A 68-year-old man with history of coronary artery disease, ischemic cardiomyopathy, diabetes mellitus, primary prevention automated implantable cardioverter defibrillator (AICD), polio, obesity and systolic heart failure presented to our institution with increasing ischemic chest pain for three days. He was found to have a non-ST segment elevation myocardial infarction with decompensated heart failure with ejection fraction of 24%, as well as acute kidney injury secondary to cardiorenal syndrome. This was also complicated by sustained slow ventricular tachycardia (VT), which caused further decompensation.

A decision was made to perform emergency cardiac catheterization with possible PCI. No good radial pulses were palpable. Secondary to his underdeveloped lower extremities from polio, obesity and faint femoral pulses, micropuncture technique under fluoroscopic guidance was used to obtain retrograde right common femoral arterial access, with placement of a 6-French sheath. Selective left coronary angiography was performed with a JL4 catheter, revealing a distal left main into ostial left anterior descending artery (LAD) 70% in-stent restenosis (ISR) lesion which gave rise to a small diagonal after which the LAD was chronically occluded, and a chronically occluded circumflex (Figure 1). This resulted in significant hypotension from severe ischemia and the development of cardiogenic shock. Distal abdominal aortography was performed using a 6-French JR4 catheter with bilateral iliofemoral runoff to determine if he was a candidate for Impella (Abiomed, Danvers, Massachusetts) percutaneous left ventricular assist device or IABP support and to outline the course of his femoral artery for contralateral groin access (Figure 2). Utilizing micropuncture technique, left common femoral arterial access was gained with placement of an 8-French sheath. A 40cc Datascope IABP was advanced via the left common femoral access into the appropriate position, with difficulty during initial wiring with the 0.028” wire secondary to a distal abdominal aortic lesion (Figure 3). IABP support was commenced at 1:1 ratio with vasopressor and inotropic support. From the right common femoral access site, a 0.035” J-wire or angled Glide wire (Terumo Interventional Systems, Somerset, New Jersey) could not get pass the abdominal aortic lesion with the IABP in situ. Thus, the distal abdominal aortic lesion was crossed with a 0.014” Runthrough coronary guidewire (Terumo Interventional Systems, Somerset, New Jersey) and the lesion was dilated with a Viatrec (Abbott, Abbott Park, Illinois) 7.0 × 40 mm balloon to 7 atm for 30 seconds serially (Figure 4). A 5-French Glidecath was then used to exchange the Runthrough for an exchange length 0.035” J-wire in the ascending aorta. A 6-French JR4 was used to perform the selective right coronary angiography. Intravenous heparin was used as the procedural anticoagulant. The left main was engaged with a 6-French EBU 3.5 side hole guide, providing good support. The diagonal was wired with 0.014” Runthrough guidewire and the left main into ostial LAD ISR was directly stented with a Xience Xpedition 2.5 × 15 mm drug eluting stent (DES) (Abbott, Abbott Park, Illinois) to 20 atm for 10 seconds (Figure 5). Subsequently a NC Trek (Abbott, Abbott Park, Illinois) 3.0 × 12 mm balloon was used to post-dilate to 24 atm for 10 seconds.

Post PCI, he developed recurrent slow VT and this was cardioverted with anti-tachycardia pacing via his implantable cardiac defibrillator (ICD). His right coronary artery (RCA) was then engaged with a 6-French AR1 guide with side holes and the posterolateral branch (PLB) was wired with the Runthrough guidewire. Overlapping Xience Xpedition 2.25 × 18 mm and 2.5 × 12 mm DES were deployed into the distal right, followed by proximally overlapping Xience Xpedition 3.0 × 38 mm and 3.0 × 15 mm DES for his mid to ostial ISR (Figure 6). Final coronary angiographic images were obtained.

Distal abdominal aortography digital subtraction angiography (DSA) was then performed with the AR1 guide and repeat dilatation was then performed with an Armada 9.0 × 80 mm balloon (Abbott, Abbott Park, Illinois) to 12 atm for 30 seconds. Secondary to concerns about limb ischemia, the IABP and 8-French sheath were both removed and manual pressure was held for 30 minutes for hemostasis. He made a good initial clinical recovery without any acute post-procedural complications such as bleeding requiring blood transfusion or pseudo-aneurysm. However, he had continued deterioration of his renal function due to acute tubular injury from his previous episodes of hypotension and cardiorenal syndrome, to the point where dialysis was required. The patient and family decided against dialysis after several days, and the patient subsequently succumbed to his renal failure.

Written informed consent was obtained from the patient’s next of kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.