Background: Patients with complex coronary disease, suboptimal haemodynamics and severe peripheral arterial disease (PAD) represent a uniquely challenging subset, as the often-required mechanical circulatory support (MCS) cannot be delivered via femoral access. Percutaneous axillary access provides an alternative access site for MCS in high-risk patients with severe PAD.
Clinical Case: An elderly man with heart and liver failure presented with chest pain and a non-ST-elevation MI, coronary angiography showed severe left main (LM), left anterior descending (LAD), ramus and right coronary artery (RCA) disease, as well as a chronic total occlusion of the left circumflex coronary artery. Aortography showed an occluded distal aorta. After a heart team discussion, it was decided to pursue percutaneous axillary access for MCS using Impella CP to deliver complete revascularisation. Left radial artery access was used to manage the axillary access site and right radial access was the primary access for coronary intervention. Successful intravascular ultrasound-guided percutaneous coronary intervention of the LM, LAD, ramus and RCA arteries was performed, and the Impella was explanted at the end of the procedure after a successful weaning trial.
Discussion: The axillary artery is a safe and feasible alternative percutaneous access site for large-bore devices in patients with prohibitive peripheral arterial disease. Explanation of axillary Impella is feasible and access site complications can be managed with appropriate planning.