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

Figures

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  Figure 1. Native 3-vessel coronary artery disease (A) Nonselective left coronary artery cannulation (AP/caudal projection) demonstrating severe diffuse LM coronary artery stenosis, a mid-LAD CTO with ambiguous cap distal to the origin of a large septal branch, and a proximal-lcx CTO distal to the origin of the 1st OM branch-again with an ambiguous proximal cap as well. (B) Selective right coronary angiography (RAO 25° projection) demonstrating severe diffuse RCA disease and a mid-RCA CTO, with a distinct microchannel following the course of the occluded vessel distal to the origin of the 1st acute marginal branch. An epicardial collateral connection between the conus branch and the proximal LAD, forming Vieussens’ arterial ring, is also visible.

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  Figure 2. Antegrade LIMA–LAD filling and its collateral supply to RCA and lcx. (A,B) Selective LIMA injection [(A) LAO 5°/Cranial 25° projection and (B) LAO 15°/Cranial 30°] showing the last-remaining patent LIMA graft with two sequential severe stenoses (each≥80%) at the distal anastomosis (orange arrow) and further distally (red arrow). Arrows indicate the target lesions. (C) Selective LIMA injection (RAO 15°/Cranial 35° projection). Retrograde collateral filling of the left circumflex artery (orange box) and the right coronary artery (green circle) from the patent LIMA graft. Notice how both the inferior wall (RCA territory) and the lateral wall (LCx territory) are essentially retrogradely supplied by the patent LIMA-LAD system. (D) Selective LIMA angiography (LAO 35°/cranial 20° projection), providing an overall assessment of the native epicardial coronary circulation through the LIMA–LAD system.

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  Figure 3. Hemodynamic support. Impella CP in position across the aortic valve with the corresponding SmartAssist placement signal and motor current waveforms, alongside the invasive arterial pressure trace during the period of no-reflow, illustrating maintenance of systemic perfusion despite absent antegrade coronary flow.

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  Figure 4. Procedural sequence. (A) A 6-F IMA guiding catheter and a 6-F Guidezilla guide-extension catheter, with the latter advanced into the distal third of the LIMA using the inchworming technique. (B) Initial attempts to cross into the LAD with multiple guidewires were unsuccessful. A 0.014-inch Sion workhorse guidewire was eventually advanced into the 2nd diagonal branch through a Corsair Pro XS microcatheter. Contrast injection through the microcatheter tip confirmed the guidewire position. (C) Redirection of the Corsair Pro XS microcatheter facilitated successful guidewire advancement into the distal LAD.

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  Figure 5. Steps of complex and higH–risk indicated PCI. (A–C) Lesion Preparation: Both lesions were predilated using 2.00 × 15 mm and 2.50 × 15 mm semi-compliant balloons, followed by dilation with a 2.50 × 15 mm non-compliant balloon at 18 atm. (D–F) Stent-delivery difficulty: Despite adequate lesion preparation, the drug-eluting stents could not be advanced across the lesions. A 6-F Guidezilla guide-extension catheter was therefore advanced into the distal third of the LIMA using the inchworming technique to provide additional support.

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  Figure 6. Initial DES implantation, subsequent no-reflow, and successful bailout management with DCB angioplasty, as demonstrated by final angiography. (A) Deployment of a 2.50 × 16 mm Firehawk Liberty drug-eluting stent (DES) at 20 atm across the LIMA–LAD anastomosis. (B) No-reflow following DES implantation; intracoronary nitroglycerin failed to restore distal coronary flow. (C,D) Because no-reflow persisted and delivery of a second DES into the distal native LAD was considered technically challenging, bailout balloon angioplasty was performed. Using a buddy-wire technique, the distal lesion was successfully treated with a 2.50 × 15 mm paclitaxel-coated balloon inflated at 12 atm, with overlap at the distal edge of the proximally implanted DES, constituting a hybrid DES–DCB strategy. (E) Final angiography demonstrating restoration of TIMI grade 3 flow and a minor, non-flow-limiting type B dissection at the DCB-treated segment (blue brace).