Protected percutaneous coronary intervention of complex distal left main disease with Impella CP™ support

Area of Science:

• Cardiology
• Interventional Cardiology
• Vascular Medicine

Background:

• Complex distal left main (LM) coronary artery disease with bifurcation involvement and chronic total occlusion (CTO) typically requires coronary artery bypass grafting (CABG).
• Patient refusal of surgery presents a challenge, necessitating high-risk percutaneous revascularization, often requiring mechanical circulatory support.
• Severe calcified distal LM stenosis with ostial circumflex involvement and a proximal left anterior descending (LAD) CTO pose significant revascularization challenges.

Purpose of the Study:

• To present a case of high-risk percutaneous coronary intervention (PCI) for complex LM coronary artery disease with CTO in a patient who declined CABG.
• To demonstrate the utility of mechanical circulatory support (Impella CP™) during high-risk PCI for LM bifurcation CTO.
• To highlight a successful revascularization strategy for complex LM disease using advanced PCI techniques and hemodynamic support.

Main Methods:

• A 66-year-old male with severe calcified distal LM stenosis and LAD CTO underwent high-risk PCI with Impella CP™ support.
• Lesion preparation involved rotational atherectomy and intravascular lithotripsy of the LM, LAD, and LCx.
• The LAD CTO was recanalized and treated with drug-eluting stents and drug-coated balloons; a double-kissing culotte technique was used for the distal LM bifurcation, guided by intravascular ultrasound.

Main Results:

• Successful recanalization and treatment of the LAD CTO and complex LM bifurcation lesion.
• Stable hemodynamics throughout the procedure, with Impella support mitigating instability during lesion modification.
• The patient was discharged on dual antiplatelet therapy and remained angina-free with preserved LVEF at 6-month follow-up, showing an excellent angiographic result.

Conclusions:

• Impella support can facilitate safe and complete revascularization for high-risk LM bifurcation CTO disease in patients who decline CABG.
• Protected PCI with Impella provides a viable alternative to surgery for anatomically complex LM disease, ensuring procedural stability.
• This case underscores the feasibility of advanced PCI techniques with mechanical support for complex coronary artery disease, leading to favorable patient outcomes.