Case 41: PCI Manual - Complex PCI in a very obese patient

A 550 lb patient presented with NSTEMI and heart failure and was found to have a chronic total occliusion of the right coronary artery and severe left main, LAD, and circumflex lesions. He was turned down for CABG and referred for complex, high-risk PCI. Given heart failure, high filling pressures, and PCI on the last remaining vessel an Impella CP device was inserted via axillary cutdown providing 3 L/min of flow. Engagement of the left main via right radial access was extremely challenging, but was eventually successful using a 6 French CLF 4.0 guide catheter. Wiring of highly angulated circumflex was also very challenging and failed despite using a TwinPass Torque microcatheter, a SuperCross 120, and multiple guidewires. LAD wiring attempts resulted in the left main dissection that required stenting, fortunately without compromising circumflex flow. Attempts to wire the circumflex were stopped and the LAD and left main successfully stented as confirmed by IVUS that showed good stent expansion anda good coverage of the left main ostium. This case provides several lessons:
(1) Visualization can be very challenging in extremely obese patients and steep imaging angles should be avoided.
(2) Arterial access can also be extremely challenging in such patients. Radial access is key, whereas surgical cutdown may be preferred for placing large bore devices, such as the Impella CP.
(3) Wiring through tortuosity may require angulated microcatheters and various guidewires and may be unsuccessful.
(4) Limiting the extent of PCI may be preferable in high-risk patients: "perfect may indeed be the enemy of good".

[@salahuddinsalahuddin3210]

Thanks a Lot. Very nice case. I learned a Lot..

[@aymantantawy1475]

Perfect is the enemy of good... I always keep this in my mind. We are not doing plastic surgery for coronaries