What type of ultrasound is recommended for checking axillary placement of Impella (Intracardiac Pump)

Ultrasound for Axillary Artery Assessment Prior to Impella Placement

Use a high-frequency linear ultrasound probe to perform real-time B-mode (2D) imaging of the axillary artery before Impella placement, evaluating vessel size, depth, patency, and proximity to surrounding neurovascular structures. 1

Recommended Ultrasound Technique

Probe Selection and Settings

• Use a high-frequency linear array transducer probe for optimal visualization of the superficial axillary artery and surrounding structures 1
• Higher frequency probes provide superior image resolution for identifying adjacent nerves and arterial branches in the axillary region 1
• Standard two-dimensional (2D) B-mode imaging is the current clinical standard for vascular access assessment 1

Pre-Cannulation Assessment Protocol

• Perform a systematic pre-cannulation ultrasound examination to assess vessel size, depth, patency, and anatomical variations before attempting access 1
• Evaluate the axillary artery in both transverse (short-axis) and longitudinal (long-axis) views to fully characterize the vessel 1
• Identify and map the relationship between the axillary artery and vein—the vein is typically caudal to the artery, smaller, and compressible 1
• Document the presence of any atherosclerotic disease, calcification, or anatomical variants that could complicate device insertion 1

Critical Anatomical Considerations

• The axillary artery is the continuation of the subclavian artery lateral to the outer border of the first rib and is relatively superficial, making it well-suited for ultrasound visualization 1, 2
• Carefully identify surrounding structures including the brachial plexus to avoid neurological injury during surgical access creation 2, 3
• The axillary region contains critical neurovascular structures that must be visualized and avoided during the procedure 1, 2

Imaging Approach for Impella 5.0 Placement

Standard Access Site

• The right axillary artery is the preferred access site for Impella 5.0 placement when femoral access is not feasible due to peripheral artery disease or hostile iliofemoral anatomy 4, 5, 3
• The right axillary artery provides a more direct anatomical course to the ascending aorta compared to the left 5

Pre-Operative Ultrasound Goals

• Confirm adequate vessel diameter (typically 10-12mm graft conduit is used for surgical access) 5
• Assess for atherosclerotic disease burden that might complicate anastomosis or device passage 5
• Evaluate the length of suitable artery available for end-to-side graft anastomosis 5
• Rule out axillary artery stenosis, occlusion, or significant tortuosity that would preclude safe device placement 1

Intraoperative Guidance

• Impella 5.0 placement is performed under combined fluoroscopic and transesophageal echocardiographic guidance to confirm proper device positioning across the aortic valve 5, 3
• Real-time ultrasound can assist with initial vessel exposure and graft anastomosis site selection 1

Common Pitfalls and How to Avoid Them

Inadequate Pre-Procedural Assessment

• Pitfall: Proceeding to surgical access without comprehensive ultrasound evaluation of vessel quality and surrounding anatomy 1
• Solution: Always perform complete bilateral axillary artery ultrasound assessment to select the optimal access site and identify any anatomical contraindications 1, 5

Failure to Identify Brachial Plexus

• Pitfall: Not mapping the brachial plexus location relative to the axillary artery, risking neurological injury during surgical dissection 2, 3
• Solution: Use high-frequency ultrasound to identify and document the relationship between the axillary artery and brachial plexus elements before surgical incision 1, 2

Overlooking Atherosclerotic Disease

• Pitfall: Missing significant calcification or atherosclerotic plaque that could complicate graft anastomosis or device passage 1
• Solution: Systematically scan the entire length of the axillary artery in multiple planes to characterize vessel wall quality and identify any disease 1

Inadequate Vessel Sizing

• Pitfall: Not accurately measuring vessel diameter, leading to graft size mismatch 5
• Solution: Obtain precise diameter measurements in multiple locations to ensure appropriate graft selection (typically 10-12mm) 5