Optimizing protected PCI strategies in the setting of chronic kidney disease and advanced coronary artery disease: a clinical case-based discussion

Patients with chronic coronary artery disease (CAD) and severely reduced left ventricular ejection fraction (LVEF) represent a particularly high-risk population often deemed unsuitable for conventional revascularization strategies. Procedural challenges arise from complex coronary anatomy, impaired cardiac reserve, and frequent comorbidities, such as frailty and chronic kidney disease, all of which predispose patients to haemodynamic instability and adverse outcomes during percutaneous coronary intervention (PCI). The use of mechanical circulatory support (MCS) devices, such as a microaxial flow pump (mAFP), has emerged as an important strategy to mitigate these risks by providing continuous left ventricular unloading and augmenting cardiac output. Moreover, improved perfusion may attenuate the risk of acute kidney injury (AKI), a major determinant of post-PCI morbidity and mortality. Herein, we present a case of Impella™-supported PCI in an elderly male patient with multivessel CAD, markedly reduced LVEF, chronic kidney disease, and multiple comorbidities, highlighting the role of MCS in optimizing procedural safety and expanding revascularization options for this vulnerable patient population.