Successful use of impella CP through femoral access in a patient with bilateral iliac and aortic endoprosthesis in the setting of cardiogenic shock

Abstract

We report the case of a 67-year-old male, with previous history of severe peripheral vascular disease (abdominal aorta aneurism and bilateral iliac stenosis) requiring the implantation of 3 endoprostheses 7 months ago (Figure 1(A)), and previous myocardial infarction 10 years ago. The left ventricular ejection fraction (LVEF) was preserved at last control (58%). The patient was referred for acute coronary syndrome complicated with pulmonary oedema and cardiogenic shock. Echocardiography showed a severe impairment of LVEF (18%) and the patient was transferred to cathlab for emergency percutaneous coronary intervention (PCI). Coronary angiography via right femoral 7Fr access showed a chronic total occlusion of the mid-segment of the right coronary artery (RCA) and a severely calcified stenosis of proximal left anterior descending (LAD) (Figure 1(B)) which provided collateral circulation to RCA. The Heart Team concluded that the patient was too fragile to undergo surgery and opted for ad-hoc PCI of the culprit lesion with circulatory support device. Despite abdominal and iliac endoprosthesis, and extreme tortuosity of the aortic arch as well as the ascending aorta, Impella CP (Abiomed Inc., Danvers, Massachusetts, USA) was able to be successfully delivered and implanted without major difficulties through left femoral arterial access (Figure 1(C). Small low profiles balloons were not able to cross LAD lesion due to severe calcifications. Therefore, rotational atherectomy of LAD with a 1.5 mm burr was performed (Figure 1(D)) allowing balloon crossing. Then, further pre-dilatation was performed followed by one drug-eluting stent implantation and post-dilatation (Figure 1(E)). Impella CP allowed satisfactory hemodynamic status along the PCI procedure. Immediate outcome was good and the patient was discharged after 4 uneventful days. At 3-month follow-up, the patient was asymptomatic and LVEF was 45%. Recently, the use of Impella as left ventricular assist device supporting PCI has increased not only in the setting of cardiogenic shock but also in complex and high-risk elective procedures, with good short and long-term outcome. While hemodynamically the intra-aortic balloon pump modestly improves cardiac output by 0.5 L/min, the Impella CP provides 3.0–4.0 L/min of increased cardiac output and improves coronary perfusion. To the best of our knowledge, this is the first report of using Impella CP in a patient with iliac and aortic endoprosthesis. Despite the theoretical risk of vascular complication, our case highlighted the feasibility and the safety of PCI supported by Impella CP delivered through endoprosthesis and challenging anatomy. Further cases and larger series are required to extend its use in this particular subset of patients.