# Extracorporeal Membrane Oxygenation-Impella (ECPELLA) for Sepsis-Induced Cardiogenic Shock: A Case Report on Vascular Access Selection and Its Use Without Systemic Anticoagulation

## TL;DR

This case report shows that combining VA-ECMO with Impella (ECPELLA) can help treat severe sepsis-induced heart failure, even without using blood thinners.

## Contribution

The paper presents a novel case of ECPELLA use in sepsis-induced cardiogenic shock with subclavian access and no systemic anticoagulation.

## Key findings

- ECPELLA improved hemodynamics and allowed weaning in a patient with sepsis-induced cardiogenic shock.
- Subclavian artery access was successfully used for Impella placement despite femoral vessel limitations.
- ECPELLA was managed without systemic anticoagulation, avoiding thrombosis through heparin purge fluid and echocardiographic monitoring.

## Abstract

Sepsis-induced cardiogenic shock (SICS) often necessitates mechanical circulatory support, but the efficacy of venoarterial extracorporeal membrane oxygenation (VA-ECMO) alone remains uncertain due to its potential to increase afterload and worsen cardiac dysfunction. The combination of VA-ECMO and Impella (ECPELLA) has emerged as a potential strategy to mitigate these effects, but its application in SICS remains poorly documented. This case highlights ECPELLA as a viable strategy to improve hemodynamics and facilitate weaning in refractory SICS, particularly in patients with vascular access limitations. A previously healthy 39-year-old man presented with septic shock secondary to necrotizing soft tissue infection and was diagnosed with streptococcal toxic shock syndrome. Despite aggressive resuscitation, refractory shock persisted, and transthoracic echocardiography revealed a left ventricular ejection fraction of 30%, consistent with SICS. VA-ECMO was initiated via the right femoral vessels. However, circulatory failure progressed, with a loss of pulse pressure and aortic valve opening, necessitating additional left ventricular unloading. Given extensive femoral necrosis, ongoing ECMO cannulation, and severe right upper limb ischemia, the left subclavian artery was chosen for Impella placement. While this decision was primarily dictated by anatomical constraints, subclavian access may offer advantages such as improved patient mobility and reduced risk of limb ischemia. Following implantation, pulse pressure improved, aortic valve function was restored, and hemodynamics stabilized, facilitating successful VA-ECMO and Impella weaning. Due to the high bleeding risk from multiple debridements, systemic anticoagulation was withheld. Thrombosis risk was mitigated through the use of heparin-containing purge fluid and serial echocardiographic assessment of left ventricular function and intracardiac thrombus formation. No thromboembolic events were observed. He underwent multiple surgical interventions, including amputation and skin grafting, before eventual recovery and transfer to rehabilitation. This case demonstrates that ECPELLA may be a viable therapeutic option for SICS, particularly in cases requiring alternative vascular access strategies. Additionally, in high bleeding-risk patients, it may be feasible to manage ECPELLA without systemic anticoagulation. Further investigation is needed to evaluate its impact on hemodynamics, thrombosis risk, and long-term outcomes.