Sheathless delivery of a transfemoral pulsatile left ventricular assist device for high-risk percutaneous interventions: a case series.

Background: The use of mechanical circulatory support (MCS) can reduce adverse events in patients with severely impaired left ventricular (LV) function and precarious haemodynamics during complex cardiovascular procedures. Despite numerous benefits, MCS requires large-bore access, which increases the risks of vascular complications. The iVAC2L (PulseCath BV, Arnhem, The Netherlands) provides up to 2.0 L/min output using pulsatile flow and is an effective tool for LV unloading, but requires a large-bore sheath (18 Fr). Case summary: We describe four cases of sheathless insertion of iVAC2L during high-risk cardiovascular interventions. Two cases consisted in high-risk percutaneous coronary interventions, and two other cases were transcatheter edge-to-edge mitral valve repair. All cases were successful, and no adverse events could be observed. Discussion: The sheathless approach requires an 11% smaller arteriotomy. This case series aims to display how the iVAC2L catheter can be deployed without a sheath to minimize access size in a safe and feasible manner and proposes a structured approach to its deployment. When performed in selected patients, this strategy may reduce vascular complications. Conclusion: Sheathless introduction of iVAC2L was feasible and safe safely deployed in selected cases of coronary and structural interventions. Larger studies are necessary to further define its impact on event rates.