Fluoroscopy-Free Axillary Impella 5.5 Implantation, Earlier Support With Just Transesophageal Echocardiography Images

Delays in mechanical circulatory support (MCS) for cardiogenic shock can be critical. However, timely access to a hybrid operating room or C-arm fluoroscopy for urgent axillary Impella 5.5 (Abiomed, Danvers, MA) implantation remains a barrier. To address this, we developed a fluoroscopy-free axillary Impella 5.5 implantation technique using transesophageal echocardiography (TEE) guidance. From January 2023 to November 2024, 19 adults underwent the procedure. A preoperative flowchart ensured appropriate selection, with the right axillary artery as the preferred access. Transesophageal echocardiography-guided pigtail advancement, valve crossing, and device positioning. All implantations (100%) were successful without conversion to fluoroscopy-guided or ECMO. There were no strokes or major complications. All patients had optimal positioning and rapid hemodynamic improvement. These findings support the feasibility and safety of TEE-guided, fluoroscopy-free Impella 5.5 implantation. It offers a significant benefit for earlier implantation of MCS in patients with cardiogenic shock, especially in settings where limited or delayed access to fluoroscopic imaging resources is a barrier to timely intervention.