High-risk PCI with axillary venoarterial ECMO support in a vasculopathic patient with a single remaining coronary artery
Presenter
Abdulla Alabagi, MD, Banner - University Medical Center Tucson, TUCSON, AZ
Abdulla Alabagi, MD1, Sean McCandless2, Juliya Cress, MD2, Toshinobu Kazui, MD, PhD1 and Deepak Acharya, M.D., FSCAI2, (1)Banner - University Medical Center Tucson, TUCSON, AZ, (2)Banner - University Medical Center Tucson, Tucson, AZ
Title:
High-Risk PCI with axillary venoarterial ECMO support in a vasculopathic patient with a single remaining coronary artery
Introduction:
Hemodynamic support during high-risk percutaneous coronary intervention (PCI) may be beneficial in selected patients with complex coronary anatomy, left main disease, severely reduced left ventricular (LV) systolic function, or in cardiogenic shock. However, patients with complex coronary disease often have peripheral vascular disease, limiting femoral access for hemodynamic support. A potential alternative is axillary access for large bore access, including venoarterial extracorporeal membrane oxygenation (VA-ECMO).
Clinical Case:
An 82-year-old male with a history of chronic systolic heart failure (LVEF 20%), left main chronic total occlusion (LM-CTO) 14 years before admission deemed too high risk for revascularization, diffuse peripheral arterial disease (PAD) status post bilateral common iliac and bilateral superficial femoral artery (SFA) stenting with known left SFA stent occlusion and carotid artery stenosis status post right carotid endarterectomy presented to the hospital after experiencing self-resolving chest pain for 30 minutes followed by persistent dyspnea at rest. Admission heart rate was 69 bpm and blood pressure was 139/84 mmHg. High-sensitivity troponin–T was 1,311 ng/L, and his EKG demonstrated sinus rhythm with an old left bundle branch block, although with a wider QRS interval. An echocardiogram revealed an unchanged LVEF of 20%. The patient underwent urgent coronary angiography, demonstrating LM-CTO with high-grade ostial stenosis of the right coronary artery (RCA) with Rentrop 3 collaterals to the entire left coronary system. Aortogram showed an aneurysmal infrarenal abdominal aorta and diffusely diseased bilateral common and external iliac arteries. He was deemed a poor surgical candidate for coronary artery bypass surgery with an STS mortality risk of 11.5%. In the setting of his severely depressed LV function, full hemodynamic support during the PCI to his single remaining artery was deemed necessary. Femoral arterial access was not feasible. Patient underwent axillary VA-ECMO via an 8 mm Hemashield graft in the right axillary artery and a 21-F cannula in the right femoral vein in the catheterization laboratory. PCI of the RCA was performed with the placement of a 5.0 x 22 mm Onyx Frontier DES. ECMO decannulation was performed in the catheterization laboratory immediately after the PCI. Patient was discharged home on postoperative day five. At his three-month follow-up, the patient had no angina, NYHA class I heart failure, and was cycling for 20 minutes regularly.
Discussion
LM CTO with high-grade RCA ostial stenosis is an uncommon occurrence. When pursuing intervention in such high-risk cases, PCI without hemodynamic support would likely lead to peri-procedural hemodynamic collapse. However, hemodynamic support via the femoral artery was not possible due to his severe PAD, necessitating axillary artery access. ECMO was chosen as the MCS modality, given his risk of cardiac arrest. While studies have demonstrated that axillary arterial access for VA-ECMO support is a safe method in patients with cardiogenic shock, reports of axillary VA-ECMO in non-cardiogenic shock PCI cases are limited. Further investigation is necessary to better understand the indications, risks, and benefits of axillary mechanical circulatory support in this setting.