Abstract
Mechanical ventricular assist support and especially Impella device that is implanted via femoral access are considered a cornerstone in the therapeutic arsenal of the management of cardiogenic shock. Indeed, the potent antithrombotic agents administered during acute coronary syndromes constitute potential bleeding risk factors. Transradial interventions are nowadays widely used in ST-elevation myocardial infarction patients. However, some operators feel uncomfortable with the transradial approach when facing cardiogenic shock. We report a case of transradial rescue percutaneous intervention for cardiogenic shock in a young man with support of an Impella device via femoral access.
1
Introduction
It has been established that transradial access for percutaneous coronary intervention (PCI) reduces vascular complications and bleeding compared with femoral access , with similar success rates . Bleeding and transfusion after PCI are correlated with mortality . Cardiogenic shock (CS) complicating a ST-elevation myocardial infarction (STEMI) is a devastating situation that is associated with high mortality rate , and mechanical support is frequently needed. The potency of the antithrombotic pharmacologic environment surrounding the CS imposed on the operator to adopt attitudes that procured a reduced risk of bleeding complications. We present a case of a young man who presented for an acute anterior STEMI complicated by CS and in whom the use of unilateral access sites was safe and efficacious in the rescue PCI via transradial approach and in offloading the left heart through the femoral implantation of an Impella device for hemodynamic support.
2
Case
We report the case of a 42-year-old man, a heavy cigarette smoker, who presented for a 1-h history of oppressive chest pain. The electrocardiography highlighted an acute anterior myocardial infarction. At this level, he was hemodynamically stable. He received intravenous adapted dose of thrombolytic agents associated with a dual antiplatelet therapy and was immediately transferred to our hospital that was the nearest center equipped with a hemodynamic catheterization laboratory. At arrival, there was no sign of clinical or electrical reperfusion, and the hemodynamic conditions of the patients have become altered with pronounced systemic hypotension resistant to fluids and vasopressors. He was transferred to the catheterization laboratory in the perspective of rescue angioplasty along with mechanical support. The left coronary angiography performed via right transradial access using a 6-Fr extra back-up 4 Launcher guiding catheter (Medtronic, USA) showed a thrombotic occlusion with a Thrombolysis In Myocardial Infarction (TIMI) 0 flow of the left main coronary artery ( Fig. 1 ). Impella 2.5 device (ABIOMED, Danvers, MA, USA) was delivered via the right femoral artery and inserted into the left ventricle assuming a cardiac output of 2.5 L/min. Then, we performed a provisional T-stenting of the left main coronary artery in the direction of the left anterior descending artery (LAD) with a drug-eluting stent (PROMUS ELEMENT 4.0×24 mm, Boston Scientific) after a manual thrombectomy using an Export Aspiration Catheter (Medtronic Corporation, CA, USA). The first angiographic control showed an unclogged left coronary artery with a diffuse distal spasm of the LAD ( Fig. 2 ) reversible after selective iterative injections of nitrate in situ via a Progreat 2.4-Fr 130-cm Microcatheter (Terumo, Japan). The final result was good, with a TIMI 3 flow ( Fig. 3 ) in the left coronary artery. The procedure was performed under therapeutic ranges of unfractionated heparin (UFH). The right coronary artery was free of atherosclerotic plaques ( Fig. 4 ). The patient was transferred to the intensive care unit and was treated with UFH in order to obtain an activated clotting time of 170 to 200 s. The cardiac ultrasound showed a severe myocardial dysfunction with large anterior akinesis. Escalation doses of beta-blocker, angiotensin-converting enzyme inhibitors and antialdosterone were added to his treatments. He made steady improvement, and the Impella device was removed on day 3 postprocedure. Later, he was discharged to rehabilitation. There were no vascular access or bleeding complications. The follow-up at 6 months was uneventful, and the patient recuperated a normal cardiac function.
2
Case
We report the case of a 42-year-old man, a heavy cigarette smoker, who presented for a 1-h history of oppressive chest pain. The electrocardiography highlighted an acute anterior myocardial infarction. At this level, he was hemodynamically stable. He received intravenous adapted dose of thrombolytic agents associated with a dual antiplatelet therapy and was immediately transferred to our hospital that was the nearest center equipped with a hemodynamic catheterization laboratory. At arrival, there was no sign of clinical or electrical reperfusion, and the hemodynamic conditions of the patients have become altered with pronounced systemic hypotension resistant to fluids and vasopressors. He was transferred to the catheterization laboratory in the perspective of rescue angioplasty along with mechanical support. The left coronary angiography performed via right transradial access using a 6-Fr extra back-up 4 Launcher guiding catheter (Medtronic, USA) showed a thrombotic occlusion with a Thrombolysis In Myocardial Infarction (TIMI) 0 flow of the left main coronary artery ( Fig. 1 ). Impella 2.5 device (ABIOMED, Danvers, MA, USA) was delivered via the right femoral artery and inserted into the left ventricle assuming a cardiac output of 2.5 L/min. Then, we performed a provisional T-stenting of the left main coronary artery in the direction of the left anterior descending artery (LAD) with a drug-eluting stent (PROMUS ELEMENT 4.0×24 mm, Boston Scientific) after a manual thrombectomy using an Export Aspiration Catheter (Medtronic Corporation, CA, USA). The first angiographic control showed an unclogged left coronary artery with a diffuse distal spasm of the LAD ( Fig. 2 ) reversible after selective iterative injections of nitrate in situ via a Progreat 2.4-Fr 130-cm Microcatheter (Terumo, Japan). The final result was good, with a TIMI 3 flow ( Fig. 3 ) in the left coronary artery. The procedure was performed under therapeutic ranges of unfractionated heparin (UFH). The right coronary artery was free of atherosclerotic plaques ( Fig. 4 ). The patient was transferred to the intensive care unit and was treated with UFH in order to obtain an activated clotting time of 170 to 200 s. The cardiac ultrasound showed a severe myocardial dysfunction with large anterior akinesis. Escalation doses of beta-blocker, angiotensin-converting enzyme inhibitors and antialdosterone were added to his treatments. He made steady improvement, and the Impella device was removed on day 3 postprocedure. Later, he was discharged to rehabilitation. There were no vascular access or bleeding complications. The follow-up at 6 months was uneventful, and the patient recuperated a normal cardiac function.
