High risk PCI with Impella Device

PIG Meeting: 29th April 2021

74-year-old man for PCI to left main coronary artery prior to vascular surgery

Background

  • Intermittent claudication at 100m
  • Thrombosed popliteal artery aneurysm, requiring stent
  • CABG 22 years ago
  • Previous LAD stent, now totally occluded
  • Open AAA repair 5 years ago, uneventful
  • Lives independently on acreage. Active, Chops wood.

Issues

  • Elective review by vascular surgeon revealed exertional dyspnoea
  • Sestamibi organised by surgical team showed a significant area of reversible ischaemia
  • Cardiologist review, proceeded to angiogram
  • Previous LAD stent, now totally occluded. All coronary grafts blocked. Native vessels severely blocked.
  • If requires PCI it would be High risk– Left-main and LAD disease. Likely need rotablade with significant chance of impaired coronary perfusion and myocardial stunning.
  • LVEF = 25%
  • Cardiologist advised that if PCI is performed preoperatively, an Impella device would be required

Discussion

Indication for stress test?

  • AHA guidelines would indicate that no myocardial stress imaging is indicated
  • Patient can perform > 4mets and is relatively asymptomatic
  • Cardiologist opinion that medical management is appropriate given lack of symptomatology
  • PCI is requirement for further anaesthesia and vascular surgery
  • Vascular symptoms are limiting exercise tolerance

What is an Impella device and why is it used?

  • Impella is a centrifugal pump which acts as Left ventricular assist device
  • The device pumps blood from the LV into the ascending aorta at an upper rate of 2.5L/min
  • Percutaneously inserted via 14fr sheath into the femoral artery
  • Multiple indications including high risk PCI. See www.impella.com and Protect II trial.

Plan

  • Continue to present novel cases such as this to aid in dissemination of knowledge
  • Consider presentation at CME
  • Note vascular surgical patients have baseline higher risk of significant coronary artery disease

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