SHiP for CHIP

Dr. Karl CHAN, Dr. Ken CHI

Prince of Wales Hospital, Hong Kong

70-year-old gentleman with background history of hypertension, diabetes on insulin, Ischemic heart disease with PCI to RCA done in one decade ago, diabetic nephropathy presented with ischemic acute pulmonary edema requiring non-invasive ventilation. His baseline Creatinine was 280umol/l. Echocardiogram showed LVEF 30%, severe hypokinesia over inferior wall, akinesia over anteroseptal wall with severe functional mitral regurgitation. Invasive coronary angiogram showed critical Left main and triple vessel disease (Movie 1, Movie 2, Movie 3, Movie 4, Movie 5, Movie 6). Cardiothoracic surgeon was urgently consulted for CABG, yet he was turn down given the porcelain ascending aorta. Patient and family opted for the Complex, Higher-risk, and indicated PCI (CHIP).

Multiple arterial access requires time and results in increased risk for vascular complications, and his arterial accesses were limited since radial accesses would be preserved for future hemodialysis. On the other hand, mechanical circulatory support devices were highly recommended given this complex and critical coronary anatomy. Thus, single access for High-risk PCI (SHiP) technique was adopted for this CHIP [1]. The Impella CP (Abiomed, Danvers, Massachusetts) percutaneous ventricular assist catheter requires implantation through a 14 French sheath. After the Impella catheter is placed in the standard fashion, a micro-puncture needle is used to pierce the hemostasis valve of the Impella insertion sheath. After dilating the hemostasis valve and exchanging for a 0.035 wire, up to a 7 French sheath can be inserted for PCI within the 14 French access sheath and alongside the 9 French portion of the Impella catheter (Figure 1).

We successfully performed the PCI with complete revascularization under this SHiP technique (Movie 7, Movie 8, Movie 9). After PCI, the sheath was simply removed since the defect closed upon itself. The arteriotomy site was closed in standard fashion after removal of Impella catheter. There were no instances of bleeding during the procedure or after removal of the PCI sheath, and no evidence of disruption of the Impella sheath. Total 22ml contrast was used. He was discharged 4 days after the procedure with cautious monitoring of renal function. His creatinine was 160umol/l upon discharge.

[1] Reference: The Single-access for Hi-risk PCI (SHiP) technique. Wollmuth J, Korngold E, Croce K, Pinto DS. Catheter Cardiovasc Interv. 2019 Oct 26. doi: 10.1002/ccd.28556.