Patients with multivessel coronary artery disease (MVD) and reduced left ventricle ejection fraction (LVEF) present a challenging population sometimes requiring short-term mechanical circulatory support (MCS), such as the Impella CP device [1]. Optimal planning and prevention of its complications plays a vital role in patients’ prognosis [2].
A 74-year-old woman with MVD and multiple comorbidities – hypertension, obesity with body mass index of 38 kg/m2, anemia, hyperlipidemia, insulin-treated type II diabetes mellitus, class II chronic coronary syndrome according to Canadian Cardiovascular Society, chronic heart failure with a reduced LVEF of 20% and recurrent cardiac decompensations – on dual antiplatelet therapy (clopidogrel) was admitted to undergo an elective percutaneous coronary intervention (PCI), after being deemed eligible by a Heart Team.
The patient underwent computed tomography angiography (angioCT) to evaluate the access site and femoral arteries, which showed bilateral presence of calcified lesions and tortuosity (Figure 1 A). The lesions were more significant on the left side, so the right common femoral artery (RCFA) was chosen as a large-bore access site.
Figure 1
A – Rendered computed tomography angiography, femoral bifurcation and iliac arteries (arrow: tortuosity of right external iliac artery). B – Coronarography of left and right coronary artery, before percutaneous coronary intervention (PCI). C – Coronarography of left and right coronary artery, after PCI. D – Computed tomography angiography, performed after PCI (left arrow: massive contrast extravasation, forming hematoma in the abdominal wall, right arrow: right inferior epigastric artery)
Under ultrasound guidance, the RCFA was punctured, and automated mechanical sutures (Abbott, USA) and Prostyle devices were deployed, followed by the insertion of an Impella CP. During the procedure, some resistance was encountered in the iliac artery just beyond the sheath, but the device ultimately crossed and was successfully delivered to the left ventricle. The PCI was performed through right radial access.
Under intravascular ultrasound (IVUS) guidance, angioplasty of the left anterior descending artery (LAD) and the right coronary artery (RCA) (Figure 1 B) with orbital atherectomy was performed. Three drug-eluting stents (Xience 3.0 × 28 mm) were implanted – one in the LAD and two in the RCA (Figure 1 C) – achieving optimal results confirmed by IVUS. Following the procedure, the Impella device was removed, and the vascular access site was closed using 2 Prostyles and AngioSeal 8F (Terumo, Japan).
Postoperatively, the patient rapidly developed symptoms of hypovolemic shock with blood pressure of 70/40 mm Hg. The patient required transfusion of one unit of red blood cells (reserved earlier) and vasopressor infusion. AngioCT confirmed extravasation of contrast from the inferior epigastric artery (Figure 1 D), which formed a massive (28 × 8 × 6 cm) hematoma in the abdominal wall and muscles as a possible complication of external iliac artery tortuosity and the patient’s morbid obesity.
Surgical exploration of the vascular access site revealed minor bleeding from soft tissues. The artery was prepared under direct visualization, with continuous vascular sutures (Prolene 5-0). Prostyle sutures were removed.
The postoperative course was complicated by pneumonia, which was treated empirically with antibiotics. Two weeks after the procedure, after cardiological rehabilitation, the patient was discharged in a stable condition for further out-patient unit care.
Large-bore access PCI carries an increased risk of vascular injuries, hemorrhage, and other complications [3, 4]. Therefore, it is necessary to be prepared for such situations, in terms of meticulous planning (CT), and also by having several units of matched red blood cells reserved prior to the procedure.
