Title
Percutaneous Axillary ECMO Supported Complex Left Main Bifurcation Percutaneous Coronary Intervention
Introduction
A 66-year-old man with multiple comorbidities presented with complex coronary artery disease and underwent percutaneous axillary VA-ECMO supported high-risk PCI of a calcified left main bifurcation lesion. We present the first description of percutaneous axillary ECMO. We also emphasize adequate lesion preparation for optimal stent expansion.
Clinical Case
A 66-year-old man with a mechanical aortic valve and bilateral femoropopliteal artery bypass presented with unstable angina. Echocardiography showed an ejection fraction of 34%. Cardiac catheterization showed 90% calcified stenosis of the distal LM extending into the LAD and LCX (Medina 1,1,1). We proceeded with PCI of the LM bifurcation. Based on initial studies, calcium modification was warranted and MCS was crucial. We proceeded with VA-ECMO. Given significant PAD, we placed the 15 Fr ECMO return cannula in the right axillary artery under fluoroscopy. Two Perclose sutures were placed to pre-close the right axillary artery. The arterial cannula was inserted 5 cm into the vessel to avoid covering the vertebral artery or right carotid artery. PCI was performed via the right femoropopliteal bypass graft with an 8 Fr EBU 3.75 guide catheter. Both lesions were wired with polymer-jacketed wires. We predilated the vessels. IVUS demonstrated 3-mm distal reference vessel size in both the LCX and LAD. There was circumferential calcium in the LM, calcium >270° for at least 5 mm, and an adjacent vessel diameter <3.5 mm. Initial balloon dilation was inadequate. We performed rotational atherectomy with a 1.5-mm burr then a 1.75-mm burr since subsequent balloon dilation remained inadequate. Intravascular lithotripsy was then performed with a 3.5-mm balloon in the LM into the LAD. Given the bifurcation anatomy, Culotte stenting technique was used. Following successful PCI, a Glidewire Advantage was advanced past the arterial cannula into the right brachial artery. An 8.0-mm balloon was advanced into the right subclavian artery. ECMO was discontinued, the balloon was inflated, and the cannula removed. The Perclose sutures were secured, and the balloon was deflated.
Discussion
Prior reports have described open cut-down to access the axillary artery. We describe a technique for percutaneous access for VA-ECMO. Axillary arteries are thinner and more friable than femoral arteries. Therefore, prophylactic use of an occlusive balloon allows Perclose suture deployment under minimal arterial pressure. Percutaneous axillary artery access can be hazardous due to its proximity to the brachial plexus. We identify and follow the branches of the brachial plexus from the mid-clavicular line back to the deltopectoral groove. Once identified, an optimal location for access can be utilized. Intracoronary imaging provides critical information on the characterization of coronary calcium, where an IVUS-specific score of ≥2 suggests the need for calcium modification. Given our patient’s calcium score of 3, rotational atherectomy and intravascular lithotripsy were appropriate. Rotational atherectomy results in successful debulking of calcium and improved lesion preparation compared with only balloon dilation. Intravascular lithotripsy has demonstrated procedural success in >90% of lesions, especially with concentric calcifications. Therefore, adequate lesion preparation with calcium modification techniques is critical for optimal stent expansion.