Live Case: High-Risk PCI with Atherectomy, Stenting, and Impella® Support

George Vetrovec, MD, presents highlights from a challenging live high-risk PCI case involving a severely calcified graft lesion successfully treated with orbital atherectomy and stenting with hemodynamic support from an Impella heart pump. The operators in this case from St. Francis Hospital in New York are Jeffrey Moses, MD, Richard Shlofmitz, MD, and Allen Jeremias, MD.

The patient is a 79-year-old female with a longstanding history of CAD who presented with NSTEMI. At presentation, angiography revealed total occlusion of both native left and right coronary arteries. The graft to the RCA was occluded but the LIMA to the LAD was patent with a stenosis in the retrograde limb. The vein graft to a large circumflex system supplying collaterals to the right coronary territory had a proximal, severe calcified stenosis at the site of a prior stent. Left ventricular function was borderline normal.

Anticipating the need for atherectomy, the team decided to proceed electively with hemodynamic support and an Impella was placed without difficulty despite left femoral calcification. The lesion was successfully ablated with orbital atherectomy and a stent was placed in the proximal graft yielding an excellent angiographic result. The patient’s hemodynamics remained stable throughout the procedure with Impella support. 

“With the Impella going from P-2 to P-8 we have a 30% increase in flow,” Dr. Jeremias explains. “Which is what you’d expect. That’s pretty good.” While Dr. Shlofmitz wouldn’t necessarily use an Impella on a vein graft case with normal LV function, in this case, with so much myocardium at risk and the need for atherectomy, if something unpredictable went wrong, he emphasizes, “we would have been in trouble, so I’m glad that we put the Impella in.”

Dr. Vetrovec describes closure for this case as an excellent example of the hybrid closure technique. Dr. Shlofmitz removed the single-access coronary sheath followed by the Impella without difficulty or residual sheath bleeding. Because of vessel size and local calcium, the pre-close was a single Perclose inserted at the time of femoral access. After cinching of the single Perclose, modest bleeding persisted and the team placed a single Angio-Seal®, resulting in effective hemostasis. 

At follow-up one week later, Dr. Moses reports he is very pleased with the results. “She did terrific. She was asymptomatic. Was discharged the next day. Did beautifully.”

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