Successful Implantation of Impella 2.5 Through Left Femoral Approach After Angioplasty of Aortic Stent Graft in High-Risk PCI

Abstract

Introduction. Left ventricular assist devices help in reducing the cardiac workload, and provide circulatory assistance and protection to the myocardium and vital organs in patients with severe systolic dysfunction. Impella 2.5, a percutaneous left ventricular assist device, is increasingly being used for circulatory support in patients with high-risk percutaneous coronary interventions. Severe peripheral vascular disease is a relative contraindication for Impella placement. Presence of vessel tortuosity, calcification, stents and stent grafts in the aortoiliac vasculature may hinder insertion of Impella. However, we have been able to implant Impella in over 135 patients with relative ease. Some of these patients presented with peripheral vascular disease, but we were able to navigate through the vessels for successful implantation. Case report. We present the case of a 73-year-old patient with ischemic cardiomyopathy and an abdominal aortic aneurysm repaired with an aortic stent graft, who presented with unstable angina and multiple episodes of ventricular tachycardia. The patient had an 80% proximal left anterior descending stenosis for which high-risk intervention was planned using Impella support. Initial attempts at crossing the aortic stent graft were not successful due to vessel tortuosity and hindrance from stent graft struts. However, we were successful in placing Impella after balloon angioplasty of the aortic stent graft. Conclusion. Impella insertion in patients with aortoiliac disease and prior stent placement can be difficult. Intervention on peripheral vascular disease is often required prior to Impella insertion for high-risk angioplasty and can be safely performed during the same procedure. In our case, high-risk coronary angioplasty was performed with Impella support after balloon angioplasty of the aortic stent graft.

Introduction

Left ventricular assist devices have revolutionized the field of interventional cardiology, expanding the horizons of high-risk coronary procedures performed in the catheterization laboratory. Percutaneous coronary intervention (PCI) to multiple vessels is an option in patients who are poor candidates for coronary artery bypass graft surgery (CABG) or in cardiogenic shock in the setting of acute myocardial infarction. The development of percutaneous circulatory support devices such as Impella 2.5 (Abiomed, Inc., Danvers, Mass.) has resulted in significant improvement in outcomes due to hemodynamic stability provided by circulatory support.

The recently concluded PROTECT II study was a prospective, multi-center, randomized trial designed to measure a composite of major adverse events (MAE) in high-risk PCI patients requiring hemodynamic support.¹ PROTECT II compared composite MAE for patients supported with the Impella 2.5 to that of patients supported with the intra-aortic balloon pump (IABP). For the entire study cohort, the Impella arm experienced a 21% reduction in MAE at 90-day follow up compared to the IABP arm using the per protocol analysis (p=0.029). Using the intent to treat analysis, the Impella arm showed a strong trend toward reduced MAE at 90-day follow up compared to the IABP arm (16% reduction in MAE, p=0.087). Overall, Impella patients experienced a 56% reduction in out-of hospital MAE compared to IABP patients.

We report here our experience using an Impella catheter in a patient with aortoiliac tortuosity and stent graft repair for abdominal aortic aneurysm.

Case Report

A 73-year-old gentleman with extensive coronary artery disease, multiple coronary interventions including left main coronary stent placement, ischemic cardiomyopathy (left ventricular ejection fraction [LVEF] 20%), an automated implantable cardioverter-defibrillator (AICD), and a history of abdominal aortic aneurysm repair with aortic stent graft presented with unstable angina and multiple ICD shocks for ventricular tachycardia. His electrocardiogram (EKG) showed atrial fibrillation with rapid ventricular response and inferior/lateral ST-T wave changes. Based on his clinical presentation, cardiac catheterization was performed via a 6 French (Fr) right femoral arterial sheath. Angiographic findings revealed an left ventricular ejection fraction (LVEF) of 20% with global hypokinesis, 80% proximal left anterior descending (LAD) stenosis, mild circumflex disease and chronic total occlusion of the right coronary artery (RCA) with left to right collaterals.

A LAD intervention with Impella hemodynamic support was planned due to the patient's high-risk status and potential for hemodynamic compromise. An additional 6 Fr arterial access was obtained in the left groin for insertion of Impella and the arteriotomy was pre-closed with two Perclose (Abbott Vascular, Redwood City, Calif.) closure devices. The 6 Fr arterial sheath was progressively upsized to a 13 Fr peel-away sheath. A 0.014” Platinum Plus guide wire (Boston Scientific, Natick, Mass.) was introduced in the LV cavity using a multipurpose catheter for retrograde Impella insertion. Significant tortuosity of the aortoiliac system was encountered at the site of the stent graft, resulting in significant difficulty in advancing the Impella through the aortic stent graft. To facilitate the passage of the Impella catheter, angioplasty of the aortic stent graft was performed with a 7.0 x 60 mm EverCross balloon (ev3, Inc., Plymouth, Minn.). A second attempt at introducing Impella through the stent graft was made after angioplasty and was successful. Once Impella was in place, percutaneous transluminal transluminal coronary angioplasty (PTCA) and stent placement in the LAD stenosis was performed without any adverse hemodynamic consequences. At the end of the procedure, the Impella catheter was removed without complications and the two Perclose devices were deployed. Brief manual compression was performed to complete hemostasis. There was no bleeding or drop in hemoglobin (Hgb), and no CKMB elevation, but the patient did have mild troponin elevation, expected after PCI. The patient was discharged home after 3 days in stable condition with no complications.

Discussion

The advent of left ventricular assist devices has expanded the horizons of minimally invasive procedures performed in the catheterization laboratory. These devices provide circulatory support in patients with severe systolic dysfunction by decreasing the cardiac workload and increasing cardiac output, resulting in improved myocardial perfusion during high-risk PCI.² With percutaneous circulatory support devices like the Impella, aggressive interventions are possible for patients with advanced cardiovascular disease and multiple co-morbidities. Unfortunately, a high percentage of patients with advanced atherosclerotic cardiovascular disease also have significant peripheral vascular disease. Not uncommonly, these patients also have a history of interventions in the peripheral arterial system, such as stents and stent grafts.

Despite significant advances in percutaneous left ventricular assist devices, severe peripheral vascular disease, including thoracoabdominal aortic disease remains a relative contraindication to insertion of these devices. Additionally, aortic dissection, aortic valve regurgitation, aortic valve stenosis, severe aortic valve calcification, aortic valve prosthesis, and femoral-popliteal bypass grafts are some of the important contraindications. Potential complications include aortic valve injury with resultant aortic insufficiency, arrythmias, cerebrovascular accident, cardiac tamponade, vascular injury, hemolysis and limb ischemia.³

Large-caliber sheaths are required for insertion of these devices, which remains a concern for access site complications in patients with peripheral vascular disease. Due to the coexistence of peripheral vascular and coronary artery disease, it often becomes necessary to treat peripheral vascular disease first in order to proceed with placement of percutaneous left ventricular assist devices.

With advances in endovascular intervention, a large number of patients with abdominal aortic aneurysms are treated with stent grafts. A significant number of these patients also have concomitant coronary artery disease. Most of the time, if the vessels are not tortuous, standard 6 Fr catheters can be advanced without significant difficulty across these stent grafts. However, difficulty may be encountered in advancing larger-caliber catheters through these grafts, especially in tortuous vessels, with the chance of having stent struts protruding into the lumen.

In our case, a high-risk LAD intervention was performed with Impella support after balloon angioplasty of the aortic vessel graft, without significant adverse effects. Tortuous aortoiliac disease with an endovascular aortic stent graft presented a significant challenge, but preparedness to deal with peripheral arterial disease helped overcome this hurdle. Published case reports about Impella insertion and advancement in patients with aortoiliac stents are few. We are describing a case of high-risk percutaneous coronary revascularization with Impella implantation in a patient with a tortuous aortic stent graft where angioplasty of the stent graft was required prior to Impella insertion. Increasingly, percutaneous left ventricular assist devices are being used in complex peripheral vascular procedures.⁴ This case demonstrates that left ventricular assist devices such as Impella can be inserted in selected patients with advanced peripheral vascular disease by performing a peripheral intervention prior to high-risk coronary intervention in the same procedural setting.

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

The authors can be contacted via Dr. Tamam Mohamad at: tmohamad@dmc.org

Disclosure: Dr. Schreiber reports he is a consultant for Abiomed. Dr. Mohamad, Dr. Munir, and Dr. Aurakzai report no conflicts of interest regarding the content herein.

References

1. O’Neill W. PROTECT II: A prospective multicenter randomized clinical trial of intra-aortic balloon pump vs Impella for hemodynamic support during high-risk PCI. Presented at: ACC.11. American College of Cardiology Annual Scientific Session; 2011 April 2-5; New Orleans, Louisiana.
2. Henriques JP, Remmelink M, Baan J Jr., et al. Safety and feasibility of elective high-risk percutaneous coronary procedures with left ventricular support of the Impella Recover LP .2.5. Am J Cardiol 2006;97:990–992.
3. Pulido JN, Pak SJ, Rihal CS. Percutaneous left ventricular assist devices: clinical uses, future applications and anesthetic considerations. J Cardiothorac Vasc Anesth 2010;24(3):478–486.
4. arhat F, Sassard T, Attof Y, Jegaden O. Abdominal aortic aneurysm surgery with mechanical support using the Impella microaxial blood pump. Interact Cardiovasc Thorac Surg 2008;7:524–526.