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Clinical Images

Percutaneous Treatment of Symptomatic Left Ventricular Assist Device Outflow Graft Obstruction

Faris G. Araj, MD1;  Robert M. Morlend, MD1;  Matthias Peltz, MD2;  Anthony A. Bavry, MD, MPH1;  Dharam J. Kumbhani, MD1

June 2022
1557-2501
J INVASIVE CARDIOL 2022;34(6):E484-E485. doi: 10.25270/jic/21.00429

Keywords: complications, graft obstruction

Araj Graft Obstruction Figure 1
Figure 1. Illustration of the left ventricular assist device outflow graft wrapped in a Gore-Tex sheet. Reproduced with permission from the publisher.

A 60-year-old female underwent a left ventricular assist device (LVAD) implant during which a 1-mm Gore-Tex sheet (Gore Medical) was used to cover the device and outflow graft to prevent future sternal re-entry injury (Figure 1). Seven years later, she developed low-flow alarms with a pattern of gradual decline in flow and power suggestive of outflow graft obstruction (Figure 2).

Araj Graft Obstruction Figure 2
Figure 2. Left ventricular assist device log file analysis showing a progressive decrease in flow and power over time.

Computed tomography confirmed stenosis of the outflow graft; however, it was not able to differentiate internal vs external obstruction secondary to thrombus formation between the Gore-Tex sheet and the true outflow graft (Figure 3). A hemodynamic ramp study failed to show an increase in cardiac output or increase in left ventricular (LV) unloading, thus further supporting a hemodynamically significant obstruction. After a discussion with the multidisciplinary team, percutaneous stenting of the outflow graft was pursued.

Araj Graft Obstruction Figure 3
Figure 3. Computed tomography of the chest with intravenous contrast. There is mural thrombus within the mid outflow tract (red arrow) of the left ventricular assist device causing approximately 50% luminal stenosis. Gore-Tex sheet (yellow arrow), outflow graft (blue arrow).

Given her body mass index of 42 kg/m2 and anterior take-off of the graft, left brachial access provided easier engagement of the outflow graft with the use of a 6-Fr multipurpose-B1 guide catheter. Intravascular ultrasound (IVUS) confirmed extrinsic compression in the mid portion of the graft, narrowing it to 4 mm. The stenosis was treated with a 10- x 60-mm balloon followed by an 11- x 79-mm VBX balloon-expandable covered stent (Medtronic). Repeat IVUS confirmed good apposition of the stent and resolution of the stenosis (Figure 4 and Figure 5; Video Series).

Araj Graft Obstruction Figure 4
Figure 4. (A-G)The outflow graft was engaged successfully with a 6-Fr MP B-1 guide catheter. The proximal portion of the outflow graft was then carefully wired with a 0.035" Wholey wire, and intravascular ultrasound (IVUS) was then performed. There was clear extrinsic compression in the mid portion of the graft without clear evidence of thrombus internally. The graft diameter was ~10-11 mm; it measured 4 mm in the smallest dimension. The stenosis was then ballooned with a 10- x 60-mm balloon. The stenosis into the proximal portion of the graft, beyond the bend relief joint, was then stented with an 11- x 79-mm VBX covered stent (LVAD flows were lowered to ~1800 rpm at this time to minimize stent movement). IVUS was performed again, which confirmed good apposition of the stent and resolution of the stenosis.

LVAD outflow graft obstruction is an infrequent cause of LVAD dysfunction and should be considered in the presence of low-flow alarms, inadequate LV unloading, or recurrent heart failure symptoms after LVAD implant. Causes of graft obstruction include kinking, twisting, narrowing at the aortic anastomosis, and thrombus within or external to the graft. Due to the risk of extrinsic outflow graft compression, use of a Gore-Tex sheet has since fallen out of favor.

Affiliations and Disclosures

Araj Graft Obstruction Figure 5
Figure 5. Computed tomography of the chest without intravenous contrast. A stent is present within the outflow graft of the left ventricular assist device (red arrow). Blue arrow points to the Gore-Tex sheet.

From the 1Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center; Dallas, Texas; 2Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center; Dallas, Texas.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted January 15, 2022.

Address for correspondence: Faris G. Araj, MD, Professional Office Bldg 2, Suite 600, 5939 Harry Hines Blvd, Dallas, Texas, 75390-9252. Email: faris.araj@utsouthwestern.edu

 

 

 

 

 

 

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