Protected percutaneous coronary intervention of complex distal left main disease with Impella CP™ support.

Complex distal left main (LM) coronary artery disease with bifurcation involvement and chronic total occlusion (CTO) is usually treated with coronary artery bypass grafting (CABG). Patient refusal of surgery necessitates high-risk percutaneous revascularization that may require mechanical circulatory support. Here, we present a case of a 66-year-old male with Canadian Cardiovascular Society Class III angina and preserved left ventricular ejection fraction (LVEF; 60%) who was diagnosed with severe calcified distal LM stenosis extending into the left ostial circumflex (LCx), and a proximal left anterior descending (LAD) CTO. CABG was recommended but declined by the patient and high-risk PCI was performed with haemodynamic support using Impella CP™ with SmartAssist. Lesion preparation included rotational atherectomy followed by intravascular lithotripsy of the LM, LAD, and LCx. The LAD CTO was successfully recanalized and treated with two drug-eluting stents and two drug-coated balloons. A double-kissing culotte two-stent strategy was applied for the distal LM bifurcation, guided by intravascular ultrasound. Haemodynamics remained stable, with Impella support successfully preventing instability during hypotensive phases and during extensive lesion modification of the LM using rotational atherectomy. The patient was discharged on dual antiplatelet therapy and remained free of angina with preserved LVEF and an excellent angiographic result at 6-month follow-up. This case demonstrates how Impella support enabled safe, complete revascularization of high-risk LM bifurcation CTO disease when CABG was declined. Moreover, it illustrates that protected PCI with an Impella device can provide a safe alternative to surgery in anatomically complex LM disease, ensuring procedural stability and complete revascularization.