Case of Percutaneous Extra-corporeal Femoro-femoral Bypass for Acute Limb Ischemia From Large Bore Access

An 80-year-old Khmer-speaking man presented with acute inferior ST elevation myocardial infarction (STEMI) and cardiogenic shock. Cardiac catheterization revealed 99 percent stenosis in the mid-RCA, a 95% focal severe stenosis in mid-LAD and a 60-70% stenosis in the proximal circumflex artery. Given advanced age and unstable hemodynamics, emergent multi-vessel percutaneous coronary intervention with complete revascularization was performed. An Intra-aortic balloon pump was initially placed but cardiogenic shock persisted despite this and multiple vasopressors. His femoral arteries were <5 mm bilaterally. Despite borderline access vessels, hemodynamic support with Impella CP was instituted via left common femoral access. He was only 4 feet 9 inches tall, weighed 50 kilograms with a BSA of 1.4 m2. As expected, there was no palpable distal pulse in the left lower extremity. Lack of flow distal to the common femoral arteriotomy was confirmed on Duplex ultrasound exam. The patient was, however, completely dependent on the Impella CP and could not be weaned off despite maximal doses of 4 vasopressors.

Which of the following is the best choice for managing the acute limb ischemia induced by the Impella large-bore access cannula?

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