Introduction

We present a 63-year-old male with chronic angina, ischemic cardiomyopathy with an ejection fraction of 20%. He had coronary artery bypass grafts placed in 1990 and has a bi-ventricular implantable cardiac defibrillator (ICD). He presented with chest pain and a mild troponin elevation. A cardiac catheterization was performed, which revealed a 95% left main calcified stenosis with an occluded left anterior descending artery (LAD) and a patent but distally diseased left interior mammary artery (LIMA). He also had an occluded circumflex vessel, a ramus with a diffuse 80% stenosis, and an occluded right coronary artery (RCA). A saphenous vein graft (SVG) to the ramus/first obtuse marginal branch (OM1) was occluded but the segment of graft from the ramus to the OM1 was patent. Hemodynamics revealed elevated pulmonary capillary wedge pressure (PCWP).

The patient was admitted to the critical care unit. An aortogram and a computed tomography (CT) scan of the chest revealed severe torturosity of the aorta. A cardiac surgery consultation concluded that there were poor distal targets and that the patient was considered too high risk for a repeat surgical procedure.

Device description

The Impella 2.5 (Abiomed, Danvers, MA) is a percutaneously placed circulatory support device which provides up to 2.5L per minute of flow from the left ventricle directly into the ascending aorta. The 12 French (Fr) pump is mounted on a 9 Fr catheter that is connected to the Impella mobile console.

Clinical summary

An attempt was made to place access for the percutaneous coronary intervention (PCI) through the left femoral artery. We were unable to pass the wire through the tortuosity. The decision was made to place the Impella via the right femoral approach and it was subsequently inserted without difficulty. We were able to carry out the PCI from the right brachial artery. This allowed us to proceed with the intervention and properly treat all of the lesions while the patient was supported by the Impella 2.5.

Discussion

This clinical case demonstrated the feasibility of a minimally invasive circulatory support device, the Impella 2.5, in the context of severe multiple coronary artery disease and a tortuous and difficult to navigate ileofemoral artery. The tortuosity presented in this case was not characterized by excessive calcification. Severely calcified vessels present a challenging situation above and beyond simple tortuosity, and should be approached with much caution. The patient’s diastolic and mean pressures were maintained during times of systolic pressure drop due to balloon inflation during stent deployment.

Dr. Mulukutla can be contacted at mulukutlasr@upmc.edu