Between a Rock and a Hard Place: Impella-Assisted Atherectomy and Lithotripsy for LAD CTO Caused by a Calcified Epicardial Mass
Presenter
Sairamya Bodempudi, The University of Texas Southwestern Medical Center, Dallas, TX
Sairamya Bodempudi, The University of Texas Southwestern Medical Center, Dallas, TX
Keywords: Atherectomy, Chronic Total Occlusion (CTO), Complex and High-risk Coronary Intervention (CHIP), Hemodynamic Support and Intravascular Lithotripsy (IVL)
Title
Between a Rock and a Hard Place: Impella-Assisted Atherectomy and Lithotripsy for LAD CTO Caused by a Calcified Epicardial Mass
Introduction
Chronic total occlusions (CTOs) within previously stented, heavily calcified coronaries remain among the most challenging lesions for percutaneous coronary intervention (PCI). Mechanical hemodynamic support can facilitate prolonged complex procedures. Combined plaque-modification strategies of rotational atherectomy (RA) and intravascular lithotripsy (IVL) may be required to treat mixed superficial and deep calcification, enabling device delivery and optimal stent expansion. We report an Impella-assisted PCI of a distal LAD CTO embedded within an epicardial calcified density.
Clinical Case
A patient with prior LAD stents and heart failure presented with ongoing angina and imaging evidence of a distal LAD CTO encased in a calcified epicardial mass. After ultrasound-guided right femoral access, an Impella CP was placed. The left main coronary artery was engaged with an EBU 4.5 guide catheter. Initial attempts to cross the mid-LAD with a Turnpike LP (TLP) microcatheter and small balloons failed due to dense calcific neo-atherosclerosis in the proximal stented segment. A Rotawire Floppy was advanced into the distal LAD, and RA was performed with a 1.5-mm burr for 12, 25-second runs at 170,000 rpm. The burr could not reach the distal LAD. A TLP was advanced over the Rota-Floppy and exchanged for a Minamo, positioned at the proximal portion of the CTO. Subsequent lesion crossing required wire escalation. A Gaia Next 2 successfully punctured the proximal cap and was exchanged for a Mongo, which then crossed the CTO. Antegrade injection confirmed wire position in the true lumen. Pre-dilation with a 1.5-mm and then 2-mm compliant balloon enabled TLP passage and exchange of the Mongo for a Minamo. Intravascular ultrasound demonstrated proximal stent mal-apposition and focal calcium nodules but an overall large lumen after RA. A 6F GuideLiner facilitated delivery of a 3.5 × 12 mm IVL balloon. IVL pulses were delivered to the distal and mid-LAD stented segments, followed by high-pressure noncompliant balloon dilation with good expansion. The distal lesion was stented with a 3.0 × 33 mm Xience Skypoint drug-eluting stent and post-dilated with a 3.5-mm noncompliant balloon. Final angiography showed TIMI-3 flow with 0% residual stenosis. The Impella was weaned and removed, and vascular closure was achieved with Perclose.
Discussion
This case highlights strategies for managing complex CTOs in previously stented, heavily calcified segments with unusual anatomic constraints, including extrinsic compression from a large epicardial calcified mass. Preemptive mechanical circulatory support with Impella CP provided hemodynamic stability during a prolonged high-risk intervention. When microcatheter and balloon crossing failed, rotational atherectomy with a 1.5-mm burr modified the calcified stented segment and facilitated wire escalation and lesion crossing. The subsequent use of intravascular lithotripsy complemented atherectomy by fracturing deeper calcium and improving vessel compliance. Although IVL is typically used to treat luminal coronary calcium, this case suggests that its acoustic energy may also affect adjacent epicardial calcification contributing to extrinsic compression. Together, the RA and IVL strategy enabled successful CTO recanalization and optimal stent expansion with an excellent angiographic result. 