Navigating high-risk PCI with axillary impella support: a case report

Abstract

Introduction and importance: Percutaneous coronary intervention (PCI) in high risk patients with complex coronary artery disease and impaired left ventricular function pose significant procedural challenges. During such interventions. Mechanical circulatory support with the Impella device has become an effective strategy to maintain hemodynamic stability. While femoral access is traditionally used, alternative routes like axillary artery access may be necessary in patients with peripheral vascular disease.

Case presentation: We present the case of a 68-year-old male with severe multivessel coronary artery disease with reduced left ventricular ejection fraction, and bilateral iliofemoral artery disease. Since there was difficulty in accessing the femoral arteries, axillary artery access was used to insert an Impella CP device to support high-risk PCI. The procedure involved successful revascularization of complex lesions using rotational atherectomy and stenting. The patient remained hemodynamically stable throughout and recovered without complications.

Discussion: In patients with contraindications to femoral access this case highlights the feasibility and clinical utility of axillary access for Impella insertion despite requiring surgical expertise and meticulous planning, the axillary route offers a safe and effective alternative for mechanical circulatory support during complex coronary interventions.

Conclusion: Axillary artery access for Impella-assisted high-risk PCI is a viable and underutilized option in select patients with complex coronary anatomy and peripheral vascular disease, expanding the therapeutic possibilities in advanced interventional cardiology. This report highlights a safe, effective alternative for patients with contraindications to femoral access and emphasizes the importance of multidisciplinary planning.

Keywords: axillary access; complex coronary artery disease; high-risk PCI; impella CP; mechanical circulatory support.

Figure 1.

(A) (left) illustrates the vascular anatomy prior to Impella CP® device placement, highlighting the suitability of the right axillary artery as the access route & (B) (right) shows the coronary angiogram before PCI, demonstrating critical stenosis in the left main, LAD, and LCx.

Figure 2.

(A) (left) and (B) (right) show post-PCI angiographic results. Successful stent deployment in the LAD and LCx arteries is evident, with restored vessel patency and improved coronary flow, confirming effective.

Figure 3.

Post-Impella angiogram showing intact right axillary artery with successful hemostasis and no vascular complications.