Complex Left Main Coronary Intervention for In-Stent Restenosis Facilitated by Use of Percutaneous Left Ventricular Assist Device

Abstract

Left ventricular assist devices have proven to reduce cardiac workload and provide circulatory assistance and protection to myocardium during revascularization of severe coronary artery disease specifically involving the left main. We present a case of successful emergent percutaneous left main coronary revascularization of in-stent restenosis using a left ventricular assist device in a 74-year-old male that endured ventricular fibrillation and cardiogenic shock upon induction of anesthesia for surgical revascularization in the operating room.

Case Report

A 74-year-old male with history of coronary artery disease, hypertension, and dyslipidemia presented with progressive symptoms of unstable angina. An initial coronary angiogram six months earlier revealed severe distal left main (LM) stenosis, complicated by diagnostic catheter tip-induced left main dissection into the ramus branch during radial angiography, followed by hypotension and cardiac arrest requiring emergent bare metal stent placement (with use of the T-stenting technique) from the LM into the left anterior descending coronary artery (LAD) and ostial ramus arteries, with good angiographic result (Figure 1). The patient was discharged home 5 days later.  However, recurrent progressive symptoms six months later prompted admission for a repeat coronary angiogram. Laboratory analysis was negative for cardiac biomarkers of myocardial infarction. Echocardiogram revealed a preserved left ventricular (LV) ejection fraction of 60%, without any wall motion abnormalities. A subsequent coronary angiogram revealed a severe proximal LM stenosis of 70-80%, and severe 90% distal LM in-stent restenosis into both the LAD and ramus arteries (Figure 2). Cardiothoracic surgery was consulted and the patient prepared for coronary artery bypass grafting (CABG).

However, on the day of CABG, during induction of general anesthesia, the patient developed sustained ventricular fibrillation and cardiogenic shock in the operating room, requiring resuscitation. CABG was deferred due to hemodynamic instability prior to initiation of surgery. A percutaneous left ventricular assist device (Impella, Abiomed, Danvers, MA) was placed in the operating room via right femoral artery access and positioned in the LV using transesophageal echocardiography guidance. The patient was transferred to the catheterization laboratory for high-risk LM coronary intervention. The Impella position was confirmed under fluoroscopy (Figure 3) and set at level P7 for a cardiac output of 1.7 L/min. Access was obtained in the left femoral artery using an 8 French sheath and an 8 French JL4 guide with side holes was used to engage the LM and confirm prior angiographic anatomy. A Kinetix wire (Boston Scientific, Natick, MA) was used to cross the lesion in the LM into the ramus branch. A Choice Intermediate wire (Boston Scientific) was used to cross the LM lesion into the distal LAD. An Apex 3.0 x 12 mm balloon (Boston Scientific) was used to pre-dilate the ostial left circumflex (LCX) at 10 atm with good expansion. Intravascular ultrasound (IVUS) of the LM bifurcation confirmed severe in-stent restenosis of the LCX and LAD stents, with a severe ostial LM stenosis that was uncovered by the previous stent. A Taxus 3.5 x 38 mm stent (Boston Scientific) was deployed in the LM extending into the first obtuse marginal branch (OM1) at 9 atm (Figure 4). The Choice Intermediate wire was retrieved from the LAD and the same wire used to cross the stent struts into the distal LAD. A second Taxus 3.5 x 38 mm stent was then deployed at 9 atm from the LM into the LAD using a culotte bifurcation technique through the LM/LCX stent (Figure 5). The Kinetix wire was retrieved from the OM branch and used to rewire through the stent struts into OM1. Simultaneous kissing balloon inflations (Figure 6) were performed using an NC Quantum Apex 2.5 x 12 mm balloon in the LAD and NC Quantum Apex 3.5 x 12 mm balloon in the LCX at 12 atm, with good expansion at the bifurcation. Next, the balloons were exchanged for the NC Quantum Apex 3.5 x 12 mm in the LAD and the NC Quantum Apex 2.5 x 12 mm balloon in LCX at 12 atm, with good expansion. Final angiogram (Figure 7) and repeat IVUS of the LAD and LCX into the LM confirmed adequate stent expansion and apposition.

The patient was transferred to the intensive care unit for further care, where Impella support was discontinued the following day. He was weaned off pressor agents and extubated for a successful recovery and discharge home 5 days later. The patient underwent repeat diagnostic coronary angiography 2 months later that confirmed patency of all his stents (Figure 8). Repeat echocardiogram showed a preserved left ventricular ejection fraction of 65% without any wall motion abnormalities.

Discussion

Until recently, CABG was the primary mode of revascularization for significant LM stenosis. Percutaneous coronary intervention (PCI) had generally been restricted to patients considered inoperable or high risk for CABG, or with prior CABG and at least one patent graft to the LAD or LCX. Early studies performed on PCI of the LM, before revascularization with CABG became the standard of care, revealed poor prognosis for these patients, with 3-year survival as low as 37 percent.¹ CABG, when directly compared to medical therapy, is associated with significantly better cardiovascular outcomes, including mortality.² A number of registry reports as well as observational studies suggested that PCI may be a viable option for patients with unprotected LM disease³, but it was not until the randomized SYNTAX (Synergy between PCI with Taxus and CABG) LM substudy that PCI was accepted as a safe and feasible alternative.⁴ According to SYNTAX, the primary outcome of major adverse cardiac or cerebrovascular events (MACCE) at 12 months was not significantly different in the PCI and CABG groups, with PCI having a significantly higher rate of repeat revascularization and a significantly lower stroke rate.⁴ More recently, the PRECOMBAT trial randomly assigned 600 patients with unprotected LMCA disease to PCI with sirolimus-eluting stents or CABG, and the primary end point of MACCE at one year met the criteria for non-inferiority of PCI.⁵ The MAIN-COMPARE registry confirmed that, at 5-year follow up, PCI had similar rates of MACCE compared to CABG.⁶ These findings resulted in the 2009 focused update of earlier guidelines, concluding that PCI of LM lesions may be considered in patients with anatomic conditions that are associated with low risk of PCI procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes.⁷ The use of the Impella 2.5 percutaneous left ventricular assist device has been shown to further reduce the incidence of major adverse events during high-risk coronary interventions.⁸ We presented a complex case of LM bifurcation in-stent restenosis that was successfully treated by PCI using a percutaneous left ventricular assist device.

This article received a double-blind peer review from members of the Cath Lab Digest editorial board.

The authors can be contacted via Dr. George at jcgeorgemd@hotmail.com.

References

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Disclosure: Dr. Desai reports no conflicts of interest regarding the content herein. Dr. George reports that he is a consultant for Boston Scientific Corporation.