Case 194: Manual of PCI - Impella assisted trifucation PCI

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An elderly woman with EF=15%, on milrinone, occluded RCA and severe disease in the left coronary arteries was found to have viability in the LAD and circumflex territory and was referred for high-risk PCI. Given low EF and complex anatomy, Impella support was recommended. Due to severe PAD surgical cutdown was done in the right subclavian and a graft was placed through which an Impella CP device was inserted. The left main was challenging to engage with a guide inserted via the Impella sheath. Using the “Air Mail” technique a workhorse wire was advanced in the LAD facilitating guide engagement of the left main. Using various projections the coronary anatomy was clarified: 90% ostial LAD, 70% mid LAD, 70% ostial diagonal, 90% ostial circumflex lesions. A Sasuke microcatheter was used to wire the diagonal. The ramus was a small branch with a CTO that was crossed with wire support by a 1.5 mm balloon. IVUS showed severe distal left main/ostial LAD calcification. After predilatation a stent was placed in the proximal circumflex, followed by provisional stenting from the left main in to the LAD that compromised flow to the diagonal. After POT the diagonal was rewired with the Sasuke, followed by kissing balloon angioplasty in the LAD/diagonal but the result in the diagonal was suboptimal. The diagonal was eventually stented using the TAP technique. The patient had good recovery and the Impella was removed 2 days later.
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Cardiology
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