Suprasternal approach for insertion of Impella 5.5 into the proximal right subclavian artery

The Impella 5.5 (Abiomed) is a percutaneous, temporary left ventricular assist device (LVAD) that serves as an important method of treatment of acute cardiogenic shock refractory to medical management. The Impella 5.5 and 5.0 are commonly inserted through the right axillary artery; however, this may be limited by inadequate vessel diameter to accommodate the Impella and inadequate vessel quality. A central approach to Impella 5.5 incision has been described in the pediatric population, particularly via the innominate artery through a suprasternal and/or neck incision, with success. As an alternative to axillary Impella placement, we propose the usage of a limited suprasternal incision for Impella 5.5 insertion in the adult population, either through the proximal right subclavian artery or the distal innominate artery. This may offer multiple advantages, such as increased vessel diameter and quality of more proximal vessels, avoidance of partial sternotomy, avoidance of a second infraclavicular wound site if the patient progresses to require LVAD or transplant, avoidance of lymphatic and nerve injury through the axillary exposure, ease of manipulation for repositioning, and patient rehabilitation. Potential limitations include difficulty due to body habitus, potential risk of stroke with the innominate approach, and wound complications. A central approach is a reasonable alternative to axillary Impella placement in patients with inadequate axillary artery caliber, defined as less than 6-7 mm diameter, poor artery quality to accommodate anastomosis, and small body habitus, allowing for ease of exposure.