Calcium in the Way: Impella-Supported High-Risk Percutaneous Coronary Intervention in an Elderly Patient with Heart Failure, Progressive Multi-Vessel Coronary Disease, and Prior Iliac Stenting

We present the case of an 80-year-old male patient with heart failure with reduced ejection fraction and heavily calcified, multi-vessel coronary artery disease involving the distal left main, left anterior descending, and left circumflex arteries, along with a chronic total occlusion of the right coronary artery. He was turned down for surgical revascularization with coronary artery bypass grafting. He initially remained stable on medical therapies and underwent implantable cardioverter defibrillator implantation. He presented back with ventricular fibrillation. Repeat angiography demonstrated progression of his disease. He was planned for high-risk percutaneous coronary intervention supported by a transcatheter micro-axial flow pump. Given his history of peripheral arterial disease (PAD) with prior iliac stenting, vascular surgery was consulted to facilitate large-bore access to initiate support, ultimately deciding on bilateral femoral arterial access.