2026 FSA Podium and Poster Abstracts

A 76-year-old man with a history of Parkinson’s disease, type 2 diabetes mellitus, hypertension, sigmoid adenocarcinoma status post sigmoidectomy, and severe multivessel coronary artery disease presented for high-risk percutaneous coronary intervention (PCI). Left heart catheterization in October 2024 demonstrated distal left main disease, proximal left anterior descending (LAD) disease, and complete occlusion of the proximal right coronary artery (RCA). He was previously deemed a poor candidate for coronary artery bypass grafting or standard percutaneous revascularization due to significant comorbidities and was managed medically. Progressive anginal symptoms prompted referral for high-risk PCI with planned intraoperative Impella support. The anesthetic plan included moderate sedation with pre-induction arterial line placement.

In the catheterization laboratory, Impella placement was successful. PCI with drug-eluting stent deployment was performed, and intravascular ultrasound confirmed excellent stent expansion with no residual stenosis. Guidewires and catheters were removed, and intravenous cangrelor was initiated for antiplatelet therapy. During groin closure, the patient developed bradycardia with intermittent Mobitz type II atrioventricular block, necessitating placement of a transvenous pacemaker via the left femoral vein. The Impella device was weaned and removed from the right femoral artery.

Shortly after vascular closure, the patient became progressively hypotensive and refractory to fluid boluses and escalating vasopressor support. The cardiology team reopened the access site for emergent angiography, while anesthesia converted to general endotracheal anesthesia. Angiography revealed plaque shift with acute total occlusion of the proximal left circumflex artery. Emergent balloon angioplasty was performed, and Impella support was reestablished. Intra-procedural echocardiography demonstrated no pericardial effusion and appropriate Impella positioning, but a newly reduced left ventricular ejection fraction consistent with acute ischemic compromise. The patient was transferred to the intensive care unit, intubated, sedated, and paced, with mechanical circulatory assistance provided.

This case illustrates the profound hemodynamic instability that can occur during high-risk left main PCI in patients with severe multivessel coronary disease and extensive comorbidities. Despite careful pre-procedural planning and prophylactic mechanical support, rapid plaque shift and acute vessel occlusion resulted in cardiogenic shock and malignant conduction disturbances. The clinical course underscores the dynamic and unpredictable nature of complex coronary interventions, particularly when surgical options are limited.

Successful management required rapid recognition of ischemic complications, immediate re-intervention, escalation of anesthetic support, temporary pacing, and reinitiation of mechanical circulatory support. This case highlights the importance of meticulous preparation, real-time multidisciplinary collaboration among interventional cardiology and anesthesia teams, and readiness to convert procedural strategies in response to sudden hemodynamic deterioration. Ultimately, it demonstrates both the life-saving potential and inherent risks of complex PCI in nonsurgical candidates, emphasizing the need for coordinated, resource-intensive care to optimize outcomes in this vulnerable population.