A case of fatal acute saddle embolism of the terminal aorta after long-term support using Impella CP.

A 69-year-old male diagnosed with subacute myocardial infarction was subsequently transferred to our institution. Upon admission, echocardiography revealed ventricular septal rupture (VSR). The patient was promptly supported via venoarterial (VA) extracorporeal membrane oxygenation (ECMO) and Impella CP before surgical VSR repair on the 12th day of admission. Following surgery, the patient decided to be transferred to the intensive care unit under new VA-ECMO assistance. Subsequently, Impella CP removal and arterial cannula reinsertion were performed at the ipsilateral site, with no pulsatile bleeding observed from the arterial cannulation site. Emergency aortography revealed a contrast defect at the terminal aorta. Owing to the possibility of acute thrombotic occlusion, the Fogarty procedure was performed through the bilateral common femoral artery (CFA); however, no thrombus retrieved. Contrast-enhanced computed tomography revealed complete occlusion of the bilateral common iliac arteries, extending to the abdominal aorta. The uncontrollable, rapid progression of acidemia resulted in sudden cardiac arrest. Acute arterial occlusion leading to fatal outcomes can occur because of thrombosis following long-term Impella CP use. Impella-associated thrombi can form around the shaft of a mixed area of blood flow caused by the interaction between Impella and ECMO and often develop distal to the aortic arch, which is often overlooked during routine examinations. Therefore, planning for long-term Impella with ECMO support must utilize various imaging modalities to search for thrombi and prepare several means of revascularization during Impella removal.