Impella™-assisted left main coronary artery intervention via aortofemoral bypass graft limb: a case report

ABSTRACT

Aortofemoral graft limbs are a rarely used and understudied option for large-bore access for mechanical support due to a risk of downstream vascular events. Here we present a case of left main coronary artery percutaneous intervention utilizing an aortofemoral bypass graft limb for large-bore access for mechanical support with successful hemostasis utilizing a widely available suture-based closure device.

Plain language summary

Article highlights.

• Aortofemoral bypass grafts are rarely utilized sites for large-bore access due to the risk of vascular complications.

• In patients with limited vascular access sites, aortofemoral bypass graft may be an option for large-bore access with safe closure achieved using a suture-based closure device.

• Close postprocedure follow-up with vascular imaging is necessary to ascertain the healing of the large-bore access site following closure.

• Additional evidence aside from anecdotal case reports supporting the safe utilization of aortofemoral bypass grafts for large-bore access is necessary.

1. Introduction

Left main coronary artery interventions in patients who are not candidates for coronary artery bypass grafting are becoming more common due to an increased life expectancy and multiple comorbidities. Mechanical circulatory support devices are routinely employed for left main complex coronary interventions in real-life practice despite a low strength of recommendation in the most current guideline iteration. Intra-aortic balloon pump (IABP) and Impella™ CP (Abiomed, MA, USA) are the two commonly used mechanical support devices for providing hemodynamic support during complex coronary interventions. The Impella CP requires the insertion of a 14-French (F) external diameter sheath. Common femoral artery, subclavian artery, and transcaval routes remain the most widely utilized large-bore access sites for mechanical circulatory support device insertion, with subclavian and transcaval routes utilized only in select institutes. An understudied and often underutilized access site is aortofemoral bypass graft limbs owing to the risk of vascular complications postprocedure, primarily driven by the lack of a safe hemostasis option emanating from the absence of physiologic recoil present in the arteries. In this Case Report, we illustrate a case of left main coronary intervention utilizing Impella CP for hemodynamic support via a right aortofemoral bypass graft and successful percutaneous hemostasis utilizing a commonly available suture-based closure device (Perclose™, Abbott Vascular, CA, USA).

2. Case presentation

A 79-year-old White male with a history of coronary artery disease and remote percutaneous coronary intervention (PCI) in the 1990s, with unknown coronary anatomy, abdominal aortic aneurysm repair, peripheral artery disease with aorto-bifemoral bypass grafting, chronic kidney disease stage III, hypertension, and hyperlipidemia, was admitted to the hospital with acute-onset chest pressure and dyspnea on exertion. His physical examination was unremarkable except for bilateral expiratory wheezing and crackles, left hallux and right first and second phalangeal amputation, absent left radial pulse, and feeble left dorsalis pedis pulse. His bloodwork was notable for anemia (Hb 10.3 g/dl), chronic kidney disease (eGFR 32 ml/min), creatinine 1.7 mg/dl (same as baseline) and an up-trending troponin I on serial measurements (peak 3.4 ng/ml). His chest x-ray showed vascular congestion with basilar edema and transthoracic echocardiogram showed a left ventricle ejection fraction 35–40% with moderate hypokinesis of entire anterolateral, inferolateral, and apical walls. His electrocardiogram was without new ST changes. His presentation, previous medical history, bloodwork, and imaging findings prompted differentiation between non-ST elevation myocardial infarction and type II myocardial infarction, for which he underwent coronary catheterization.

The patient was managed utilizing the early invasive pathway due to heart failure symptoms with concern for non-ST elevation myocardial infarction. He was initiated on heparin infusion, loaded with aspirin 324 mg, started on intravenous furosemide, and referred for coronary catheterization. Coronary angiogram via right radial artery approach showed distal left main bifurcation stenosis (Medina 1,1,1) (Figure 1) with 80% calcified ostial left circumflex stenosis, 60% distal left main stenosis extending into the proximal left anterior descending artery and 70% mid-left anterior descending artery stenosis with poststenotic dilation. HEART team discussion ensued Society of Thoracic Surgeons (STS) score for mortality 5% and was not considered a suitable candidate for coronary artery bypass grafting due to his comorbidities.

Figure 1.

Diagnostic coronary angiogram. Coronary angiogram of left coronary artery with a true bifurcation stenosis (Medina 1,1,1).

There was a severe disease of the native common femoral arteries and the aortofemoral bypass graft was used as a conduit for large-bore access after discussion with vascular surgery (Figures 2 & 3). The patient underwent successful Impella CP-supported (14-F sheath inserted via the right graft limb of the aortofemoral bypass graft), single-access PCI of the distal left main bifurcation using nano-crush, intravascular lithotripsy for predilation and kissing balloon inflation poststenting (Figure 4). The Impella CP was removed at the end of the procedure and hemostasis was achieved using three Perclose suture-based closure devices for preclosing (10, 3 and 6 o'clock positions). Written informed consent was obtained from the patient.

Figure 2.

Right femoral sheath injection. Peripheral angiogram of the right common femoral artery via a 5-F sheath revealing severe disease of the native right iliofemoral artery.

Figure 3.

Right aorto-femoral graft limb access. Fluoroscopic image of a 0.035″ J-tip wire passed into the aorta after vascular access utilizing the right aorto-femoral bypass graft limb.

Figure 4.

Post-intervention angiogram image. Final angiogram after successful percutaneous coronary intervention showing patent stents in the left main, proximal left anterior descending, and proximal left circumflex. There is pinching of the ramus ostium.

3. Follow-up

The patient did well with an improvement in heart failure symptoms. There was no vascular access site complication. He was discharged from the hospital to return home on the second postprocedure day. He was seen in the clinic on follow-up with improvement in his symptoms, no new complaints, and a lower artery duplex showing a patent and well-functioning bypass graft limb (Figure 5).

Figure 5.

Follow-up duplex ultrasound. Duplex ultrasound of the right aorto-femoral bypass graft showing patent graft and absent stenosis.

4. Discussion

This case highlights three important learning points. First, the utilization of hemodynamic support for complex PCIs has been extensively debated. Hemodynamic support prevents hypotension and augments cardiac output when periods of instability are expected with left main interventions in patients with reduced cardiac output, as in this case. Despite this, present guidelines provide a weak (IIb) recommendation in favor of hemodynamic support utilization during complex PCIs due to largely negative or equivocal studies [1–3]. It is important to note that the trials influencing the current guidelines do not include Impella CP, which is the current common iteration of Impella devices utilized and provides better hemodynamic support compared with the devices studied in the above-referenced trials and was the hemodynamic support device utilized in this case.

Second, the choice of hemodynamic support device used varies, with IABP and Impella being the most commonly utilized devices. Each device offers its particular set of advantages and risks, with a head-to-head comparison showing no significant advantage of Impella LP over IABP, although, as mentioned above, the current iteration (Impella CP) was not studied [3]. Availability, local practices, patient comorbidities, and operator comfort currently dictate the choice of hemodynamic support device used.

Third and final, the utilization of peripheral bypass graft limbs as an access site for large-bore access has been reported sparsely and not studied [4]. When utilized, access-site management is also understudied, with guidelines lacking regarding optimal management. Utilization of vascular closure devices is discouraged due to the risk of bleeding, limb ischemia, and/or infection because of the decreased elasticity of the polytetrafluoroethylene graft when compared with the native artery and surgical closure is encouraged [5,6]. The use of a suture-based closure device (Perclose) is a theoretically attractive option in terms of its similarity to surgical closure and avoidance of remnant intravascular components. This case reports on the successful utilization of an aortofemoral bypass graft limb for large-bore access and utilization of the Abbott Perclose Proglide system for successful closure postprocedure. We successfully utilized three Perclose devices, as opposed to the usual two devices, due to sutures breaking during the deployment of the second device. Although this is limited to a single case, we hope that this case may provide an impetus for further research to study the safety and efficacy of suture-based closure devices for hemostasis of large-bore access in aortofemoral bypass grafts, thereby allowing the utilization of aortofemoral bypass grafts as an additional avenue for safe large-bore mechanical access sites.

Author contributions

Each author contributed equally and substantially to the conception, writeup, revision and final proofreading of this manuscript.

Financial disclosures

The authors have no financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Competing interests disclosure

The authors have no competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Writing disclosure

No writing assistance was utilized in the production of this manuscript.

Ethical conduct of research

Written informed consent was obtained from the patient.