Calcium in the Way: Impella-Supported High-Risk Percutaneous Coronary Intervention in an Elderly Patient with Heart Failure, Progressive Multi-Vessel Coronary Disease, and Prior Iliac Stenting

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Elderly male patient (80 years) with heart failure with reduced ejection fraction (LVEF 20-25%), progressive multi-vessel heavily calcified coronary artery disease including unprotected distal left main, and prior bilateral iliac artery stenting for peripheral arterial disease (n=1). Intervention: Impella CP mechanical circulatory support device with high-risk percutaneous coronary intervention employing rotational atherectomy, intravascular lithotripsy, and double-kissing crush two-stent strategy. Primary outcome: Successful high-risk PCI supported by Impella device with no intra-procedural complications and freedom from recurrent ventricular arrhythmias or angina at 3 months follow-up.

Q: What does this research mean for the field?

Impella-supported high-risk percutaneous coronary intervention with combined rotational atherectomy and intravascular lithotripsy can safely achieve revascularization in elderly patients with severe left ventricular dysfunction, progressive multi-vessel disease, and prior iliac stenting. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Nina S Appareddy; Bradley Casey; Bhavith Aruni

doi:10.7759/cureus.104613

March 3, 2026CureusOpen Access

Calcium in the Way: Impella-Supported High-Risk Percutaneous Coronary Intervention in an Elderly Patient with Heart Failure, Progressive Multi-Vessel Coronary Disease, and Prior Iliac Stenting

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Key Points

To describe hemodynamic support and vascular access strategies during high-risk percutaneous coronary intervention in an elderly patient with heart failure and prior iliac stenting.
Evaluated an 80-year-old male presenting with heart failure with reduced ejection fraction, ventricular fibrillation, and multivessel coronary artery disease turned down for coronary artery bypass grafting.
Assessed peripheral vasculature using computed tomography and angiography to plan 14 Fr large-bore femoral access through previously stented iliac arteries for mechanical circulatory support.
Angiography identified an LVEF of 20-25%, 60% distal left main stenosis, 70% proximal left anterior descending stenosis, 95% proximal left circumflex stenosis, and a right coronary artery chronic total occlusion.
Multidisciplinary planning enabled bilateral femoral arterial access to deliver transcatheter micro-axial flow pump support alongside rotational atherectomy and intravascular lithotripsy for complex calcium modification.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 80-year-old male patient with heart failure with reduced ejection fraction (LVEF 20-25%), heavily calcified multi-vessel coronary artery disease (distal left main, LAD, LCx, and RCA CTO), and peripheral arterial disease with prior bilateral iliac stenting.

I

Intervention

High-risk percutaneous coronary intervention (PCI) using rotational atherectomy, intravascular lithotripsy, and double-kissing crush stenting, supported by a transcatheter micro-axial flow pump (Impella CP) via bilateral femoral arterial access.

O

Outcome

Procedural success and clinical stability without complications.

Multidisciplinary planning and careful access assessment can enable safe and successful Impella-supported high-risk PCI via femoral access even in patients with severe peripheral arterial disease and prior iliac stenting.

Limitations

Single patient case report without a comparator
No long-term outcome data beyond three months
Findings not generalizable due to single case
Lack of quantitative outcome measures such as mortality or rehospitalization rates

Implication

Careful access assessment enables safe femoral Impella use in high-risk PCI despite prior iliac stenting; extends options in severe PAD but remains hypothesis-generating.

Abstract

We present the case of an 80-year-old male patient with heart failure with reduced ejection fraction and heavily calcified, multi-vessel coronary artery disease involving the distal left main, left anterior descending, and left circumflex arteries, along with a chronic total occlusion of the right coronary artery. He was turned down for surgical revascularization with coronary artery bypass grafting. He initially remained stable on medical therapies and underwent implantable cardioverter defibrillator implantation. He presented back with ventricular fibrillation. Repeat angiography demonstrated progression of his disease. He was planned for high-risk percutaneous coronary intervention supported by a transcatheter micro-axial flow pump. Given his history of peripheral arterial disease (PAD) with prior iliac stenting, vascular surgery was consulted to facilitate large-bore access to initiate support, ultimately deciding on bilateral femoral arterial access.

Discussion

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Cite This Study

Appareddy et al. (2026) conducted a case report in Elderly male patient (80 years) with heart failure with reduced ejection fraction (LVEF 20-25%), progressive multi-vessel heavily calcified coronary artery disease including unprotected distal left main, and prior bilateral iliac artery stenting for peripheral arterial disease (n=1). Impella CP mechanical circulatory support device with high-risk percutaneous coronary intervention employing rotational atherectomy, intravascular lithotripsy, and double-kissing crush two-stent strategy was evaluated on Successful high-risk PCI supported by Impella device with no intra-procedural complications and freedom from recurrent ventricular arrhythmias or angina at 3 months follow-up.

synapsesocial.com/papers/69aa6ee2531e4c4a9ff590a1 https://doi.org/10.7759/cureus.104613