Unexpected deformation of the right coronary artery during percutaneous coronary intervention with venoarterial extracorporeal membrane oxygenation combined with Impella: a case report

BACKGROUND: The establishment of cautionary notes regarding percutaneous coronary intervention (PCI) with venoarterial extracorporeal membrane oxygenation combined with Impella (ECMELLA) is still lacking. CASE SUMMARY: A 68-year-old man was transferred to our hospital with cardiac arrest. ECMELLA insertion was performed via the bilateral femoral artery and vein for refractory ventricular fibrillation. Coronary angiography revealed an occluded lesion in the right coronary artery (RCA). Contrast injection was administered after confirming backflow through the guide catheter (GC) to avoid coronary dissection because the artery pressure was non-pulsatile during total circulation support. Prudent coronary angiography revealed a couple of accordion phenomena. Additionally, coronary angiography showed a shorter distance from the right border of the cardiac silhouette to the RCA and the venous line of extracorporeal membrane oxygenation than before PCI. This drastic change in the cardiac silhouette suggested that ECMELLA induced the collapse of the right heart system. Subsequently, a drug-eluting stent was implanted successfully. Final coronary angiography confirmed severe bending in the proximal segment of the RCA, which was absent in the reference coronary angiography. The patient had an uneventful course except for mild cognitive impairment. The computed tomography coronary angiography after ECMELLA removal indicated the RCA without deformation. DISCUSSION: In the present case, the collapse of the right heart system caused by ECMELLA resulted in RCA deformation. This case also underscored that contrast injection to the coronary artery in total circulation support should be administered after confirmation of backflow through a GC.