Vascular Access Sites Management in the Context of Mechanical Circulatory Assist Devices Explantation

INTRODUCTION
Mechanical circulatory support (MCS) systems such as Impella CP®, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and combined (ECMella) require femoral vascular access, typically using large-caliber cannulas (≥14 Fr). Safe management of vascular access sites upon MCS removal is essential to ensure patient safety, involving either manual or device-based closure methods. This study examines the effectiveness of closure devices, clinical outcomes, and transfusion needs associated with MCS explantation.

METHODS
A retrospective cohort of 470 patients who received MCS devices between 2004 and 2023 was analyzed. Devices studied included Impella CP® and VA-ECMO. Data included closure device types (Angio-Seal®, ProGlide®), use of vascular compression devices (FemoStop®), blood transfusion requirements, and clinical parameters. Outcomes such as device stabilization success rates and hemostasis efficacy were recorded and compared across device types.

RESULTS
Of the 470 patients (baseline characteristics in Figure 1), 31.7% used Impella, 58.5% VA-ECMO, and 9.8% ECMella. Right common femoral artery (CFA) and vein (CFV) where the most frequently used access sites with cannula sizes ranging from 15-22Fr (CFA) and 17-25Fr (CFV). Additional limp perfusion during VA- ECMO and ECMella treatment was established in 90.6% of the cases (7Fr).  The Impella had a fixed access size of 14Fr. Figure 2 displays the results for the access site management: Explantation could be achieved in 57% (Impella), 45.1% (VA-ECMO) and 23.9% (ECMella) of the cases, in 96%-98% due to hemodynamic stabilizing and in 2-4% of cases it was necessary due to technical MCS - device failure. Closure devices (Angio-Seal® / ProGlide®) were used in 48.4 % / 55.6% for VA-ECMO, 36.4% / 54.5% for ECMella and in 1.2% / 11.7% for Impella patients (p<0.05). ECMella patients required most devices for successful access site closure ( 2 Angio-Seals® in 66.7% and 2-3 ProGlides® in 83.8% of cases) and Impella patients required the least number of closure devices (no Angio-Seals® in 98.8% and 2 ProGlides® in 70% of cases). Bedside closure was feasible in 63% of VA-ECMO, in 45% of ECMella and in 91% of Impella cases while ECMella patients required surgical removal / assisted surgical removal in 55% of cases. Hemostasis was maintained through conservative compression techniques, with FemoStop® utilized in 88% (Impella), 69% (VA-ECMO) and 73% (ECMella) of the cases. 58.1% of ECMO cases and 100% of ECMella cases required blood transfusions, typically 1-2 RBC units per access site closure procedure (71% for ECMO) and 3 RBC units in 82% for ECMella. Hemoglobin levels were monitored pre- and post-MCS, with ECMO, ECMella and Impella cases showing mean levels of 5.4±0.6 mmol/L pre-procedure and 5.6±0.7 mmol/L post-procedure, indicating only minor variances.

CONCLUSION
Vascular access management for MCS device removal can be successfully conducted at the bedside for most cases, though the removal of ECMella often necessitates surgical intervention. Closure devices are increasingly effective, though conservative compression techniques remain adjunctively important, and transfusions are frequently required to address procedural blood loss. Standardized follow-up protocols are advised for early complication detection and improved interdisciplinary patient care.