327 - “Impella”-ment of Peripheral Nerves Leading to Hand Weakness

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

SS

Shirley Shen, MD

Resident Physician
JFK-Johnson Rehabilitation Institute
Parlin, New Jersey, United States

Co-Author(s)

SJ

Stacey Jou, MD

Resident
JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
SM

Steven Markos, MD

Physician
JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
DB

David Brown, DO

Physician
JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States

Case Diagnosis: Severe axonal peripheral nerve injuries following failed Impella insertion

Case Description: 79 year-old male with history of coronary artery disease was found to have non-ST elevation myocardial infarction with multivessel disease. He underwent cardiac stent placement and percutaneous coronary intervention (PCI). Due to high-risk nature of PCI, multiple Impella insertions were attempted via right axillary approach. This ultimately failed, requiring endovascular repair of right axillary artery pseudoaneurysm. 2 weeks later in inpatient rehabilitation, initial evaluation revealed atrophy of intrinsic hand muscles. Trace strength was found in wrist and finger flexion and extension, finger abduction and adduction, and later elbow flexion. No sensory changes were observed. Nerve conduction studies and electromyography revealed separate incomplete, axonal injuries to right musculocutaneous, median, and ulnar nerves. After two weeks, motor strength improved to 4/5 in the fingers, and 5/5 in the wrist. Sensation to pinprick notably decreased in the right palm and all 5 digits.

Discussions: Iatrogenic brachial plexus injury can occur as a result of transaxillary approach placements of cardiac assistive devices, but no cases have been reported in literature regarding nerve injuries caused by Impella placement. In this patient's history, repetitive blunt trauma in the area of the plexus correlated with persistent upper extremity weakness. Initial normal sensory exam pointed to a possible medial cord injury, however deficits in sensation and in elbow flexion strength appeared later in the IPR course that were consistent with electrodiagnostic findings. Rather than a more typical brachial plexus trunk or cord injury, electrodiagnostics helped identify that axonal injuries to multiple plexus terminal branches were causing patient’s presentation.

Conclusions: It is important to recognize multi-nerve injury as possible complications from Impella insertion. IPR is an important time to rehabilitate these injuries. Electrodiagnostic testing during this time is useful for formally diagnosing post-procedural nerve injuries, and helping prognosticate to improve management.