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Retrograde Recanalization of Left Main from Saphenous Vein Graft Supported by Percutaneous Impella Recover LP 2.5 Assist Device
From the Catholic University of the Sacred Heart, Rome, Italy. The authors report no conflicts of interest regarding the content herein. Manuscript submitted March 2, 2009 and accepted March 31, 2009. Address for correspondence: Francesco Burzotta, MD, PhD, Catholic University of the Sacred Heart, Cardiology Department, Rome, 00168, Italy. E-mail: f.burzotta@rm.unicatt.it
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J INVASIVE CARDIOL 2009;21:E147-E150 ABSTRACT: Percutaneous coronary interventions (PCI) in patients with severely depressed left ventricular (LV) function and in those with chronic total occlusions are technically challenging and at high risk of complications. Here we report a case of successful retrograde transradial recanalization and stenting of a chronically occluded left main coronary artery (LMCA) from a saphenous vein graft supported by the Impella Recover LP 2.5 assist device. Key words: retrograde recanalization, left main, saphenous vein graft, Impella Complex percutaneous coronary interventions (PCI) in patients with severely depressed left ventricular (LV) function are increasingly performed in patients in whom the inherent risk of the underlying disease is very high. During these procedures, the risk of major hemodynamic and ischemic consequences is increased and is specially related to the prolonged ischemia time.1 The use of elective intra-aortic balloon pump (IABP) therapy may reduce acute complications occurring during PCI, but its efficacy in reversing this hemodynamic instability is limited.2 Therefore, a number of devices have been proposed for circulatory support during these high-risk PCIs, but no single approach has achieved wide acceptance.3–8 We previously reported the feasibility and long-term clinical results obtained using the Impella® Recover LP 2.5 assistance device (Abiomed Inc., Danvers, Massachusetts) during high-risk PCI, showing encouraging results.9 Among high-risk lesions, chronic total occlusions (CTOs) are known to be a relevant subset. Recently, retrograde recanalization has been proposed as a valuable technique to improve success rates in patients with prohibitive anatomy using the conventional antegrade approach.10 Here, we report a case of successful retrograde transradial recanalization and stenting of a chronically occluded left main coronary artery (LMCA) from a saphenous vein graft (SVG) supported by the Impella Recover LP 2.5 assist device. Case Presentation. A 72 years-old male with worsening heart failure (NYHA Class IV, lower limb edema) was referred to our department. He had a history of ischemic cardiomyopathy, isolated left main disease treated by coronary artery bypass graft surgery (CABG) with two grafts: the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and a SVG to the first obtuse marginal branch (OM). Relevant comorbidities were present including chronic obstructive pulmonary disease, peripheral artery occlusive disease and chronic renal failure, so that the patient’s calculated Euroscore was 14. Transthoracic echocardiography (TTE) showed severe deterioration (compared to previous controls) of LV function (ejection fraction [EF] = 25%), severe mitral regurgitation (which was not present in past examinations) and pulmonary hypertension (systolic pulmonary pressure = 56 mmHg). According to our catheterization laboratory practice,11 we performed coronary angiography via radial access which revealed chronic ostial LMCA occlusion, a proximal LIMA occlusion and a patent SVG with significant OM stenosis proximal to the anastomosis which retrogradely supplied the entire left system (Figure 1). The right coronary artery (RCA) was not significantly diseased. In order to treat the patient’s severe coronary artery disease, we planned to attempt retrograde recanalization of the LMCA from the SVG. Due to the significantly jeopardized area and the severe reduction of LV function, we decided to perform PCI with support using the Impella Recover 2.5 assist device. The procedure was performed 8 days after the coronary angiography. To perform the antegrade and retrograde approaches, we decided to use the right and left radial arteries. Two 25 cm long 6 Fr hydrophilic sheaths (Terumo Medical Corp., Tokyo, Japan) were inserted in the right and left radial arteries. Peripheral angiography performed from the right radial artery revealed mild aneurysmatic dilatation of the abdominal aorta and critical stenosis of the left common iliac artery, so that the right femoral artery was selected for Impella assistance. After arterial puncture and preimplantation of 2 suture-mediated vessel closure devices (Abbott Laboratories, Abbott Park, Illinois), the 13 Fr sheath (Terumo) necessary for Impella implantation was inserted. Under fluoroscopic guidance, the Impella pump was advanced over a dedicated 0.014 inch exchange guidewire into the LV; once in position, the output was fixed at maximal speed. A 6 Fr Amplatz left 1 (left radial artery) and 6 Fr 3.5 extra-backup (right radial artery) guiding catheters were inserted to cannulate, respectively, the SVG and the left coronary sinus (due to ostial LMCA occlusion, selective left coronary cannulation was not possible). Then, a 0.014 inch BMW universal coronary wire (Guidant Corp., Indianapolis, Indiana) was advanced retrogradely through the SVG into the proximal left circumflex artery (LCX) supported by a Falcon CTO 1.0 mm over-the-wire balloon (Invatec SpA, Roncadelle, Italy). The wire was placed in the distal portion of the LAD (Figure 2), thus allowing sufficient support for retrograde advancement of the over-the-wire balloon up to the proximal segment of the LCX. With the over-the-wire balloon in such a position, several unsuccessful attempts with a Choice PT Graphix (Boston Scientific Corp., Natick, Massachusetts), a Pilot 200 (Abbott), a Miracle 6 and 9 g Conquest Pro (Asahi Intecc, Tokyo, Japan) guidewires were performed before the occlusion was successfully crossed with a 0.014 inch 12 g Conquest-Pro guidewire (Figure 3). Then, the wire was left in the ascending aorta and dilatations were performed retrogradely with 1.0 x 10 mm, 2.5 x 15 mm and 3 x 20 mm balloons. Subsequently, it was possible to selectively cannulate the LMCA using the contralateral 6 Fr 3.5 extra-backup guiding catheter (Figure 4), and two 0.014 inch BMW universal guidewires (Abbott) were positioned antegradely in the LAD and LCX. Next, a 4 x 15 mm Xience everolimus-eluting stent (Abbott) was deployed, achieving a good final angiographic result (Figure 5). After the procedure, the patient’s hemodynamic status remained stable so that the Impella pump and the femoral sheath were removed immediately after the PCI and immediate hemostasis was achieved with the 2 preimplanted suture-mediated vessel closure devices. The patient had an uneventful post-PCI course and a TTE control performed 4 days later showed marked LV contractility improvement, with a LVEF of 40% and regression of mitral regurgitation to a mild degree (systolic pulmonary pressure = 31 mmHg). Six days after the procedure, the patient was discharged. Discussion. The reported case represents successful percutaneous management of a patient who presented the combination of high risk of hemodynamic deterioration, relevant comorbidities and complex target lesion anatomy with anticipated procedure-related prolonged ischemia. Repeat CABG might have been considered an alternative to PCI, but our patient was regarded as a poor candidate due to his comorbidities (chronic obstructive pulmonary disease, peripheral artery occlusive disease and chronic renal failure) and his unstable clinical conditions leading to a prohibitive surgical risk (as estimated by Euroscore). The target lesion was an ostial LMCA occlusion with no stump in the coronary sinus. Such an anatomical scenario represents a special situation where the adoption of a retrograde approach may increase the success rate.10 Since the procedure was retrogradely performed using the SVG to the OM (and a significant stenosis was present immediately proximal to the graft’s distal anastomosis on the OM), a high risk of prolonged ischemia and hemodynamic intolerance were anticipated. In such cases, hemodynamic support devices (able to provide more efficient support compared to a simple IABP) are considered to offer an important option to reduce the risk of procedure-related hemodynamic complications. Among such devices, the Impella is a promising one, as it may be inserted percutaneously at the time of the coronary procedure,12 provides effective hemodynamic support7 and has been shown to be safe during high-risk PCI.9 Finally, it is noteworthy to underline that complex patients with unstable compensation are fragile and may not tolerate hemorrhagic complications related to arterial access. Accordingly, we tried to minimize such risks by selecting double-radial access for PCI and a double-Perclose suture-mediated closure device (Abbott Vascular) preimplantation technique for 13 Fr femoral sheath immediate removal.9,13 The absence of access-site complications further support the efficacy of suture mediated haemostasis when bulky devices are implanted. Minden et al14 described one case of transradial LMCA angioplasty supported by the Impella device. However, to the best of our knowledge, this is the first report of successful retrograde recanalization of the LMCA via transradial access supported by a percutaneously implanted Impella LP 2.5 assist device.
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