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