Impella utilization in high-risk percutaneous coronary intervention (last remaining vessel)

#CardioTwitterCase originally published on Twitter

This case was originally published on Twitter by @AsherElad

Case description

We present the case of an 87-year-old male with sepsis and type II myocardial infarction who underwent Impella utilization in high-risk PCI.

The patient's RCA and LCX were occluded, and the last remaining coronary vessel was the LAD (and D1) (Figure 1).

The mid-LAD had a tight and heavily calcified lesion. Hence, we elected to use Impella mechanical support device in this high-risk PCI. We used ultrasonography together with micropuncture technic in order to get both accesses for the Impella and the “regular” 7F femoral sheath.

After guiding was placed in the LM coronary artery, a semi-compliant balloon was delivered, but, before we succeed to expand the lesion, the balloon burst. Hence, non-compliant and cutting balloons were also delivered but, again, burst before expanding the lesion (Figure 2 & Video 1).

Finally, we succeeded in expanding the lesion with a shockwave-balloon technique (Video 2). Lastly, a DES was placed and was further expanded with non-compliant balloon (Figure 3). 

Throughout the procedure, the patient was hemodynamically stable, with no chest pain. After PCI completion, the femoral sheaths were removed, and haemostasias was achieved, using ProGlide closure devices.

Final remarks

In conclusion, planning high-risk PCI is of paramount importance, especially if there is a “last remaining vessel”. Impella utilization in high-risk PCI might be a good option to treat this kind of patients.