Work

Case Report: Impella CP-protected percutaneous coronary intervention of the last remaining vessel—a LIMA-to-LAD graft—complicated by no-reflow and rescued with a drug-coated balloon

Year: 2026

Type: article

Abstract: Percutaneous coronary intervention (PCI) of the last remaining conduit in a patient with severely impaired left ventricular function is among the most hazardous procedures in contemporary interventional cardiology, as any interruption of flow essentially constitutes a global ischemic insult. We describe a 77-year-old man, a former heavy smoker with an 80-pack-year smoking history, who had undergone three-vessel coronary artery bypass grafting (CABG) 22 years previously. His medical history also included chronic obstructive pulmonary disease, severe heart failure with a left ventricular ejection fraction of 25–30%, and severe mitral regurgitation (MR). At presentation, he had Canadian Cardiovascular Society class III angina and New York Heart Association class III symptoms. The most recent coronary angiogram, performed 6 months earlier, demonstrated chronic total occlusion (CTO) of both saphenous vein grafts, in addition to CTO of all three native epicardial coronary arteries. Thus, the left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD) represented the sole functional conduit, directly perfusing the LAD territory and supplying the right coronary and circumflex territories through primarily septal and epicardial collaterals, respectively. The LAD displayed two sequential severe stenoses (≥80% each), one at the distal LIMA–LAD anastomosis and another further distally in the native vessel. In accordance with current coronary revascularization guidelines, the Heart Team recommended evaluation by cardiac surgeons. Two independent cardiothoracic surgeons declined redo CABG as a viable therapeutic option. Complex and high-risk indicated PCI (CHIP) was therefore considered the only feasible revascularization strategy. Additional hemodynamic support with percutaneous mechanical circulatory support (pMCS) was deemed necessary. Residual MR and arrhythmic risk, including the potential indication for an implantable cardioverter-defibrillator (ICD), were planned to be reassessed 3 months after successful percutaneous revascularization. CHIP was performed under full hemodynamic support with a continuous-flow microaxial pump (Impella CP with SmartAssist) inserted via the left femoral artery, while coronary intervention was performed through the ipsilateral radial artery using a 6-F IMA guiding catheter. The lesions were successfully crossed with a workhorse wire, despite substantial technical difficulty and with the aid of a microcatheter; however, distal flow was immediately lost, and intracoronary nitroglycerin failed to restore it. Balloon angioplasty restored flow only partially, and a decision was made to proceed with stent implantation. However, stent delivery proved challenging, requiring a guide-extension catheter to be advanced deep into the LIMA body using the so-called ‘inchworming technique.’ Despite successful implantation of the first drug-eluting stent (DES) at the distal anastomotic lesion, a second DES could not be advanced to the more distal native LAD lesion, despite the use of multiple guidewires and supportive guiding-catheter strategies. Therefore, a drug-coated balloon (DCB) was used as a bailout strategy, immediately restoring TIMI grade 3 flow and leaving only a minor, non-flow-limiting type B dissection. Impella support was discontinued early because of access-related left lower-limb ischemia, and successful percutaneous hemostasis was achieved using a suture-based closure technique. Peak high-sensitivity troponin I, measured the following evening, was 10,800 pg/mL. The patient was discharged ambulatory on day 2 and remained asymptomatic at 3-month follow-up, when an ICD was implanted for primary prevention. This case illustrates the critical role of pMCS in maintaining hemodynamic stability when native coronary flow is lost during PCI of the last remaining conduit and highlights the value of DCB angioplasty as a bailout strategy when stent delivery is not feasible.

Source: Frontiers in Cardiovascular Medicine

DOI: 10.3389/fcvm.2026.1951936