A Stepwise Bail-Out Approach to Protected High-Risk PCI in a Complex CHIP Patient: A Case Report

Background: Patients with complex coronary artery disease, concomitant cardiovascular disease, and multiple comorbidities are classified as complex higher-risk indicated patients (CHIPs). They preclude surgical revascularization due to high perioperative morbidity and mortality. Intervention with left-ventricular assist device support using Impella CP is an alternative strategy. It may serve as a temporary circulatory support during complex intervention and cardiogenic shock and provides LV unloading, antegrade blood flow generation, infarct size limitation, and recovery promotion. However, its use in CHIPs remains a matter of debate. Case summary: A challenging case presented with CHIP. The combination of baseline comorbidities, underlying complex coronary artery disease, and evolving hemodynamics synergistically jeopardized the physiological reserve and necessitated management with innovative strategies. A stepwise bail-out approach to the challenges during the procedure is provided. Using a longer sheath to overcome advanced peripheral arterial disease, peeling the shaft of the Impella CP sheath and removal of sheath’s protection cover enables an additional 25 cm to reach the left ventricle, and a second access for PCI facilitates the standard length of the guide catheter to reach the left coronary artery. However, different plaque modification techniques did not prevent 30% of stent underexpansion. The 6-month follow-up was uneventful. Conclusions: The adoption of mechanical circulatory support in daily medical practice has been propelled more by clinically estimated risk than definitive evidence. Although ongoing innovations facilitate interventions in more complex scenarios, bailout strategies help to rescue the patient and address new insights for the next innovations.