Gallardo Galeas et al. publish in this issue1 a clinical case of complex coronary angioplasty with iVAC2L ventricular assistance in a patient with severely deteriorated ejection fraction. The device allowed for the stabilization of blood pressure and successful revascularization without complications. This report clearly illustrates the value of the iVAC2L as effective pulsatile hemodynamic support in high-risk procedures, while also introducing one of its potential limitations so that we can prevent it: the use of an 18-Fr arterial introducer, which may compromise lower limb perfusion and restrict support duration, which was not necessary in the reported case but could be an eventual requirement.

The use of percutaneous ventricular assist devices, such as iVAC2L® (PulseCath BV, Amsterdam, Netherlands), has expanded the limits of complex coronary revascularization by providing effective pulsatile hemodynamic support in patients with severe ventricular dysfunction or cardiogenic shock. However, a possible limitation arises from the diameter of the arterial introducer, which entails a potential risk of lower limb ischemia, especially in small-caliber femoral arteries, calcified arteries, or diffuse atherosclerotic disease.

The phenomenon of distal ischemia during possible prolonged use of large-bore introducers can lead to metabolic acidosis, lactate release, and secondary renal failure, particularly when the procedure extends beyond 2–3 hours. This problem is not limited to interventional cardiology: the situation is similar during extensive endovascular procedures, such as aortic repairs with fenestrations or branches, which are usually prolonged procedures.

In light of this limitation, we propose a strategy already in place for other procedures involving percutaneous femoro-femoral bypass, which allows for distal limb perfusion to be maintained during the use of the iVAC2L in cases with presumed risk of ischemia.

The first publication describing percutaneous femoro-femoral bypass as a technique to prevent or treat limb ischemia during long-term procedures using large-caliber femoral introducers dates back to March 2002. This study was first reported by Lin et al. in the Journal of Vascular Surgery: a minimally invasive endovascular technique was used to create a temporary percutaneous femoro-femoral bypass graft at the patient’s bedside to treat acute limb ischemia caused by the placement of an intra-aortic counterpulsation balloon2.

This is the technique proposed for cases involving iVAC2L or other large-introducer procedures:

1. The left femoral artery is punctured with a 6-Fr introducer.

2. Using a crossover technique, the right superficial femoral artery is opacified to guide a downward puncture (which may be guided by ultrasound), directing a 5-Fr introducer toward the right popliteal artery.

3. Subsequently, the right common femoral artery is punctured in an ascending direction; the 18-Fr introducer is implanted and the iVAC2L catheter is introduced.

4. Finally, both introducers (the left retrograde one and the right descending, antegrade one) are connected through a closed circuit. The type of connection used is similar to that employed for injector pumps and male-to-male connectors, thus allowing flow from the left femoral artery to the distal right femoral artery, thereby preventing ischemia.

5. Systemic anticoagulation with heparin is maintained, and flow is monitored clinically and angiographically.

This maneuver creates a functional femoro-femoral bypass, which ensures distal oxygenation during assistance and prevents prolonged hypoperfusion.

The proposed strategy—a percutaneous femoro-femoral bypass—could prolong even the duration of iVAC2L support in patients who require it, broadening its applicability beyond complex angioplasty. This bypass could also be used in prolonged endovascular procedures (such as cases of aortic repair with multiple fenestrations or complex reintervention).

This technique offers several advantages: it does not require a surgical team; it maintains distal perfusion during prolonged procedures (>3 h); it is compatible with the use of the iVAC2L and subsequently does not preclude percutaneous closure (for example, PROGLIDE®, Abbott Vascular, Santa Clara, California, United States).

While this strategy is yet to be formally reported, it is inspired by temporary femoro-femoral bypasses used during extracorporeal membrane oxygenation (ECMO) or complex aortic repair.

It should be noted that there is limited but growing evidence supporting the use of percutaneous femoro-femoral bypass (also known as ex vivo percutaneous bypass) as a temporary measure to prevent or treat limb ischemia during procedures requiring large-caliber femoral introducers. Case reports and small case series have shown that this technique can restore antegrade flow to the ischemic limb when a large-caliber introducer causes significant arterial obstruction, particularly in a setting of mechanical circulatory support or complex endovascular intervention. These reports describe the successful preservation of limb perfusion through a percutaneous bypass circuit between the contralateral and ipsilateral femoral arteries, allowing for continuous hemodynamic support and minimizing the risk of acute limb ischemia3, 4.

However, this approach is not standard treatment and is generally reserved for situations where conventional strategies (such as minimizing introducer size, limiting procedure duration, or using alternative access sites) are insufficient or unfeasible. Available evidence is limited to isolated clinical experiences, and there are no randomized trials or recommendations from major scientific societies that specifically endorse the routine use of percutaneous femoro-femoral bypass for this indication. This technique is considered a rescue or adjunctive option in selected high-risk cases3, 4.

Finally, current best practices for large-bore femoral access focus on meticulous preoperative planning, optimal puncture technique, and use of vascular closure devices to minimize vascular complications, as described in recent reviews3, 5.

Dr. Carlos Fernández Pereira, PhD, FACC, FESC, FSCAI
Editor-in-Chief of the Argentinian Journal of Interventional Cardiology (RACI)
cfernandezpereira@centroceci.com.ar

1. Gallardo Galeas P, Carminatti J, Cuezzo J, Pereyra M , Pérez MM. Angioplastia coronaria compleja con dispositivo de asistencia ventricular IVAC2L en paciente con deterioro severo de la fracción de eyección. Revista Argentina de Cardioangiología Intervencionista. 2025;16(3):111-114. doi: 10.30567/RACI/202503/0111-0114.

2. Lin PH, Bush RL, Conklin BS, Chaikof EL, Lumsden AB. Percutaneous bedside femorofemoral bypass grafting for acute limb ischemia caused by intra-aortic balloon pump. J Vasc Surg. 2002 Mar;35(3):592-4. doi:10.1067/mva.2002.119039.

3. Shah Z, Alraies MC, Soud M, Kaki A. Ex-Vivo Percutaneous Bypass: Limb Perfusion in the Setting of Occlusive Large Bore Sheath. Catheterization and Cardiovascular Interventions: Official Journal of the Society for Cardiac Angiography & Interventions. 2019;93(4):673-677. doi:10.1002/ccd.28022.

4. Merhi WM, Turi ZG, Dixon S, Safian RD. Percutaneous Ex-Vivo Femoral Arterial Bypass: A Novel Approach for Treatment of Acute Limb Ischemia as a Complication of Femoral Arterial Catheterization. Catheterization and Cardiovascular Interventions: Official Journal of the Society for Cardiac Angiography & Interventions. 2006;68(3):435-40. doi:10.1002/ccd.20875.

5. Paraggio L, Bianchini F, Aurigemma C, et al. Femoral Large Bore Sheath Management: How to Prevent Vascular Complications from Vessel Puncture to Sheath Removal.Circulation. Cardiovascular Interventions. 2024;17(9):e014156. doi:10.1161/CIRCINTERVENTIONS.124.014156.

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