Subclavian Impella 5.0 to the rescue in a non-ST elevation myocardial infarction patient requiring unprotected left main rotablation: A case report

Figure 1 Heavily diseased peripheral and coronary vascular trees. A: 3D reconstructions of abdominal and ilio-femoral arterial systems showing previous abdominal aneurysm, and endovascular aneurysm repair alongside the extensive ilio-femoral disease; B: Initial coronary angiogram demonstrating tight distal left main stem and proximal left circumflex calcific disease. The right coronary artery is a chronic total occlusion.

Figure 2 A 10-mm silver-coated Dacron graft was anastomosed to the subclavian artery and an Impella 5. 0 was inserted.

Figure 3 During rotablation runs with the 1. 75 mm burr the pulsatility was lost, however, the mean arterial pressure was maintained due to the presence of the Impella.

Figure 4 After a stormy procedure a good angiographic and intravenous ultrasound result was obtained. A: Support issues despite use of guideliner leading on to stent dismounting off its balloon undeployed after it got trapped on a calcific bend; B: Localised small perforation/dissection at the distal left main; C: Extreme left circumflex tortuosity causing deformation of Choice PT XS coronary wire and balloon trapping on the wire; D: Spider view and intravenous ultrasound in distal left main stem showing good stent expansion and apposition; E: LAO cranial view showing good final left main stem Culotte result.