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IMAGES IN INTERVENTION

Percutaneous Stenting of aLeft Ventricular Assist Device Outflow Kink

Abdallah El Sabbagh, MD,a Mohammed Al-Hijji, MD,a Rajiv Gulati, MD, PHD,a Charanjit S. Rihal, MD,a

Peter M. Pollak, MD,b Atta Behfar, MD, PHDa

A 70-year old man with end-stage ischemiccardiomyopathy status post HeartMate II(Thoratec, Pleasanton, California) left ven-

tricular assist device (LVAD) implantation asdestination therapy presented with recurrent

FIGURE 1 Computed Tomography Imaging

Computed tomography angiography of the chest revealing the 90� ang

From the aDepartment of Cardiovascular Diseases, Mayo Clinic and Mayo Fou

Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Jacksonville, F

relationships relevant to the contents of this paper to disclose.

Manuscript received September 12, 2016; accepted September 26, 2016.

gastrointestinal bleeding. He was seen by gastroen-terology and had a work-up that revealed proximaljejunal angiodysplasia. Device parameters revealeda high velocity of his pump with evidence ofpoor decompression of the left ventricle on the

ulation in the left ventricular assist device outflow cannula.

ndation, Rochester, Minnesota; and the bDivision of

lorida. All authors have reported that they have no

FIGURE 2 Fluoroscopy Images

Procedural fluoroscopy showing the 20 � 55 mm WallStent self-expanding stent (A) being delivered; (B) being positioned and deployed,

(C) being post-dilated, and (D) final result (Online Video 1).

FIGURE 3 Change of LVAD Speed With Time

Decrease in left ventricular assist device (LVAD) pump speed following stenting of LVAD

outflow.

El Sabbagh et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 2 4 , 2 0 1 6

LVAD Kink Stenting D E C E M B E R 2 6 , 2 0 1 6 : e 2 2 9 – 3 1

e230

transthoracic echocardiogram. Computed tomogra-phy angiography of the chest revealed a 90� angula-tion in the LVAD proximal outflow cannula withno cannula thrombosis (Figure 1). It was thoughtthat this outflow obstruction is causing acquiredvon Willebrand’s disease, which was confirmedby a von Willebrand factor multimer analysistesting.

Through femoral access and a JR4 diagnosticcatheter (Cordis, Miami, Florida), the graft was can-nulated retrogradely with the stiff angled Glidewire(Terumo Medical Corporation, Somerset, New Jer-sey). This led to unkinking the grafts and providedimmediate improvement with robust increase in theLVAD flow.

The Glidewire was then exchanged with an extrastiff wire then a Lunderquist wire (Cook Medical,Bjaeverskov, Denmark) with upsizing of the femoral

FIGURE 4 Post-Procedural Imaging

Computed tomography angiography showing unkinking of left ventricular assist device outflow with stent (Online Video 2).

FIGURE 5 Change of Hemoglobin Level With Time

Graph showing recurrent decrease in hemoglobin due to gastrointestinal bleeding before

intervention and improved hemoglobin post-intervention.

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 2 4 , 2 0 1 6 El Sabbagh et al.D E C E M B E R 2 6 , 2 0 1 6 : e 2 2 9 – 3 1 LVAD Kink Stenting

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sheath for better support. A 20 � 55 mm WallStentself-expanding stent (Boston Scientific, Natick,Massachusetts) was delivered to unkink the LVADoutflow graft (Figure 2A). The stent was positioneddistally and deployed (Figure 2B), followed by post-dilation (Figure 2C) with a Z-Med balloon (NuMED,Inc., Hopkinton, New York).

The patient had excellent angiographic results(Figure 2D, Online Video 1) and hemodynamicresponse based on the LVAD settings (Figure 3). Therewere no complications associated with the procedure.Repeat computed tomography angiography showedthe stent in place with decrease in the angulation ofthe kink (Figure 4, Online Video 2). On a 2-year followup visit, the patient had not had any further GIbleeding (Figure 5) and device monitoring highlightedimproved flow dynamics.

REPRINT REQUESTS AND CORRESPONDENCE: Dr.Atta Behfar, Department of Cardiovascular Disease,Mayo Clinic, 200 First Street Southwest, Rochester,Minnesota 55905. E-mail: behfar.atta@mayo.edu.

KEY WORDS left ventricular assist device, outflow kink, stent

APPENDIX For supplemental videos and their legends, please seethe online version of this article.