Background

In severe three-vessel coronary artery disease with high SYNTAX score coronary bypass surgery is the preferred treatment option in patients suitable for surgery. However, in patients with severe comorbidities and high perioperative risk, PCI should be considered. Protected-PCI with a percutaneous axial pump allows to treat very severe coronary disease with a high risk of hemodynamic compromise. We present a case of a protected PCI in a patient with complex coronary artery disease, two chronic total occlusions (CTO) and significant left main (LM) disease.

Case report

An 81-year-old patient was admitted to our clinic due to acute coronary syndrome. We established the diagnosis of non-ST-segment myocardial infarction and performed early coronary angiography. This revealed a severe three-vessel coronary artery disease with high-grade LM stenosis and CTOs of the left anterior descending (LAD) and right coronary artery (RCA) with preserved systolic left ventricular function. Left circumflex (LCX) was stented 10 years ago and showed mild to moderate disease (Figure 1). The patients’ medical history included prostate carcinoma and pharyngeal carcinoma. Pharyngeal carcinoma was treated by local resection an adjuvant radiotherapy. Furthermore, peripheral artery disease and moderate carotid artery stenoses on both sides were diagnosed. Interdisciplinary heart-team recommended interventional treatment due to high surgical risk.

Due to risk of hemodynamic compromise due to last-vessel PCI we decided to perform protected PCI. First, percutaneous axial circulatory support with Impella CP® was introduced over the right femoral artery (Figure 2). Thereafter, LM PCI was performed as provisional stenting LMàLAD (Figure 3). Then, antegrade recanalization of the LAD with balloon dilatation was performed (Figure 4). Via the second arterial access through right radial artery, we aimed to antegrade recanalize the RCA. Unfortunately, this was not successful due to a long occlusion. Thus, we successful performed retrograde recanalization through a septal collateral from LAD with externalization and final stenting of the RCA (Figure 5). Finally, the LAD was stented (Figure 6). The patients remained hemodynamically stable and symptom-free throughout the whole procedure. The Impella pump was explanted directly after the procedure and the femoral artery was closed by two percutaneous sutures (Proglide®). The patient did well after the procedure and was discharged two days later.

Conclusion

We present a coronary procedure with last-vessel LM-PCI and recanalization of two CTOs. Hemodynamic support with a percutaneous axillary pump allows to safely perform even complex PCIs with significant reduction of risk of hemodynamic instability during the procedure.