{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,25]],"date-time":"2026-06-25T07:46:29Z","timestamp":1782373589604,"version":"3.54.5"},"reference-count":14,"publisher":"Oxford University Press (OUP)","issue":"Supplement_7","license":[{"start":{"date-parts":[[2026,2,14]],"date-time":"2026-02-14T00:00:00Z","timestamp":1771027200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004331","name":"Johnson & Johnson","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004331","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,6,25]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>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\u2122 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.<\/jats:p>","DOI":"10.1093\/eurheartjsupp\/suag004","type":"journal-article","created":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T12:48:55Z","timestamp":1770814135000},"page":"vii32-vii38","source":"Crossref","is-referenced-by-count":0,"title":["Protected percutaneous coronary intervention of complex distal left main disease with Impella CP\u2122 support"],"prefix":"10.1093","volume":"28","author":[{"given":"Jan-Malte","family":"Sinning","sequence":"first","affiliation":[{"name":"Department of Cardiology and Rhythmology , St. Vinzenz Hospital K\u00f6ln, Merheimer Stra\u00dfe 221-223, 50733 K\u00f6ln, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthias","family":"Bossard","sequence":"additional","affiliation":[{"name":"Heart Centre, Luzerner Kantonsspital, University Research and Teaching Hospital, Spitalstrasse 16, 6000 Luzern ,","place":["Switzerland"]},{"name":"Faculty of Health Sciences and Medicine, University of Lucerne , Alpenquai 4, 6005 Luzern ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2338-8346","authenticated-orcid":false,"given":"Christophe","family":"Vandenbriele","sequence":"additional","affiliation":[{"name":"Heart Center AZORG , Campus Moorselbaan, Moorselbaan 164, 9300 Aalst ,","place":["Belgium"]},{"name":"Cardiac Intensive Care, Royal Brompton and Harefield Hospitals, Guy\u2019s and St Thomas\u2019 NHS Foundation Trust , London SW3 6NP ,","place":["UK"]},{"name":"Department of Surgery and Cancer, Faculty of Medicine, Imperial College London , Exhibition Road, London SW7 2AZ ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Assad","family":"Haneya","sequence":"additional","affiliation":[{"name":"Heart Centre Trier, Hospital of the Brothers of Mercy , Nordallee 1, 54292 Trier ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nilesh","family":"Pareek","sequence":"additional","affiliation":[{"name":"King\u2019s College Hospital NHS Foundation Trust , London SE5 8AF ,","place":["UK"]},{"name":"British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Medicine and Sciences , King\u2019s College London, London SE5 8AF ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Geppert","sequence":"additional","affiliation":[{"name":"3rd Department of Medicine with Cardiology and Intensive Care Medicine, Clinic Ottakring , A-1160 Vienna ,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikos","family":"Werner","sequence":"additional","affiliation":[{"name":"Heart Centre Trier, Hospital of the Brothers of Mercy , Nordallee 1, 54292 Trier ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,2,14]]},"reference":[{"key":"2026062502520311200_suag004-B1","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1093\/eurheartj\/ehy394","article-title":"2018 ESC\/EACTS guidelines on myocardial revascularization","volume":"40","author":"Neumann","year":"2019","journal-title":"Eur Heart J"},{"key":"2026062502520311200_suag004-B2","doi-asserted-by":"crossref","first-page":"684","DOI":"10.1016\/j.ijcard.2015.07.065","article-title":"Impella ventricular support in clinical practice: collaborative viewpoint from a European expert user group","volume":"201","author":"Burzotta","year":"2015","journal-title":"Int J Cardiol"},{"key":"2026062502520311200_suag004-B3","first-page":"114","article-title":"The Single-access for Hi-risk PCI (SHiP) technique","volume":"96","author":"Wollmuth","year":"2020","journal-title":"Catheter Cardiovasc Interv"},{"key":"2026062502520311200_suag004-B4","doi-asserted-by":"crossref","first-page":"457","DOI":"10.4244\/EIJ-D-22-00166","article-title":"Treatment of coronary bifurcation lesions, part II: implanting two stents. The 16th expert consensus document of the European Bifurcation Club","volume":"18","author":"Lassen","year":"2022","journal-title":"EuroIntervention"},{"key":"2026062502520311200_suag004-B5","doi-asserted-by":"crossref","first-page":"3415","DOI":"10.1093\/eurheartj\/ehae177","article-title":"2024 ESC guidelines for the management of chronic coronary syndromes: developed by the task force for the management of chronic coronary syndromes of the European Society of Cardiology (ESC) endorsed by the European Association for Cardio-Thoracic Surgery (EACTS)","volume":"45","author":"Vrints","year":"2024","journal-title":"Eur Heart J"},{"key":"2026062502520311200_suag004-B6","doi-asserted-by":"crossref","first-page":"562","DOI":"10.23736\/S0026-4725.18.04656-X","article-title":"Percutaneous coronary intervention in patients refused from surgery: a different entity?","volume":"66","author":"Montone","year":"2018","journal-title":"Minerva Cardioangiol"},{"key":"2026062502520311200_suag004-B7","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1016\/S0140-6736(19)32972-1","article-title":"Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non-inferiority NOBLE trial","volume":"395","author":"Holm","year":"2020","journal-title":"Lancet"},{"key":"2026062502520311200_suag004-B8","doi-asserted-by":"crossref","first-page":"2388","DOI":"10.1161\/CIRCULATIONAHA.113.006689","article-title":"Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with taxus and cardiac surgery trial","volume":"129","author":"Morice","year":"2014","journal-title":"Circulation"},{"key":"2026062502520311200_suag004-B9","doi-asserted-by":"crossref","first-page":"1820","DOI":"10.1056\/NEJMoa1909406","article-title":"Five-year outcomes after PCI or CABG for left main coronary disease","volume":"381","author":"Stone","year":"2019","journal-title":"N Engl J Med"},{"key":"2026062502520311200_suag004-B10","doi-asserted-by":"crossref","first-page":"ezad286","DOI":"10.1093\/ejcts\/ezad286","article-title":"2022 joint ESC\/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease in patients at low surgical risk and anatomy suitable for PCI or CABG","volume":"64","author":"Byrne","year":"2023","journal-title":"Eur J Cardiothorac Surg"},{"key":"2026062502520311200_suag004-B11","doi-asserted-by":"crossref","first-page":"e149","DOI":"10.4244\/EIJ-D-24-00386","article-title":"Mechanical circulatory support for complex, high-risk percutaneous coronary intervention","volume":"21","author":"Ferro","year":"2025","journal-title":"EuroIntervention"},{"key":"2026062502520311200_suag004-B12","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.pcad.2024.12.001","article-title":"Calcified plaque modification during percutaneous coronary revascularization","volume":"88","author":"Frizzell","year":"2025","journal-title":"Prog Cardiovasc Dis"},{"key":"2026062502520311200_suag004-B13","first-page":"E501","article-title":"Outcomes of bailout percutaneous ventricular assist device versus prophylactic strategy in patients undergoing nonemergent percutaneous coronary intervention","volume":"98","author":"O\u2019Neill","year":"2021","journal-title":"Catheter Cardiovasc Interv"},{"key":"2026062502520311200_suag004-B14","doi-asserted-by":"crossref","first-page":"101453","DOI":"10.1016\/j.jacadv.2024.101453","article-title":"Patient management following percutaneous coronary intervention","volume":"4","author":"Wennberg","year":"2025","journal-title":"JACC Adv"}],"container-title":["European Heart Journal Supplements"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/eurheartjsupp\/advance-article-pdf\/doi\/10.1093\/eurheartjsupp\/suag004\/66895832\/suag004.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/eurheartjsupp\/article-pdf\/28\/Supplement_7\/vii32\/66895832\/suag004.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/eurheartjsupp\/article-pdf\/28\/Supplement_7\/vii32\/66895832\/suag004.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,25]],"date-time":"2026-06-25T06:52:08Z","timestamp":1782370328000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/eurheartjsupp\/article\/28\/Supplement_7\/vii32\/8483302"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,14]]},"references-count":14,"journal-issue":{"issue":"Supplement_7","published-online":{"date-parts":[[2026,2,14]]},"published-print":{"date-parts":[[2026,6,25]]}},"URL":"https:\/\/doi.org\/10.1093\/eurheartjsupp\/suag004","relation":{},"ISSN":["1520-765X","1554-2815"],"issn-type":[{"value":"1520-765X","type":"print"},{"value":"1554-2815","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,6]]},"published":{"date-parts":[[2026,2,14]]}}}