Case Review, Shockwave, AMI Cardiogenic Shock, Protected PCI
Protected PCI with Shockwave Assisted Large Bore Access
Large bore access and delivery of the Impella® heart pump can be challenging in patients with significant peripheral vascular disease. Alternative access options, such as axillary or transcaval, require a certain learning curve and case volume. In this video, Andrew Goodman, MD, discusses the use of Shockwave Medical Intravascular Lithotripsy (IVL) System to facilitate treatment of a patient requiring Protected PCI.
Dr. Goodman is an interventional cardiologist at TriStar Centennial Medical Center in Nashville, TN. As he explains to interviewer Cathy Jeon, MD, “Facilitated transfemoral device delivery with the Shockwave Intravascular Lithotripsy System is a very safe and a very effective option that should be a part of everyone’s insertion algorithm for large bore access.”
The Shockwave technology, Dr. Goodman explains, is an intravascular lithotripsy treatment option delivered through a balloon. Lithotripsy causes calcium within the vessel wall to fracture, resulting in acute luminal gain and a potentially more compliant vessel through which to facilitate large bore access. “It is something that doesn’t require a lot of additional training,” Dr. Goodman tells Dr. Jeon. “Most of us, as interventional cardiologists, are very comfortable inflating a balloon. This is inflating a balloon and pushing a button to delivery lithotripsy.”
To illustrate Shockwave use, Dr. Goodman presents a case of a 69-year-old male with multiple risk factors, including advanced lung disease and peripheral arterial disease. The patient had had a small NSTEMI. Echocardiography revealed reduced ejection fraction and coronary angiography demonstrated severe, calcified 2 vessel CAD. The patient presented to Dr. Goodman for evaluation for revascularization options.
After deciding on an option that would include Impella® supported IVUS guided multivessel PCI with atherectomy, Dr. Goodman and his heart team evaluated access options to determine the best way to support the patient. CT scan revealed heavy calcium throughout both iliofemoral systems. Dr. Goodman and his team weighed the options of a facilitated transfemoral procedure with ballooning or Shockwave against a percutaneous axillary or transcaval procedure. With significant tortuosity and calcification in the subclavian arteries and circumferential calcium and no clear transcaval crossing zone, the team decided on Shockwave facilitated Protected PCI via the right iliofemoral.
When asked by Dr. Jeon about patient selection for Shockwave, Dr. Goodman replies that there’s still a lot to learn about Shockwave and it is important to consider plaque versus calcium when considering Shockwave. “But certainly, for very heavily calcified and even tortuous iliacs, I think this is a really good option.” With regard to use in cardiogenic shock, Dr. Goodman explains that the Shockwave procedure adds about 5 to 10 minutes if using it in multiple segments of the iliac. While that time may not be available in a shock case, Dr. Goodman emphasizes that you must also consider the time needed to crossover to an alternative access technique. “I certainly do think that it can help with shock patients,” Dr. Goodman concludes.