Case 140: PCI Manual - Wait until the end...

A patient with unstable angina and left ventricular ejection fraction of 30% was found to have 3-vessel coronary artery disease (80% proximal RCA, 80% OM1, 70% proximal LAD, 100% mid LAD CTO). Cardiac MRI showed viability in all myocardial territories. She was turned down for CABG and referred for PCI. Right heart catheterization showed PA systolic pressure of 60 mmHg. An Impella CP device was placed via the right common femoral artery, followed by insertion of a 7 French sheath through the Impella sheath. We also obtained left common femoral access. The RCA and obtuse marginal lesions were successfully stented, followed by easy crossing of the mid LAD CTO with a Fielder XT-A guidewire. The LAD lesion was balloon undilatable but eventually expanded using an Angiosculpt balloon at 26 atm. Stenting of the LAD ostium was complicated by left main/circumflex dissection that required stenting of the left main. After removal of the Impella CP device the patient developed sudden hypotension. Iliac angiography showed a right common iliac perforation that was successfully sealed with a Viabahn VBX stent. The patient developed acute kidney injury but subsequently recovered without requiring dialysis.