Case 120: PCI Manual: Staged culprit and non-culprit PCI

A patient with diabetes and prior below-the-knee amputation presented with NSTEMI. He had an ejection fraction of 35% with anterior and inferior ischemia on stress testing. Coronary angiography showed a mid right coronary artery lesion with an intraluminal filling defect and a heavily calcified chronic total occlusion of the mid LAD. He had acute on chronic renal disease with a creatinine of 2.6 mg/dL. The heart team recommended staged PCI of the RCA and the LAD.
Given a pulmonary capillary wedge of 33 mmHg, we decided to use hemodynamic support with an Impella CP device. Preclosure of the femoral access site was done with Perclose sutures but there was poor antegrade flow post insertion of the Impella sheath. After discussion with vascular surgery we proceeded with PCI of the RCA that was successfully completed using a Spider embolic protection device. The patient remained hemodynamically stable and the Impella device was removed at the end of the procedure with restoration of antegrade flow to the leg and good hemostasis after removal of the Impella sheath.
The patient underwent staged PCI of the LAD CTO. Antegrade wiring and re-entry attempts with a Stingray balloon failed, but retrograde crossing was successful using the guide extension reverse CART technique with a nice final result.