Defining the Optimal Revascularization Strategy During Protected High-Risk Procedures With Impella® Heart Pumps¹

This article explores optimal revascularization strategies for patients undergoing Protected PCI. The authors note that recently published PROTECT III trial data suggest that more complete revascularization (CR) during Impella-protected PCI with more extensive lesion preparation and treatment results in reduced need for repeat revascularization and improved survival. They recommend that to achieve complete revascularization and improve survival it is essential to have procedural guidance by intravascular imaging, extensive lesion preparation, debulking with atherectomy devices, advanced chronic total occlusion (CTO) revascularization techniques, and post-interventional treatment with modern antiplatelet medication.

While CR is an ideal objective for all patients with multivessel coronary artery disease (CAD) undergoing myocardial revascularization, the authors acknowledge that CR is not always possible in clinical practice. Operators determine whether to treat all lesions in one procedure or to stage revascularization. Contrast volume, length of fluoroscopy, and renal insufficiency may dictate staging a procedure. 

To achieve CR, especially in complex cases, interventional cardiologists need to be trained on the use of mechanical circulatory support devices such as the Impella® heart pump, as well as specialized techniques for handling CTOs, calcified vessels, and complex bifurcation disease. Results from the PROTECT III trial have helped to expand knowledge of CR in these complex cases and highlight best practices for Protected PCI.