“Shock-Pella”: Combined management of an undilatable ostial left circumflex stenosis in a complex high-risk interventional procedure patient

摘要

A 67-year-old woman with stage 4 chronic kidney disease, implantable cardioverter-defibrillatorand a history of multiple coronary interventions,both percutaneous (stenting of anterior descending artery [LAD], ramus and right coronary artery[RCA]) and surgical left internal mammary artery[LIMA] graft on LAD and saphenous vein grafts[SVG] on ramus and RCA), was admitted becauseof congestive heart failure with evidence of severe left ventricular ejection fraction decrease(25%). Coronary angiography showed occludedLIMA and SVG to ramus, patent SVG to RCA anda critical ostial left circumflex artery (LCx) stenosis(Fig. 1A). Since myocardial perfusion scintigraphy showed no viability on anterior wall and apex(Fig. 1B), a protected LCx lesion revascularizationwas attempted, positioning a circulatory mechanical support (Impella CP; Abiomed, Danvers, MA).Non-compliant balloons did not fully expand duringlesion predilatation, probably due to severe fibrocalcification and protruding ramus stent struts (intravascular ultrasound catheter did not cross the lesion) (Fig. 1C). Intravascular lithotripsy (IVL) wasthen performed (Shockwave Medical, Fremont,CA), inflating a 3.0 × 12 mm balloon (at 4–6 atmfor 8 cycles of 10 pulses each) with angiographicevidence of complete device expansion (Fig. 1D)and subsequent optimal lesion predilation withnon-compliant balloon (Fig. 1E). A 3.5 × 15 mmdrug-eluting stent was successfully implanted(Fig. 1F). This is a case of complex, high-riskinterventional procedure managed with combinedstrategy “Impella-assisted IVL” to prevent the riskof hemodynamic compromise in a time-demandingprocedure where an optimal and aggressive lesiondebulking was required.