Single-access percutaneous coronary intervention with IMPELLA CP support using a 16F sheath in refractory ventricular fibrillation: a case report

BACKGROUND: Complex cardiac arrest cases may require concurrent veno-arterial extracorporeal membrane oxygenation (VA-ECMO), left-ventricular unloading using Impella, and urgent percutaneous coronary intervention (PCI), vascular access sometimes becomes a procedural bottleneck. Conventional single-access Impella-PCI via a 14 Fr peel-away sheath expedites workflow but increases femoral bleeding risk; conversely, the lower-bleeding 16 Fr Medikit sheath used in Japan typically precludes true single-access PCI. We report a rescue strategy employing a coaxial 16 Fr/14 Fr peel-away/6 Fr sheath configuration to achieve single-access Impella-supported PCI when radial access was unobtainable. A 53-year-old man in refractory ventricular fibrillation received VA-ECMO via right femoral cannulation; coronary angiography through the left femoral artery revealed subtotal proximal right-coronary-artery occlusion. Radial access was unobtainable. An Impella CP was implanted through a 14 Fr peel-away sheath coaxially inserted into a 16 Fr Medikit sheath placed in the left common femoral artery. A 6 Fr sheath was advanced through the same peel-away sheath, permitting single-access PCI and successful stent deployment. After revascularization the 6 Fr and 14 Fr sheaths were removed, leaving the Impella supported by the 16 Fr sheath without bleeding complications. CONCLUSION: A coaxial 16 Fr/14 Fr/6 Fr femoral strategy enables safe single-access Impella-supported PCI, combining procedural efficiency with a lower bleeding risk when radial routes are not feasible.