Intravascular Lithotripsy with Shockwave prior to Protected PCI with Impella CP

Shockwave Intravascular Lithotripsy for Large Bore Access Followed by High-Risk PCI

Dr. Chandan Devireddy, interventional cardiologist from Emory School of Medicine joins Dr. George Vetrovec to present a high-risk PCI case using intravascular lithotripsy to prepare a complex, calcified femoral artery for large bore access. This case demonstrates a novel, adjunctive technique to gain femoral access prior to Protected PCI with Impella CP.

The 46-year-old male patient had known end stage renal disease requiring dialysis for eight years, a previous non-ischemic cardiomyopathy with an ejection fraction of 10-15%, and NY heart association class III. The patient had moderate mitral regurgitation, moderate tricuspid, acute limb ischemia and a recent CRT-D device removal that needed to be removed due to infection. Despite these comorbidities, the patient was doing well on his own, but developed angina three days prior to hospital admission.

At admission, the patient was diagnosed with a type I non-STEMI and was given anticoagulation and a cardiac catherization was performed the next morning. The catheterization revealed a 30% left anterior descending, 30% left circumflex, 99% mid right coronary artery and 99% proximal Ramus with distal 70%.

The heart team evaluated the case and the patient was turned down for CABG. However, the team recognized that the PCI required rotational atherectomy and was high-risk for hemodynamic collapse given the ejection fraction of 15% and therefore, decided to perform a Protected PCI with Impella CP.

During pre-planning, Dr. Devireddy and his team took a CTA, which revealed severely calcified and obstructive disease of the iliac arteries bilaterally. The team therefore used intravascular lithotripsy with Shockwave to modify vascular compliance for the 14Fr sheath and proceed with the Protected PCI and use rotablator for the Ramus and RCA.

Dr. Devireddy shows his step-by-step approach using Shockwave, Impella, and rotablator to perform this high-risk PCI with very satisfying results for the team and the patient.

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