Right Brachial Plexus Neuropathy Following Axillary Impella Placement: A Case Report

Case Diagnosis: A 33-year-old male with heart failure/reduced ejection fraction (LVEF 14%) secondary to ischemic cardiomyopathy diagnosed with brachial plexus neuropathy following Impella placement.

Case Description or Program Description: The patient was admitted following cardiac catheterization and underwent right axillary Impella placement. On Day 1 post-Impella placement, PM&R consultation noted sensory deficits in digits 4-5, and the medial forearm, with decreased strength of grip, medial FDP (2/5) and finger abductors (4-/5); digits 1-3 and lateral forearm remained unaffected. A CT of chest identified a 1.5 x 2.6 subacute hematoma or pseudoaneurysm, near the right subclavian artery. Despite continued occupational therapy treatment, deficits persisted post-Impella removal at 26 days. Nerve conduction studies on Day 42 demonstrated no response in the medial antebrachial cutaneous, median motor, and ulnar sensory and motor nerves, suggesting a medial cord brachial plexopathy. EMG findings supported this with involvement of muscles innervated by the median and ulnar nerves, but sparing of the pronator teres. There was denervation without reinnervation, indicating an acute process. Hospital readmission exam on Day 78 noted ongoing sensory deficits in the medial forearm and digits 4-5, with FDP weakness (3/5), impaired fine motor skills, and difficulty opposing digit 5. An MRI of the brachial plexus showed increased T2 signal and enhancement in the right medial cord and branches, with resolution of the mass seen on previous imaging.

Setting: Tertiary Care Hospital

Assessment/Results: The patient continued with cardiac rehabilitation and remained independent in ADLs, but has not regained fine motor skills to return to work as nail technician.

Discussion (relevance): This case highlights the potential for brachial plexus neuropathy following axillary Impella placement, with need for PM&R Consultation and ongoing OT treatment even after removal.

Conclusions: Clinicians should evaluate for upper extremity neuropathic injury after axillary Impella placement, as this may be a contribute to long-term deficits in functional capacity, affecting primarily fine-motor activities.