BCIS3 showed no benefit of elective microaxial flow pump (Impella CP) support over standard care PCI in patients with severely impaired LV function undergoing complex PCI (win ratio 0.85; 95% CI 0.63–1.15). A signal toward higher cardiovascular death was observed in the mAFP arm (26.7% vs 14.5%; HR 1.91; 95% CI 1.11–3.30), warranting caution. “The pump is not a bulletproof vest.” The presence of a mechanical circulatory support device should not create a false sense of security that leads operators to pursue more aggressive, single-session complete revascularization. Interventionalists have the privilege of staging procedures — and should use it when appropriate. Right heart catheterization before high-risk PCI provides useful information to fully characterize the hemodynamic substrate (cardiac output, filling pressures, pulmonary hypertension) and guide decision-making regarding MCS, rather than reflexively placing a device based on anatomy alone. Not all CHIP is created equal. The trial enrolled a heterogeneous population — left main bifurcation PCI, multivessel calcium modification, and retrograde CTO — each carrying different prognostic implications and procedural risk profiles. Retrograde CTO, performed primarily for symptom relief, may not carry the same prognostic weight as left main revascularization. Vascular access planning matters. CHIP-BCIS3 mandated pre-procedural vascular imaging (CT, ultrasound, or invasive angiography) before mAFP insertion, contributing to record-low vascular complication rates (16.9% mAFP vs 10.6% standard care, mostly minor). This rigorous protocol may underestimate real-world vascular complications but sets a standard for best practice. Notes 1. Background and Evidence Gap Complex PCI in patients with severely impaired LV function carries a high risk of hemodynamic collapse, periprocedural MI, and death. Percutaneous mechanical circulatory support (pMCS) has been increasingly used to mitigate these risks — a strategy termed “Protected PCI.” Prior to CHIP-BCIS3, no randomized trial had compared the elective use of a microaxial flow pump with PCI without planned MCS. The existing evidence base included: BCIS-1 (2010; long-term follow-up 2013): 301 patients with LVEF ≤30% and BCIS Jeopardy Score ≥8 randomized to elective IABP vs. no planned IABP during high-risk PCI. No difference in the primary composite of MACCE at 28 days (15.2% vs 16.0%). However, long-term follow-up at a median of 51 months showed a 34% relative reduction in all-cause mortality with elective IABP (HR 0.66; 95% CI 0.44–0.98). PROTECT II (2012): 452 patients randomized to Impella 2.5 vs. IABP during high-risk PCI. Stopped early for futility — no difference in 30-day MAE (35.1% vs 40.1%). Impella provided superior hemodynamic support. A trend toward lower 90-day MAE was observed in the per-protocol Impella arm. PROTECT III: A post-marketing registry (not a randomized trial) of 1,143 patients showing lower 90-day MACCE with Impella 2.5/CP compared to historical PROTECT II controls. The 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization gave a Class 2b (Level of Evidence B-R) recommendation: “In selected high-risk patients, elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reasonable.” Despite limited evidence, the FDA approved Impella for high-risk PCI in 2015 (severe LV dysfunction) and expanded the indication in 2018 (mildly reduced EF), leading to rapid adoption. 2. CHIP-BCIS3 Study Design and Methodology Design: Prospective, multicenter, open-label, randomized controlled trial Funder: UK National Institute for Health and Care Research (NIHR) — independent of device manufacturer Sites: 21 NHS hospitals in the United Kingdom Enrollment: August 2021 – December 2024; 300 patients randomized 1:1 Intervention: Elective Impella CP insertion prior to PCI (mAFP arm, n=148) vs. standard care PCI without planned MCS (n=152) Inclusion criteria (all three required): Severely impaired LV systolic function: LVEF <35%, or severe MR with LVEF <40% Large area of jeopardized myocardium: BCIS Jeopardy Score >8/12 Complex coronary intervention: (a) True left main bifurcation PCI with CTO of RCA or left-dominant system; (b) Multivessel calcium modification involving LM, final patent conduit, or SYNTAX ≥32; or (c) Retrograde CTO PCI Exclusion criteria: Cardiogenic shock or STEMI at randomization Primary outcome: Hierarchical composite analyzed by win ratio — death from any cause, disabling stroke, spontaneous MI, hospitalization for cardiovascular causes, and periprocedural myocardial injury (minimum 12-month follow-up) Key protocol features: Pre-procedural vascular imaging (CT, ultrasound, or invasive angiography) mandated before mAFP insertion Complete revascularization encouraged during the index procedure; staged PCI required pre-specification Bailout MCS (IABP or VA-ECMO) permitted in the standard-care arm 3. Baseline Characteristics Well-balanced between groups (slight excess of diabetes in mAFP arm) 83% male; median age 73 years; 85% Caucasian, 12% South Asian 76% presented with acute coronary syndrome 40% had significant angina (CCS III/IV) or heart failure symptoms (NYHA III/IV) Median LVEF: 27% (both groups) Median BCIS Jeopardy Score: 12/12 (maximum jeopardy) Median SYNTAX score: 38 (high complexity) 72% underwent left main PCI; 81% required atherectomy; 27% underwent retrograde CTO 4. Procedural Details mAFP insertion unsuccessful in 4 patients (3%) due to obstructive PAD Bailout MCS in standard-care arm: 9 patients (6.0%) — 8 IABP, 1 Impella CP Staged PCI: 6.8% in mAFP arm vs. 17.9% in standard-care arm (more single-session complete revascularization in the mAFP arm) Median procedure duration: 188 min (mAFP) vs. 139 min (standard care) Median lesions treated: 3 (mAFP) vs. 2 (standard care) Calcium modification: 71% in both arms; IVL was the primary modality (81% vs 66%), followed by rotational atherectomy (55% vs 59%) Intravascular imaging: 91% vs 93% (high utilization in both arms) Median mAFP support time: 134 min (device removed at end of PCI in most cases) 5. Key Results Primary outcome (win ratio): 0.85 (95% CI 0.63–1.15; P=0.30) — no significant difference between mAFP and standard care. 36.6% of pairwise comparisons favored mAFP; 43.0% favored standard care. All-cause death: 47 patients (32.6%, mAFP) vs. 33 patients (23.4%, standard care); HR 1.54 (95% CI 0.99–2.41) — numerically higher in the mAFP arm, borderline significance. Cardiovascular death (prespecified secondary outcome): 26.7% vs. 14.5%; HR 1.91 (95% CI 1.11–3.30) — significantly higher in the mAFP arm, with an absolute increase of 12.2 percentage points at 24 months. Periprocedural myocardial injury (per patient): 61.7% in the mAFP group compared to 50.0% with standard care (RR 1.23; 95% CI 0.99–1.54). While numerically higher in the pump cohort, this did not reach statistical significance. Note: While the primary manuscript reports per-patient data, the podcast discussion highlights “per procedure” results from Supplementary Table 10 (61% vs 44%; 95% CI 1.11–1.75), suggesting a more pronounced signal of injury per intervention. Vascular complications: 16.9% (mAFP) vs. 10.6% (standard care) — mostly minor; record-low rates attributed to mandated vascular imaging protocol. Procedural complications (VT/VF, CPR, pulmonary edema, prolonged hypotension): similar between groups. 6. Interpretation and Clinical Implications CHIP-BCIS3 challenges the prevailing assumption that elective Impella CP support during high-risk PCI improves outcomes. The trial found no benefit and a concerning signal toward increased cardiovascular death. Several factors may explain the findings: “Go all-in” behavior: The mAFP arm had longer procedures, more lesions treated, and less staged PCI — suggesting operators pursued more aggressive single-session revascularization when the pump was in place. This may have contributed to higher periprocedural myocardial injury. Periprocedural myocardial injury: The mAFP arm had significantly more myocardial injury per procedure, contrary to the hypothesis that the pump would ameliorate ischemia. Whether this contributed to the observed CV mortality difference remains unclear. Short support duration: Median support time of 134 minutes suggests the device was removed at the end of PCI in most cases, without extended post-procedural hemodynamic support — a practice that may not allow recovery from myocardial stunning. The trial does not mean MCS should never be used in high-risk PCI. Rather, it argues against routine, elective use and supports individualized decision-making based on hemodynamic assessment. Importantly, these results apply to elective/non-emergent high-risk PCI and cannot be extrapolated to cardiogenic shock, where the DanGer Shock trial demonstrated a mortality benefit with Impella CP in STEMI-related cardiogenic shock (HR 0.74; 95% CI 0.55–0.99). 7. Limitations Sample size: 300 patients — relatively small, though event rates exceeded pre-trial estimates, reducing the risk of type II error. Open-label design: Operators knew the treatment assignment, which may have influenced procedural behavior (more aggressive revascularization in the mAFP arm). Heterogeneous CHIP population: Retrograde CTO, left main bifurcation PCI, and multivessel calcium modification carry different risk profiles and prognostic implications — lumping them together may dilute or confound treatment effects. Vascular complication rates may be artificially low: The mandated pre-procedural vascular imaging protocol may not reflect real-world practice, potentially underestimating the downside of large-bore access. Short post-procedural support: Most devices were removed at the end of PCI. The trial did not evaluate extended hemodynamic support or standardized weaning protocols. UK-only enrollment: 85% Caucasian population; generalizability to other healthcare systems and demographics requires consideration. No hemodynamic substudy data yet: A prespecified hemodynamic substudy may provide mechanistic insight into the role of LV unloading and myocardial stunning. Diverging mortality curves: Death and adverse event curves appeared to diverge in favor of standard care over time, suggesting longer follow-up is unlikely to reverse the findings. 8. Case Application The case patient (84-year-old, LVEF 25%, NSTEMI, left-dominant system with distal LM 80%, severe multivessel calcified CAD) meets all CHIP-BCIS3 inclusion criteria. The team performed right heart catheterization first (CO 4.3 L/min, CI 2.4, RAP 10, PCWP 15) — confirming compensated hemodynamics. Given the complexity (DK CRUSH bifurcation stenting for LM, IVL in LAD and LCx, left-dominant system with entire coronary circulation dependent on the LM), the team elected to proceed with Impella CP support. Key decision points informed by CHIP-BCIS3: Staging was considered but not feasible for the LM bifurcation component RHC was performed to characterize hemodynamic reserve before committing to MCS Post-PCI hemodynamics were reassessed on Impella P2 support before removal Device was removed with pre-deployed Perclose sutures without complications 9. Future Directions PROTECT IV: Prospective, multicenter, randomized trial (n=1,252) comparing Impella CP supported PCI vs. PCI with or without IABP in patients with LVEF ≤40% and complex CAD deemed at excessive surgical risk. Primary endpoint: composite of all-cause death, stroke, MI, unplanned revascularization, durable LVAD/transplant, or CV hospitalization at 3 years. Results will provide the largest randomized dataset in this space. CHIP-BCIS3 hemodynamic substudy: Prespecified substudy evaluating detailed hemodynamic assessments before and during PCI — may clarify the mechanistic role of LV unloading and myocardial stunning. Intra-procedural hemodynamic monitoring: Future studies should evaluate real-time parameters such as loss of Impella pulsatility (indicating LV standstill during balloon inflation), which may guide procedural strategy (e.g., shorter balloon inflations, switching atherectomy modality). Post-procedural MCS management: Standardized weaning protocols and extended post-procedural support strategies need investigation — the optimal duration of hemodynamic support after high-risk PCI remains undefined. Patient selection refinement: Better tools to identify which CHIP patients may benefit from MCS (e.g., those with the most tenuous hemodynamics, single-vessel-dependent circulations) vs. those who can safely undergo PCI without support. References ⭐ Perera D, Ryan M, Ezad SM, et al. Left ventricular unloading in high-risk percutaneous coronary intervention. N Engl J Med. 2026;394(13):1271-1281. doi:10.1056/NEJMoa2415498. https://www.nejm.org/doi/full/10.1056/NEJMoa2415498 ⭐ Ryan M, Ezad SM, Webb I, et al. Percutaneous left ventricular unloading during high-risk coronary intervention: rationale and design of the CHIP-BCIS3 randomized controlled trial. Circ Cardiovasc Interv. 2024;17(3):e013367. doi:10.1161/CIRCINTERVENTIONS.123.013367. https://pubmed.ncbi.nlm.nih.gov/38410944 Perera D, Stables R, Thomas M, et al. Elective intra-aortic balloon counterpulsation during high-risk percutaneous coronary intervention: a randomized controlled trial (BCIS-1). JAMA. 2010;304(8):867-874. doi:10.1001/jama.2010.1190. ⭐ Perera D, Stables R, Clayton T, et al. Long-term mortality data from the Balloon Pump-Assisted Coronary Intervention Study (BCIS-1): a randomized, controlled trial of elective balloon counterpulsation during high-risk percutaneous coronary intervention. Circulation. 2013;127(2):207-212. doi:10.1161/CIRCULATIONAHA.112.132209. https://pubmed.ncbi.nlm.nih.gov/23224207 O’Neill WW, Kleiman NS, Moses J, et al. A prospective, randomized clinical trial of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: the PROTECT II study. Circulation. 2012;126(14):1717-1727. doi:10.1161/CIRCULATIONAHA.112.098194. ⭐ Møller JE, Engstrøm T, Jensen LO, et al. Microaxial flow pump or standard care in infarct-related cardiogenic shock. N Engl J Med. 2024;390(15):1382-1393. doi:10.1056/NEJMoa2312572. https://www.nejm.org/doi/full/10.1056/NEJMoa2312572 Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79(2):e21-e129. doi:10.1016/j.jacc.2021.09.006. Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care. J Am Coll Cardiol. 2015;65(19):e7-e26. doi:10.1016/j.jacc.2015.03.036. Pahuja M, Johnson A, Kabir R, et al. Randomized trials of percutaneous microaxial flow pump devices: JACC state-of-the-art review. J Am Coll Cardiol. 2022;80(21):2028-2049. doi:10.1016/j.jacc.2022.09.048. ⭐ Mangner N, Sharma SK, O’Connor C, et al. Mechanical circulatory support in high-risk elective PCI: rationale and design of the PROTECT IV trial. EuroIntervention. 2025;21(15):e1057-e1067. doi:10.4244/EIJ-D-24-00893. https://pubmed.ncbi.nlm.nih.gov/41024656 Protty M, Sharp ASP, Gallagher S, et al. Defining percutaneous coronary intervention complexity and risk: an analysis of the United Kingdom BCIS database 2006-2016. JACC Cardiovasc Interv. 2022;15(1):39-49. doi:10.1016/j.jcin.2021.09.039. Parikh PB, Bhatt DL, Bhasin V, et al. Impact of percutaneous coronary intervention on outcomes in patients with heart failure: JACC state-of-the-art review. J Am Coll Cardiol. 2021;77(19):2432-2447. doi:10.1016/j.jacc.2021.03.310.
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  3. Crisis Control: VA-ECMO – An Ischemic Leg! 16.06.2026 9p

  CathMasters Drs. Nazli Okumus and Daniel Ambinder, along with expert faculty Drs. Ann Gage and Marwan Jumean, tackle the management of limb ischemia — one of the most feared complications of peripheral VA-ECMO (veno-arterial extracorporeal membrane oxygenation) and large-bore mechanical circulatory support (MCS). Through the case of a 50-year-old woman with ischemic cardiomyopathy on VA-ECMO and Impella CP who develops right leg ischemia, the team walks through bedside assessment of the ischemic limb, equipment and technique for placing a distal perfusion catheter (DPC) on an existing ECMO circuit, strategies to mitigate limb ischemia with Impella, assessment of vascular patency during large-bore access removal, and the recognition and management of compartment syndrome. Audio editing for this episode was performed by CardioNerds Intern, Dr. Julia Marques Fernandes.  CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls Limb ischemia on VA-ECMO is a clinical diagnosis made at the bedside. Compare the cannulated leg to the non-cannulated leg: assess color (pallor, mottling), temperature, capillary refill, and Doppler signals (dorsalis pedis and posterior tibial). Near-infrared spectroscopy (NIRS) provides continuous, objective monitoring — an absolute rSO2 <40%, a >20% drop from baseline, or a>15–20% difference between legs should prompt urgent evaluation. The distal perfusion catheter (DPC) should be the standard of care for all patients on femoral VA-ECMO. Prophylactic DPC reduces limb ischemia by ~60% (OR 0.31–0.41). When placing a DPC on a patient already on ECMO, use ultrasound-guided antegrade access into the superficial femoral artery (SFA) — the stick is more challenging with a large arterial cannula already in place, so patience and meticulous ultrasound technique are critical. For Impella CP, the 14F peel-away introducer sheath can be removed (“peeled away”), leaving only the smaller 9F repositioning sheath around the catheter. This simple maneuver may be sufficient to restore distal limb perfusion without the need for a separate DPC. After removing any large-bore access (TAVR sheath, Impella, ECMO cannula), consider performing completion angiography — ideally via radial or contralateral femoral access — to confirm vessel patency and rule out dissection, thrombosis, or stenosis before leaving the lab. Compartment syndrome on ECMO is paradoxically most dangerous after reperfusion, not during ischemia. When a DPC is placed in an ischemic limb, reperfusion causes cellular edema within fascial compartments. If compartment pressures exceed 20 mmHg (or are within 30 mmHg of diastolic blood pressure), emergency fasciotomy is required. Elevated CPK and lactate are late and concerning findings — do not wait for them. Notes 1. Assessment of an Ischemic Limb Limb ischemia occurs in approximately 10–20% of patients on peripheral VA-ECMO, historically 16.9% with fasciotomy needed in 10.3% and amputation in 4.7%. Contemporary data from high-volume centers using prophylactic DPC, smaller arterial cannulas, and ultrasound-guided access report limb ischemia rates as low as 3.5%. The mechanism is multifactorial: the large arterial cannula (15–20F) partially or completely occludes the common femoral artery, reducing antegrade flow to the ipsilateral leg. Contributing factors include peripheral arterial disease (PAD), hemodynamic instability/low cardiac output, vasoconstriction from vasopressors, and thromboembolism. Bedside assessment (compare cannulated vs. non-cannulated leg): Inspection: Pallor, mottling, cyanosis, or dusky discoloration. Late findings include blistering and gangrene. Palpation: Temperature differential (cool vs. warm), capillary refill time (>3 seconds is concerning), and palpation of pedal pulses. Doppler assessment: Check dorsalis pedis (DP) and posterior tibial (PT) artery signals. Absent or monophasic signals on the cannulated side with normal signals contralaterally are highly concerning. Hourly Doppler checks should be standard nursing protocol. NIRS monitoring: Near-infrared spectroscopy placed on the calves of both legs provides continuous, real-time tissue oxygen saturation (rSO2). An absolute rSO2 <40%, a drop >20% from baseline, or a difference >15–20% between legs should trigger urgent evaluation. Studies demonstrate that NIRS-guided DPC placement reduces limb ischemia requiring surgical intervention from 8.5% to 2.6% and eliminates the need for fasciotomy in monitored cohorts. Laboratory markers: Elevated serum creatine phosphokinase (CPK) and lactate levels are late and very concerning findings, indicating that muscle necrosis has already begun. These should not be relied upon for early detection. Risk factors for limb ischemia: PAD (OR 2.19), female sex, smaller vessel caliber, larger arterial cannula size, diabetes, and prolonged ECMO duration. 2. Equipment for Adding a DPC to a Patient on ECMO Vascular ultrasound (linear probe) Micropuncture access kit (21G needle, 0.018″ wire, 4–5F micropuncture sheath) 0.035″ guidewire for exchange Antegrade sheath: 5–8F braided sheath (braided sheaths resist kinking in the antegrade orientation). A 6F or 7F sheath is most commonly used. Y-connector and arterial tubing to connect the DPC sheath side-arm to the arterial limb of the ECMO circuit Fluoroscopy (if available) to confirm wire position in the SFA and rule out inadvertent entry into the profunda femoris Sterile prep and drape for the ipsilateral groin/thigh Sheath size selection: The DPC sheath should be large enough to provide adequate flow but small enough to avoid further vascular compromise. A 6–7F sheath is standard. The donor vessel (ECMO arterial limb) should ideally be a larger French size than the recipient (DPC sheath) to promote flow via a high-to-low pressure gradient. 3. Procedure for Adding a DPC to a Patient Already on ECMO This is one of the more technically challenging sticks in interventional cardiology because the large arterial cannula already occupies the CFA, thereby limiting space and altering anatomy. Step 1 — Position and prep: The patient is supine. Sterile prep of the ipsilateral groin and thigh. Identify the SFA distal to the arterial cannula insertion site using ultrasound. Step 2 — Ultrasound-guided antegrade CFA-SFA access: Using a linear ultrasound probe, identify the SFA below the femoral bifurcation, distal to the ECMO arterial cannula. Perform an antegrade stick with a micropuncture needle. The key challenge is that the large cannula may compress or displace the SFA, and flow in the SFA may be diminished, making the vessel harder to visualize and access. Step 3 — Wire and sheath placement: Advance the micropuncture wire and confirm position with fluoroscopy, if available (ensure the wire is in the SFA, not the profunda femoris). Exchange for a 0.035″ wire and place a 6–7F braided sheath in the antegrade direction. Step 4 — Connect to circuit: Connect the side-arm of the DPC sheath to the arterial limb of the ECMO circuit using a Y-connector and arterial tubing. This diverts a portion of oxygenated, pressurized blood from the ECMO circuit into the distal leg. Step 5 — Confirm perfusion: Reassess distal pulses by Doppler, check NIRS values, and assess clinical improvement (color, temperature, capillary refill). Improvement should be seen within minutes. Alternative approaches if antegrade SFA access is not feasible: Retrograde posterior tibial artery access with a 5–6F sheath Contralateral femoral-to-ipsilateral SFA internal bypass (up-and-over technique): Retrograde access of the contralateral CFA with a 7F sheath, advance a 4–5F sheath up and over the aortic bifurcation into the ipsilateral SFA or profunda Surgical cutdown with side-arm graft sewn onto the femoral artery 4. Ischemia Avoidance with Impella Limb ischemia with Impella CP occurs in up to 12.5% of cases, primarily due to the occlusive 14F introducer sheath in the CFA. Peel-away sheath technique: The Impella CP is inserted through a 14F peel-away introducer sheath. Once the device is positioned and secured, the outer 14F sheath can be “peeled away” (split and removed), leaving only the 9F repositioning sheath around the Impella catheter. This reduces the effective sheath size from 14F to 9F, which may be sufficient to restore adequate distal perfusion. DPC configuration for Impella: If peeling away the sheath is insufficient, a DPC can be placed using the same antegrade SFA technique described above. The donor vessel options include: Ipsilateral CFA: External bypass from the large-bore sheath side-port to the DPC sheath side-port using a male-to-male connector and arterial tubing Contralateral femoral artery: External bypass to the antegrade ipsilateral SFA sheath Contralateral femoral internal bypass: Up-and-over technique General principles: Minimize arterial cannula/sheath size when possible, use ultrasound-guided access to ensure a clean CFA stick, and continuously monitor distal perfusion with NIRS and perform hourly Doppler checks. 5. Assessing Vascular Patency During/After Large-Bore Access Removal Vascular complications after large-bore access removal (TAVR, Impella, VA-ECMO decannulation) are common and include thrombosis, dissection, stenosis, pseudoaneurysm, and distal embolization. Strategies for assessment: Pre-removal baseline: Document pedal pulses (Doppler DP and PT signals) and NIRS values on the ipsilateral leg before decannulation. Know what the baseline was so post-removal changes can be detected. Completion angiography: After achieving hemostasis, perform angiography of the access vessel — ideally via radial access or contralateral femoral access. This confirms vessel patency, rules out dissection/thrombosis/stenosis, and identifies any residual thrombus. This is the single most important step. Post-closure Doppler assessment: Immediately after closure, reassess pedal pulses. Loss of previously present signals warrants urgent angiography and potential intervention. Protamine administration: After hemostasis is achieved, protamine can be used to reverse residual heparin effect and reduce oozing from the access site. Dry-field closure technique: Via radial or contralateral femoral access, a peripheral balloon sized 1:1 with the ipsilateral external iliac artery can be inflated at 2–4 atm to achieve temporary hemostasis during deployment of suture-based closure devices, providing a controlled, bloodless field. Post-procedure surveillance: Vascular duplex ultrasound within 24–48 hours to screen for pseudoaneurysm, AV fistula, or thrombosis may be considered. Late vascular complications occur in ~8% of survivors and may present weeks to months after discharge. 6. Compartment Syndrome and Fasciotomy Compartment syndrome is a surgical emergency that occurs when pressure within a closed fascial compartment rises to a level that compromises tissue perfusion, leading to muscle necrosis and potentially limb loss. Paradox of reperfusion: Compartment syndrome is rarely seen in profoundly ischemic limbs before reperfusion. It is most commonly triggered after reperfusion — when a DPC is placed in an ischemic limb, or when ECMO is initiated, and flow is restored. Reperfusion causes cellular edema, capillary leak, and swelling within the rigid fascial compartments of the lower leg. Incidence: ECMO-associated compartment syndrome occurs in approximately 2.5% of all ECMO patients (598/24,047 in a national database study). Lower extremity compartment syndrome accounts for 85% of cases. Mortality in patients who develop ECMO-associated compartment syndrome is 58–65%. Clinical findings: The limb becomes swollen and the skin taut. Pain out of proportion to exam (though often difficult to assess in sedated/intubated patients), pain with passive stretch of the compartment muscles, and a tense/woody feel to the compartment are classic findings. Diagnosis: Clinical suspicion is paramount — do not wait for laboratory confirmation. Compartment pressure measurement: A pressure >20 mmHg warrants fasciotomy per the JACC Expert Panel. The ACC/AHA PAD guideline uses a delta pressure threshold (compartment pressure within 30 mmHg of diastolic blood pressure) as an alternative criterion. Laboratory: Elevated CPK (often markedly elevated, >10,000 U/L) and rising lactate are late findings indicating muscle necrosis has already occurred. Myoglobinuria (dark urine) may be present. Management: Emergency four-compartment fasciotomy of the lower leg (anterior, lateral, superficial posterior, deep posterior) by a surgeon (vascular, orthopedic, or trauma surgery). Time to fasciotomy is critical — delays correlate with worse muscular findings and higher rates of amputation. Prophylactic fasciotomy should be considered at the time of reperfusion in patients with prolonged ischemia (>4–6 hours) or severe tissue ischemia (Rutherford IIa/IIb). Systemic consequences of reperfusion/rhabdomyolysis: Hyperkalemia, metabolic acidosis, acute kidney injury from myoglobin nephrotoxicity. Aggressive IV hydration and monitoring of electrolytes and renal function are essential. If the limb is unsalvageable (extensive necrosis, gangrene), amputation may be necessary. Historically, 4.7% of VA-ECMO patients required amputation; contemporary rates at high-volume centers are <1%. References ★ Guglin M, Zucker MJ, Bazan VM, et al. Venoarterial ECMO for adults: JACC Scientific Expert Panel. J Am Coll Cardiol. 2019;73(6):698-716. doi:10.1016/j.jacc.2018.11.038 ★ Damluji AA, Tehrani B, Sinha SS, et al. Position statement on vascular access safety for percutaneous devices in AMI complicated by cardiogenic shock. JACC Cardiovasc Interv. 2022;15(20):2049-2071. doi:10.1016/j.jcin.2022.08.040 ★ Bonicolini E, Martucci G, Simons J, et al. Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment. Crit Care. 2019;23(1):266. doi:10.1186/s13054-019-2541-3 ★ Marbach JA, Faugno AJ, Pacifici S, et al. Strategies to reduce limb ischemia in peripheral venoarterial extracorporeal membrane oxygenation: a systematic review and meta-analysis. Int J Cardiol. 2022;361:77-84. doi:10.1016/j.ijcard.2022.04.084 ★ Lamb KM, DiMuzio PJ, Johnson A, et al. Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation. J Vasc Surg. 2017;65(4):1074-1079. doi:10.1016/j.jvs.2016.10.071 ★ Vinogradsky A, Kurlansky P, Ning Y, et al. Continuous near-infrared reflectance spectroscopy monitoring to guide distal perfusion can minimize limb ischemia surgery for patients requiring femoral venoarterial extracorporeal life support. J Vasc Surg. 2023;77(5):1456-1465. doi:10.1016/j.jvs.2022.12.028 Sohn B, Lee H. Near-infrared spectroscopy for preventing limb ischemia in extracorporeal membrane oxygenation. Artif Organs. 2025. doi:10.1111/aor.14978 Kim DJ, Cho YJ, Park SH, et al. Near-infrared spectroscopy monitoring for early detection of limb ischemia in patients on veno-arterial extracorporeal membrane oxygenation. ASAIO J. 2017;63(5):613-617. doi:10.1097/MAT.0000000000000532 Matthews R, Surti A, Bahroloomi D, et al. Contemporary practices and limb outcomes in peripheral venoarterial extracorporeal membrane oxygenation at a high-volume single institution. J Vasc Surg. 2026;83(4):1234-1242. doi:10.1016/j.jvs.2025.10.015 Son AY, Khanh LN, Joung HS, et al. Limb ischemia and bleeding in patients requiring venoarterial extracorporeal membrane oxygenation. J Vasc Surg. 2021;73(2):669-676. doi:10.1016/j.jvs.2020.05.073 Chanan EL, Bingham N, Smith DE, Nunnally ME. Early detection, prevention, and management of acute limb ischemia in adults supported with venoarterial extracorporeal membrane oxygenation. J Cardiothorac Vasc Anesth. 2020;34(11):3125-3132. doi:10.1053/j.jvca.2020.03.005 ★ Seto AH, Estep JD, Tayal R, et al. SCAI position statement on best practices for percutaneous axillary arterial access and training. J Soc Cardiovasc Angiogr Interv. 2022;1(4):100365. doi:10.1016/j.jscai.2022.100365 Davis HD, Habarth-Morales TE, Messa CA, Broach RB, Lin IC. Extracorporeal membrane oxygenation-associated compartment syndrome: review of a national database. J Surg Res. 2024;298:61-68. doi:10.1016/j.jss.2024.03.024 ★ Writing Committee Members, Gornik HL, Aronow HD, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease. J Am Coll Cardiol. 2024;83(24):2497-2604. doi:10.1016/j.jacc.2024.02.013 Juo YY, Skancke M, Sanaiha Y, et al. Efficacy of distal perfusion cannulae in preventing limb ischemia during extracorporeal membrane oxygenation: a systematic review and meta-analysis. Artif Organs. 2017;41(11):E263-E273. doi:10.1111/aor.12942 Balthazar T, Vandenbriele C, Verbrugge FH, et al. Managing patients with short-term mechanical circulatory support: JACC review topic of the week. J Am Coll Cardiol. 2021;77(9):1243-1256. doi:10.1016/j.jacc.2020.12.054 Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America guideline on acute mechanical circulatory support. J Card Fail. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003 Lorusso R, Whitman G, Milojevic M, et al. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg. 2021;161(4):1287-1331. doi:10.1016/j.jtcvs.2020.09.045 Wong JK, Smith TN, Pitcher HT, Hirose H, Cavarocchi NC. Cerebral and lower limb near-infrared spectroscopy in adults on extracorporeal membrane oxygenation. Artif Organs. 2012;36(8):659-667. doi:10.1111/j.1525-1594.2012.01496.x Cuculi F, Burkart P, Cioffi G, et al. Manual compression versus MANTA device for access management after Impella removal on the ICU. Sci Rep. 2022;12(1):14044. doi:10.1038/s41598-022-18316-z
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  2. Proctor’s Playbook: VA-ECMO 09.06.2026 9p

  CathMasters Drs. Nazli Okumus and Daniel Ambinder, along with expert faculty Drs. Ann Gage and Marwan Jumean, walk through the step-by-step procedural approach to VA-ECMO (veno-arterial extracorporeal membrane oxygenation) cannulation. Building on the Data to Delivery episode, this Proctor Playbook episode covers pre-procedural planning, cannula selection, team composition and equipment, the role of the distal perfusion cannula (DPC), decision-making on mechanical left ventricular (LV) unloading, anticoagulation dosing and timing, the cannulation procedure itself, and vascular closure strategies during decannulation. The hypothetical case continues with the 36-year-old man with fulminant myocarditis, biventricular failure, and cardiogenic shock. Audio editing for this episode was performed by CardioNerds Intern, Dr. Julia Marques Fernandes.  CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls “Cannulation for VA-ECMO is a team sport.” Success begins with pre-procedural planning: review the patient’s history, prior vascular imaging, echocardiography, invasive hemodynamics, labs, and EKG to phenotype the shock (left, right, or biventricular) and select the appropriate support configuration and cannula sizes. The distal perfusion cannula (DPC) should be the standard of care. Meta-analyses demonstrate that prophylactic DPC placement reduces limb ischemia by ~60% (OR 0.31–0.41). A practical tip from Dr. Gage: perform the antegrade SFA stick for the DPC simultaneously with the retrograde CFA stick before upsizing — this avoids the difficulty of obtaining antegrade access after a large arterial cannula is already in place. Heparin dosing at cannulation: administer an initial bolus of 50–100 U/kg of unfractionated heparin (UFH) after access but before dilation. For a 70 kg patient, this is approximately 5,000 units. Maintain anticoagulation with a UFH infusion targeting ACT 180–220 seconds, aPTT 1.5–2.5× baseline, or anti-Xa 0.3–0.7 IU/mL. Consider upsizing the dilator 1–2 French above the intended cannula size (e.g., dilate to 27F for a 25F venous cannula) to facilitate smooth cannula insertion. Dr. Jumean’s pro tip: after removing the dilator, check wire movement before advancing the cannula — a kinked wire during dilation is a preventable but dangerous complication. Percutaneous decannulation is an evolving and viable alternative to surgical cutdown. Pre-closing at the time of cannulation (two Perclose ProGlide devices per site) enables percutaneous explantation with technical success rates of 91–95% and lower groin infection rates compared with surgical cutdown. Notes Pre-Procedural Planning VA-ECMO cannulation requires significant pre-planning and coordination, even when time is limited. The operator should review all primary data with the team before proceeding. Key data to review: Echocardiography: Biventricular function, valvular disease (especially aortic insufficiency and mitral regurgitation), wall motion abnormalities, and chamber sizes. Echo also helps refine the differential diagnosis (e.g., regional wall motion abnormalities suggest CAD; flail mitral leaflet suggests delayed MI complication). Invasive hemodynamics (PA catheter): Phenotype the shock as left-dominant, right-dominant, or biventricular. This determines the support configuration (VA-ECMO alone vs. VA-ECMO + LV unloading vs. VAV-ECMO for additional oxygenation). Prior vascular imaging: Review prior angiograms or CT scans of the femoral/iliac vessels to assess vessel size, tortuosity, calcification, and PAD. This informs cannula sizing and access strategy. EKG and labs: Confirm diagnosis, assess for arrhythmias, and evaluate organ function (renal, hepatic, coagulation). Dr. Gage’s program uses a formal ECMO timeout before cannulation — a checklist that reviews indications, contraindications, equipment, and team roles. Equipment and Team Team composition: Cannulating operator (interventional cardiologist, cardiac surgeon, or critical care physician), assistant (fellow or second operator), perfusionist (to prime and manage the circuit), ICU or cath lab nurse, and a cardiac surgeon aware and available as backup. The equipment cart should include: Vascular access kit with micropuncture needles and sheaths A stiff guidewire  Sequential dilators Venous cannula: 23–25F multi-stage (most common); 21F may be used in smaller patients. Flow through the circuit is primarily determined by the venous drainage cannula size. Arterial cannula: 15–20F single-stage, selected based on patient body size and vessel diameter. There is a trend toward smaller arterial cannulas (15–17F) to minimize bleeding and ischemic complications and facilitate percutaneous removal. The vessel should ideally be 1–2 mm larger than the cannula to reduce limb ischemia risk. Distal perfusion cannula: 5–8F antegrade sheath for the SFA or retrograde via the posterior tibial artery Surgical cutdown kit (backup) Ultrasound for vascular access guidance Pre-close devices (Perclose ProGlide) if percutaneous decannulation is planned ECMO cannulations may occur in the cath lab, ICU, emergency department, or in the field. Having a mobile ECMO cart with all equipment pre-assembled allows rapid deployment to any location. Distal Perfusion Cannula (DPC) The DPC should be considered standard of care for all patients receiving femoral VA-ECMO. Limb ischemia historically occurred in ~17% of peripheral VA-ECMO patients, with 10% requiring fasciotomy and ~5% requiring amputation. A meta-analysis by Juo et al. (2017) demonstrated that prophylactic DPC placement reduced the incidence of limb ischemia from 25.4% to 9.7% (RR, 0.41; 95% CI, 0.26–0.65). A subsequent meta-analysis by Marbach et al. (2022) confirmed this finding (OR 0.31; 95% CI 0.21–0.47; p<0.001). A multicenter registry study (Lee et al., 2023) further showed that prophylactic DPC was associated with lower 30-day mortality (33.1% vs. 53.2%; RR 0.68). Technique: A 6–8F antegrade sheath is placed in the ipsilateral SFA and connected to the arterial limb of the ECMO circuit via a Y-connector (using a male-to-male connection), diverting a portion of oxygenated blood to the distal limb. Dr. Gage’s tip: Perform the antegrade SFA stick at the same time as the retrograde CFA stick, before any cannulas are placed. Using ultrasound, obtain retrograde CFA access with the right hand, leave the micropuncture wire, then quickly scan distally to the SFA and obtain antegrade access with the left hand. Place 6F sheaths over both wires. This provides the best ultrasound view (no large cannula obstructing), preserves SFA flow for the antegrade stick. Exception: do not do this during active ECPR — proceed directly to cannulation and obtain the DPC later once the patient is stabilized. Monitoring: Hourly Doppler checks of distal pulses, near-infrared spectroscopy (NIRS) of the cannulated vs. non-cannulated leg, and clinical assessment (pallor, temperature, capillary refill). Elevated CPK or lactate are late and concerning findings. Decision-Making on Mechanical LV Unloading VA-ECMO increases LV afterload via retrograde aortic flow. The decision to add an unloading device depends on the underlying etiology, expected recovery timeframe, and real-time hemodynamic assessment. Key assessment parameters: Arterial pulsatility: A pulse pressure ≥20 mmHg suggests some native cardiac output and aortic valve opening. If pulsatility is absent or minimal, LV distension and stasis are more likely. Echocardiographic assessment: Aortic valve opening with each cardiac cycle, LV cavity size, presence of spontaneous echo contrast or thrombus, and degree of mitral regurgitation. In practice, most patients do not meet the 20 mmHg pulse pressure threshold immediately after cannulation, so many operators deploy an upfront unloading strategy (IABP or Impella) when the patient is already in the cath lab — avoiding the need for repeated transport on ECMO. The goal of ECMO support also matters: if the goal is LV recovery (e.g., myocarditis), aggressive unloading to rest the myocardium may be more important than if the goal is bridge to transplant or durable VAD. Unloading options: IABP (reduces afterload, improves coronary perfusion), Impella (directly unloads LV), transseptal LA cannulation, or atrial septostomy. Anticoagulation Unfractionated heparin (UFH) is the standard anticoagulant for VA-ECMO. The ELSO guidelines (2017) and ISHLT/HFSA guideline (2023) recommend an initial bolus of 50–100 U/kg at the time of cannulation. Timing: Administer heparin after vascular access is obtained but before dilation and cannula insertion. In the episode, Dr. Gage’s protocol uses 70 U/kg (e.g., 70 kg × 70 U/kg = ~5,000 U). Maintenance anticoagulation targets (significant institutional variability exists): ACT: 180–220 seconds (ELSO recommendation) aPTT: 1.5–2.5× baseline (approximately 50–75 seconds) Anti-Xa: 0.3–0.7 IU/mL Alternatives for heparin-induced thrombocytopenia (HIT): Bivalirudin or argatroban, monitored by aPTT 50–60 seconds. The balance between thrombotic and hemorrhagic complications is critical. The ECMO circuit’s nonendothelial surface triggers an inflammatory and prothrombotic response with consumptive coagulopathy, while simultaneously causing platelet dysfunction and von Willebrand factor proteolysis, creating a pro-hemorrhagic phenotype. Cannulation Procedure: Step-by-Step Step 1 — Access: Using ultrasound guidance, obtain femoral arterial and venous access with micropuncture needles. Ultrasound-guided access is strongly preferred to reduce vascular complications, though in emergencies (ECPR) it may not always be feasible. Step 2 — Wire exchange: Exchange the micropuncture wire for a supportive guidewire through the micropuncture sheath (after obtaining a femoral angiogram if in the cath lab). Step 3 — Antegrade DPC access (if time permits): Before upsizing, obtain antegrade SFA access for the distal perfusion catheter (see DPC section above for Dr. Gage’s simultaneous access technique). Place a 6–7F sheath. Step 4 — Heparin administration: Give weight-based UFH bolus (50–100 U/kg) after access, before dilation. Step 5 — Pre-close (if percutaneous decannulation planned): Deploy two Perclose ProGlide devices at each cannulation site before upsizing. Step 6 — Serial dilation: Dilate the tract sequentially. Consider upsizing the dilator by 1–2F above the intended venous cannula size (e.g., a 27F dilator for a 25F venous cannula) to facilitate smooth insertion. Dr. Jumean’s pro-tip: after removing each dilator, briefly advance and withdraw the wire to confirm it is not kinked or stuck. Step 7 — Cannula insertion: Place the venous drainage cannula (23–25F multi-stage) with the tip at the SVC-RA junction. Place the arterial return cannula (15–20F single-stage) with the tip in the descending aorta or common iliac artery. Step 8 — Clamp and connect: Clamp both cannulas. Perform a wet connection (to avoid air entrainment) to the ECMO circuit tubing. The perfusionist initiates flow. Step 9 — Confirm positioning: Verify cannula tip positions with fluoroscopy and/or echocardiography. Assess for adequate flows, hemodynamic improvement, and distal limb perfusion. Step 10 — Connect DPC: Connect the antegrade perfusion sheath to the arterial limb of the circuit via a Y-connector with a male-to-male connection. Decannulation and Vascular Closure Decannulation strategy is program-dependent and evolving. Two main approaches exist: Surgical cutdown: Traditional approach. The femoral vessels are exposed, cannulas removed, and vessels repaired under direct vision. Advantages: direct visualization, ability to perform Fogarty thrombectomy (significant thrombus burden is common). Disadvantages: longer procedure time, higher groin infection rates (up to 19% vs. 2% with percutaneous), requires OR availability. Percutaneous decannulation: Increasingly adopted by interventional cardiologists. Two strategies: Pre-close technique: At the time of cannulation, two Perclose ProGlide devices are deployed at each site before upsizing. At decannulation, cannulas are removed and the pre-deployed sutures are tightened. Technical success rates of 91–95% have been reported, with lower groin infection rates and shorter procedure times compared with surgical cutdown. Post-close technique (no pre-close): Clamp both cannulas. Puncture the soft plastic portion of the cannula with a large-bore (16–18G) needle, wire through it with a stiff wire, remove the cannula over the wire. Options include: (a) deploy two Perclose devices sequentially; or (b) use a “two 8F sheath” technique — place an 8F sheath, insert two wires, remove the sheath, place an 8F sheath over each wire, and pre-close each separately. Key considerations for percutaneous decannulation: Document baseline pedal pulses before decannulation. Perform angiography before and after closure to confirm vessel patency and rule for stenosis/occlusion. Have a surgeon aware and available as backup. Maintain contralateral femoral access capability in case bailout intervention is needed. Failure risk is higher in patients with BMI ≥35 or cannulas inserted through the inguinal ligament or at the SFA bifurcation. Hybrid approach: Many patients transition from VA-ECMO to a durable device (e.g., Impella 5.5) in the OR, where surgeons perform decannulation and implantation of the new device simultaneously. In this scenario, an interventional cardiologist may assist by percutaneously closing the DPC site. Post-decannulation surveillance: Vascular complications after VA-ECMO are common — CT studies show up to 81% of patients have some vascular finding (thrombosis, stenosis, or bleeding) after decannulation. Routine vascular screening with duplex ultrasound or CT angiography is recommended. Late vascular complications (infection, limb-threatening ischemia) occur in ~8% of survivors and may present weeks to months after discharge. References Guglin M, Zucker MJ, Bazan VM, et al. Venoarterial ECMO for adults: JACC Scientific Expert Panel. J Am Coll Cardiol. 2019;73(6):698-716. doi:10.1016/j.jacc.2018.11.038 Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America guideline on acute mechanical circulatory support. J Card Fail. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003 Juo YY, Skancke M, Sanaiha Y, et al. Efficacy of distal perfusion cannulae in preventing limb ischemia during extracorporeal membrane oxygenation: a systematic review and meta-analysis. Artif Organs. 2017;41(11):E263-E273. doi:10.1111/aor.12942 Marbach JA, Faugno AJ, Pacifici S, et al. Strategies to reduce limb ischemia in peripheral venoarterial extracorporeal membrane oxygenation: a systematic review and meta-analysis. Int J Cardiol. 2022;361:77-84. doi:10.1016/j.ijcard.2022.04.084 Lee HH, Jang WJ, Ahn CM, et al. Association of prophylactic distal perfusion cannulation with mortality in patients receiving venoarterial extracorporeal membrane oxygenation. Am J Cardiol. 2023;207:418-425. doi:10.1016/j.amjcard.2023.07.149 Ezad SM, Ryan M, Donker DW, et al. Unloading the left ventricle in venoarterial ECMO: in whom, when, and how? Circulation. 2023;147(16):1237-1250. doi:10.1161/CIRCULATIONAHA.122.062371 Geller BJ, Sinha SS, Kapur NK, et al. Escalating and de-escalating temporary mechanical circulatory support in cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2022;146(6):e50-e68. doi:10.1161/CIR.0000000000001076 Randhawa VK, Al-Fares A, Tong MZY, et al. A pragmatic approach to weaning temporary mechanical circulatory support: a state-of-the-art review. JACC Heart Fail. 2021;9(9):664-673. doi:10.1016/j.jchf.2021.05.011 Kato C, Oakes M, Kim M, et al. Anticoagulation strategies in extracorporeal circulatory devices in adult populations. Eur J Haematol. 2021;106(1):19-31. doi:10.1111/ejh.13520 Martin-Tuffreau AS, Bagate F, Boukantar M, et al. Complete percutaneous angio-guided approach using preclosing for venoarterial extracorporeal membrane oxygenation implantation and explantation in patients with refractory cardiogenic shock or cardiac arrest. Crit Care. 2021;25(1):93. doi:10.1186/s13054-021-03522-8 Liu TX, Medina MG, McGregor R, et al. Percutaneous postclosure vs femoral arterial cutdown for venoarterial extracorporeal membrane cannulation sites. Ann Thorac Surg. 2026;121(1):233-238. doi:10.1016/j.athoracsur.2025.07.026 Hayakawa N, Tobita K, Kodera S, et al. Efficacy and safety of percutaneous venoarterial extracorporeal membrane oxygenation decannulation using endovascular balloon dilation and Perclose ProGlide closure device: results from the multicenter SKYLINE study. Ann Vasc Surg. 2023;96:357-364. doi:10.1016/j.avsg.2023.03.025 Ng JJ, Lee SHT, Lim JKW, et al. Percutaneous decannulation of venoarterial extracorporeal membrane oxygenation using the Manta vascular closure device: a systematic review and meta-analysis. Artif Organs. 2023;47(9):1431-1441. doi:10.1111/aor.14554 Jia D, Yang IX, Ling RR, et al. Vascular complications of extracorporeal membrane oxygenation: a systematic review and meta-regression analysis. Crit Care Med. 2020;48(12):e1269-e1277. doi:10.1097/CCM.0000000000004688 Djavidi N, Boussouar S, Duceau B, et al. Vascular complications after venoarterial extracorporeal membrane oxygenation support: a CT study. Crit Care Med. 2025;53(1):e96-e108. doi:10.1097/CCM.0000000000006476 Bidar F, Lancelot A, Lebreton G, et al. Venous or arterial thromboses after venoarterial extracorporeal membrane oxygenation support: frequency and risk factors. J Heart Lung Transplant. 2021;40(4):307-315. doi:10.1016/j.healun.2020.12.007 Fisser C, Armbrüster C, Wiest C, et al. Arterial and venous vascular complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation. Front Med. 2022;9:960716. doi:10.3389/fmed.2022.960716 Combes A, Price S, Slutsky AS, Brodie D. Temporary circulatory support for cardiogenic shock. Lancet. 2020;396(10245):199-212. doi:10.1016/S0140-6736(20)31047-3 Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care. J Am Coll Cardiol. 2015;65(19):e7-e26. doi:10.1016/j.jacc.2015.03.036 Lanoiselée J, Mourer J, Jungling M, et al. Heparin dosing regimen optimization in veno-arterial extracorporeal membrane oxygenation: a pharmacokinetic analysis. Pharmaceutics. 2024;16(6):770. doi:10.3390/pharmaceutics16060770 Goldberg JB, Giri J, Kobayashi T, et al. Surgical management and mechanical circulatory support in high-risk pulmonary embolisms: a scientific statement from the American Heart Association. Circulation. 2023;147(9):e628-e647. doi:10.1161/CIR.0000000000001117 Banks CA, Blakeslee-Carter J, Nkie V, et al. Occurrence, predictors, and management of late vascular complications following extracorporeal membrane oxygenation. J Vasc Surg. 2024;80(3):864-872.e1. doi:10.1016/j.jvs.2024.04.041
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  1. Data to Delivery: The Evidence Base for VA-ECMO 09.06.2026 23p

  In this episode, CathMasters hosts Drs. Nazli Okumus and Daniel Ambinder, joined by expert faculty Drs. Ann Gage and Marwan Jumean, examine the foundational principles of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Utilizing a case study of a 36-year-old patient with fulminant myocarditis and biventricular failure, the panel analyzes the VA-ECMO circuit’s anatomy, clinical indications and contraindications, and the supporting evidence across various shock etiologies. The discussion also covers the debate over left ventricular (LV) unloading, the vital function of multidisciplinary shock teams, and strategies for informed consent and family counseling. This episode serves as an introduction to future discussions on cannulation techniques and complication management. Audio editing for this episode was performed by CardioNerds Intern, Dr. Julia Marques Fernandes.  Contribute to CathMasters by submitting your case for CathConference HERE. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls “ECMO is an egotistical machine.” Inflow and outflow are referenced from the perspective of the ECMO circuit — inflow = blood entering the machine (venous/drainage cannula); outflow = blood leaving the machine (arterial/return cannula). VA-ECMO is the only temporary mechanical circulatory support (MCS) device that provides both full circulatory and respiratory support — making it uniquely suited for biventricular failure with concomitant hypoxemia, as in fulminant myocarditis. “VA-ECMO increases LV afterload” — but the hemodynamic story is more nuanced. The venous drainage cannula reduces right-sided preload, which may decrease LV filling and partially counterbalance the increase in afterload. Not every patient requires mechanical LV unloading; the loading conditions and contractility of both ventricles must be considered. Randomized controlled trial data for VA-ECMO in cardiogenic shock (ECLS-SHOCK, ECMO-CS) have been neutral. However, underlying diagnosis matters: survival is highest in fulminant myocarditis (~65%) and primary graft failure, and lowest in postcardiotomy shock (mortality ~65–75%). Shock teams improve outcomes. Multicenter data demonstrate that centers with shock teams have ~28% lower adjusted odds of cardiac ICU (CICU) mortality (adjusted OR 0.72), driven by earlier recognition, increased pulmonary artery catheter (PAC) use, and more appropriate deployment of MCS. Notes Anatomy of the VA-ECMO Circuit ECMO = Extracorporeal Membrane Oxygenation. VA-ECMO does the work of both the heart and the lungs — it provides full circulatory support and gas exchange, normalizing pCO2, pO2, and pH. The circuit is the complete path blood travels from venous drainage to arterial return. Deoxygenated blood is drained via a large-bore venous cannula → centrifugal pump → membrane oxygenator (gas exchange) → oxygenated blood returned via a large-bore arterial cannula. The two cannulas have three interchangeable naming conventions: Venous/Arterial, Inflow/Outflow (relative to the machine), or Drainage/Return (relative to the patient). Peripheral VA-ECMO is placed percutaneously (Seldinger technique), often by an interventional cardiologist, surgeon, or critical care physician. The most common configuration is femoro-femoral: venous cannula tip at the SVC-RA junction, arterial cannula tip in the descending aorta. Alternatives include IJ venous/axillary arterial, or percutaneous left atrial VA-ECMO via transseptal cannulation (e.g., TandemHeart system or multi-stage cannula). Central VA-ECMO requires surgical anastomosis to intrathoracic vessels; most commonly used in postcardiotomy patients. A distal perfusion cannula (typically 5F–8F) is placed in the superficial femoral artery (SFA) to prevent limb ischemia. Indications and Contraindications for VA-ECMO VA-ECMO is indicated for acute, potentially reversible cardiac or cardiopulmonary failure when conventional therapies have failed. It serves as a bridge to recovery, a bridge to decision, or a bridge to advanced therapies (durable VAD or heart transplant). Indications: Cardiogenic shock (CS): AMI, fulminant myocarditis, acute decompensated biventricular HF, postcardiotomy shock, cardiac transplant primary graft failure, arrhythmic storm, drug overdose/cardiotoxicity Massive pulmonary embolism (PE): Bridge to thrombectomy or thrombolysis Extracorporeal cardiopulmonary resuscitation (ECPR): Refractory cardiac arrest Procedural support: High-risk PCI or structural procedures Contraindications: Relative: Contraindication to systemic anticoagulation, severe PAD limiting peripheral access (central cannulation may be considered), aortic dissection, significant aortic insufficiency Absolute: Comfort-focused goals of care, irreversible neurological catastrophe, conditions incompatible with recovery, limited life expectancy (e.g., end-stage malignancy), established irreversible multi-organ failure Data for VA-ECMO Across Different Indications The Extracorporeal Life Support Organization (ELSO) registry is the largest source of VA-ECMO outcomes data. Overall survival to hospital discharge for adult cardiac VA-ECMO is approximately 42% (Combes et al., Lancet 2020; 19,627 patients). Survival has remained relatively stable despite increasing utilization. Survival varies significantly by underlying diagnosis (Danial et al., JACC 2023; Guglin et al., JACC 2019): Fulminant myocarditis: ~65% survival (highest) Primary graft failure after heart transplant: >50% Drug overdose/cardiotoxicity: >50% AMI-related CS: ~35–47% Postcardiotomy shock: ~25–35% survival (poorest outcomes) ECPR in adults: ~29.5% survival (ELSO 2022 report) Pre-ECMO risk factors for poor outcomes: older age, higher BMI, renal/hepatic/CNS dysfunction, longer pre-ECMO mechanical ventilation, elevated lactate, reduced prothrombin activity, and pre-ECMO cardiac arrest. The SAVE (Survival After Veno-Arterial ECMO) score is the most widely cited risk prediction tool, incorporating diagnosis, age, weight, organ function, and pre-ECMO intubation duration. AUROC 0.68 in derivation, 0.90 in external validation (Schmidt et al., Eur Heart J 2015). Key RCT data: ECLS-SHOCK (NEJM 2023): Largest RCT; AMI-CS patients randomized to early VA-ECMO vs. standard care. No difference in 30-day mortality (47.8% vs. 49.0%; RR 0.98; p=0.81). More bleeding/vascular complications with ECMO. ECMO-CS (Circulation 2023): 117 patients with rapidly deteriorating/severe CS (multiple etiologies) randomized to immediate VA-ECMO vs. early conservative strategy. No difference in composite primary endpoint at 30 days (63.8% vs. 71.2%; HR 0.72; p=0.21). Post-hoc analyses suggest potential benefit in patients with CI <2.2 L/min/m², SvO2 <60%, or elevated pCO2 gap (Ostadal et al., Crit Care 2025). IPD meta-analysis of four RCTs (Zeymer et al., Lancet 2023): No mortality benefit with routine VA-ECMO in AMI-CS; more complications in the device group. ECPR data: ARREST (Lancet 2020): Refractory OHCA with VF; stopped early for superiority — 43% vs. 7% survival to discharge. Prague OHCA (JAMA 2022): Shockable and non-shockable rhythms; 180-day neurologically favorable survival 31.5% vs. 22.0% (p=0.09); 30-day neurologic recovery significantly better (30.6% vs. 18.2%; p=0.02). INCEPTION (NEJM 2023): Multicenter; refractory OHCA with ventricular arrhythmias; 30-day favorable neurologic outcome 20% vs. 16% (OR 1.4; p=0.52). Longer cannulation times and lower-volume centers may have contributed to neutral results. Pooled analysis of ARREST + Prague OHCA (Belohlavek et al., EClinicalMedicine 2023): Significant benefit for ECPR in shockable rhythms — 47.1% vs. 28.3% neurologically favorable survival at 180 days (NNT = 5). The 2023 AHA Focused Update on Adult ACLS (Circulation 2024) gives a Class 2b (conditional) recommendation for ECPR in select patients with refractory OHCA at experienced, high-volume centers. LV Unloading on VA-ECMO VA-ECMO increases LV afterload via retrograde aortic flow. The concern: increased afterload → elevated LVEDP/volume → increased myocardial O2 demand → worsened LV function → pulmonary congestion and LV stasis. The nuance: The venous drainage cannula directly drains the right heart, reducing RA preload and RV stroke volume. On the ascending limb of the Frank-Starling curve, decreased RV preload → less LV filling, partially counterbalancing the afterload increase. The hemodynamic response depends on loading conditions and contractility of both ventricles (University of Minnesota group, in vivo data). LV unloading strategies: IABP (reduces afterload, improves coronary perfusion), micro-axial flow pump/Impella (directly unloads LV), transseptal LA cannulation, atrial septostomy, surgical LV apical drainage. Observational data (Schrage et al., Circulation 2020): LV unloading associated with lower mortality in a multicenter cohort. RCTs have not confirmed the benefit of routine unloading: EARLY-UNLOAD (Circulation 2023): Early LV unloading vs. conventional approach — no mortality difference (46.6% vs. 44.8%; p=0.94). EVOLVE-ECMO (Eur J Heart Fail 2023): Early LA venting vs. conventional — no difference in ECMO weaning or survival. Practical consideration: Many operators deploy upfront unloading because the patient is already in the cath lab, avoiding repeated transport on ECMO. The decision should also factor in the goal of ECMO (LV recovery vs. bridge to replacement therapy). The Role of the Shock Team Shock teams are multidisciplinary groups (interventional cardiology, heart failure/transplant, cardiac surgery, critical care, and anesthesiology) that facilitate early recognition, evaluation, and management of CS. Multicenter data (Papolos et al., JACC 2021; >1,200 CS admissions): Centers with shock teams had ~28% lower adjusted odds of CICU mortality (adjusted OR 0.72; 95% CI 0.55–0.95; p=0.019). Mechanisms of benefit: earlier identification before multi-organ dysfunction, increased PAC use for hemodynamic phenotyping, more appropriate/timely MCS deployment, streamlined care delivery. The 2025 ACC Expert Consensus Statement on Cardiogenic Shock (Sinha et al., JACC 2025) strongly recommends a standardized, interdisciplinary, team-based approach and early contact with regional Level 1 CS centers. Consent for VA-ECMO: Risks, Benefits, Alternatives Consent is frequently obtained from a surrogate (POA/next of kin) because patients are often too ill to participate. Key elements: Simple description: VA-ECMO is full life support that does the work of the heart and lungs for days to weeks. Indication: Support the heart and maintain organ function while treating the underlying cause. Procedure: Large cannulas placed in the groin vessels, connected to an external machine. Risks: Life-threatening bleeding, stroke, limb ischemia, infection. Overall survival <50%, though individual prognosis varies by underlying condition. Benefits: Time for the heart to recover, for additional treatments, and for organ preservation. If no recovery, may bridge to durable VAD or transplant. Alternatives: Continued medical therapy with vasoactive medications. Expectations: Period of attempted stabilization → best case: recovery. If not, ECMO maintained days to weeks while evaluating advanced therapies. Typical course: 1–3 weeks in cardiac ICU, potentially extended rehabilitation. Understanding the patient’s premorbid condition and wishes is imperative. An ECMO coordinator can serve as an early information gatherer, contacting the POA to learn about baseline condition and preferences before the physician seeks formal consent. Discontinuation should be discussed upfront. The “bridge to nowhere” scenario raises profound ethical challenges; early palliative care and ethics consultation involvement is recommended. References ★ Combes A, Price S, Slutsky AS, Brodie D. Temporary circulatory support for cardiogenic shock. Lancet. 2020;396(10245):199-212. doi:10.1016/S0140-6736(20)31047-3 ★ Tonna JE, Boonstra PS, MacLaren G, et al. Extracorporeal Life Support Organization Registry International Report 2022: 100,000 survivors. ASAIO J. 2024;70(2):131-143. doi:10.1097/MAT.0000000000002128 ★ Thiele H, Zeymer U, Akin I, et al. Extracorporeal life support in infarct-related cardiogenic shock. N Engl J Med. 2023;389(14):1286-1297. doi:10.1056/NEJMoa2307227 ★ Ostadal P, Rokyta R, Karasek J, et al. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: results of the ECMO-CS randomized clinical trial. Circulation. 2023;147(6):454-464. doi:10.1161/CIRCULATIONAHA.122.062949 Ostadal P, Rokyta R, Karasek J, et al. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: 1-year outcomes of the ECMO-CS trial. Eur J Heart Fail. 2025;27(1):30-36. doi:10.1002/ejhf.3398 Ostadal P, Vondrakova D, Rokyta R, et al. Cardiac index, SvO2 or pCO2 gap may determine benefit from ECMO in cardiogenic shock: post-hoc analysis of the ECMO-CS trial. Crit Care. 2025;29(1):303. doi:10.1186/s13054-025-05513-5 ★ Zeymer U, Freund A, Hochadel M, et al. Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials. Lancet. 2023;402(10410):1338-1346. doi:10.1016/S0140-6736(23)01607-0 ★ Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST). Lancet. 2020;396(10265):1807-1816. doi:10.1016/S0140-6736(20)32338-2 ★ Belohlavek J, Smalcova J, Rob D, et al. Effect of intra-arrest transport, extracorporeal cardiopulmonary resuscitation, and immediate invasive assessment and treatment on functional neurologic outcome in refractory out-of-hospital cardiac arrest (Prague OHCA). JAMA. 2022;327(8):737-747. doi:10.1001/jama.2022.1025 ★ Suverein MM, Delnoij TSR, Lorusso R, et al. Early extracorporeal CPR for refractory out-of-hospital cardiac arrest (INCEPTION). N Engl J Med. 2023;388(4):299-309. doi:10.1056/NEJMoa2204511 Belohlavek J, Yannopoulos D, Smalcova J, et al. Intraarrest transport, extracorporeal cardiopulmonary resuscitation, and early invasive management in refractory out-of-hospital cardiac arrest: an individual patient data pooled analysis of two randomised trials. EClinicalMedicine. 2023;59:101988. doi:10.1016/j.eclinm.2023.101988 Supady A, Bělohlávek J, Combes A, et al. Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest. Lancet Respir Med. 2025;13(9):843-856. doi:10.1016/S2213-2600(25)00122-5 ★ Schmidt M, Burrell A, Roberts L, et al. Predicting survival after ECMO for refractory cardiogenic shock: the Survival After Veno-Arterial-ECMO (SAVE)-score. Eur Heart J. 2015;36(33):2246-2256. doi:10.1093/eurheartj/ehv194 ★ Danial P, Olivier ME, Bréchot N, et al. Association between shock etiology and 5-year outcomes after venoarterial extracorporeal membrane oxygenation. J Am Coll Cardiol. 2023;81(9):897-909. doi:10.1016/j.jacc.2022.12.018 ★ Guglin M, Zucker MJ, Bazan VM, et al. Venoarterial ECMO for adults: JACC Scientific Expert Panel. J Am Coll Cardiol. 2019;73(6):698-716. doi:10.1016/j.jacc.2018.11.038 ★ Papolos AI, Kenigsberg BB, Berg DD, et al. Management and outcomes of cardiogenic shock in cardiac ICUs with versus without shock teams. J Am Coll Cardiol. 2021;78(13):1309-1317. doi:10.1016/j.jacc.2021.07.044 ★ Sinha SS, Morrow DA, Kapur NK, Kataria R, Roswell RO. 2025 Concise clinical guidance: an ACC expert consensus statement on the evaluation and management of cardiogenic shock. J Am Coll Cardiol. 2025;85(16):1618-1641. doi:10.1016/j.jacc.2025.02.018 ★ Schrage B, Becher PM, Bernhardt A, et al. Left ventricular unloading is associated with lower mortality in patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation. Circulation. 2020;142(22):2095-2106. doi:10.1161/CIRCULATIONAHA.120.048792 Kim MC, Lim Y, Lee SH, et al. Early left ventricular unloading or conventional approach after venoarterial extracorporeal membrane oxygenation: the EARLY-UNLOAD randomized clinical trial. Circulation. 2023;148(20):1570-1581. doi:10.1161/CIRCULATIONAHA.123.066179 Park H, Yang JH, Ahn JM, et al. Early left atrial venting versus conventional treatment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: the EVOLVE-ECMO randomized clinical trial. Eur J Heart Fail. 2023;25(11):2037-2046. doi:10.1002/ejhf.3014 Russo JJ, Aleksova N, Pitcher I, et al. Left ventricular unloading during extracorporeal membrane oxygenation in patients with cardiogenic shock. J Am Coll Cardiol. 2019;73(6):654-662. doi:10.1016/j.jacc.2018.10.085 Perman SM, Elmer J, Maciel CB, et al. 2023 American Heart Association focused update on adult advanced cardiovascular life support. Circulation. 2024;149(5):e254-e273. doi:10.1161/CIR.0000000000001194 Thiele H, Hassager C. Cardiogenic shock. N Engl J Med. 2026;394(1):62-77. doi:10.1056/NEJMra2312086 Lüsebrink E, Binzenhöfer L, Adamo M, et al. Cardiogenic shock. Lancet. 2024;404(10466):2006-2020. doi:10.1016/S0140-6736(24)01818-X Enumah ZO, Carrese J, Choi CW. The ethics of extracorporeal membrane oxygenation: revisiting the principles of clinical bioethics. Ann Thorac Surg. 2021;112(1):61-66. doi:10.1016/j.athoracsur.2020.08.045 Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America guideline on acute mechanical circulatory support. J Card Fail. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003
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  Introducing: CardioNerds CathMasters – The Interventional Cardiology Podcast 07.06.2026 6p

  In this inaugural episode of CardioNerds CathMasters, co-founders Dr. Amit Goyal and Dr. Daniel Ambinder introduce a new podcast dedicated to democratizing interventional cardiology (IC) education. Recognizing the need for high-quality, evidence-based, and experience-driven content tailored to the busy, technically advanced proceduralist, the hosts launch this series to foster lifelong learning. The episode outlines the core mission of CathMasters and introduces five recurring episode formats: Data to Delivery, Proctor Playbook, Crisis Control, Cath Conference, and Beyond the Lab. Drs. Goyal and Ambinder invite the global interventional community to engage, collaborate, and contribute, emphasizing that collective experience and a commitment to growth are essential to advancing the field of interventional cardiology. Contribute to CathMasters by submitting your case for CathConference HERE. CathMasters is for educational purposes only. Music by Elijah K from Pixabay