Coronary artery malperfusion in Stanford A-AAD accounts for 7–11% of cases. Although previous reports have often indicated a higher prevalence in the right coronary artery [1,2,3], recent studies have shown no significant difference in the occurrence of malperfusion between the left and right coronary arteries [4]. In the case of left or bilateral coronary atresia, myocardial damage can result in widespread circulatory collapse, and conventional emergency open heart surgery has poor surgical outcomes [1,2,3]. Performing LMT-percutaneous coronary intervention (PCI) in patients with a dissection is technically challenging; however, it is crucial to restore coronary perfusion as soon as possible [5]. In addition, a recent study reported the death of all its patients who required VA-ECMO, regardless of aortic repair [6].

Impella is a microaxial-flow pump that is inserted percutaneously through peripheral vessels to pump blood directly from the LV into the aorta. It is particularly beneficial in cases of cardiogenic shock caused by acute myocardial infarction. LV unloading during reperfusion reduces myocardial damage, decreases infarct size, and prevents progression to advanced-stage heart failure. These factors strongly support the early introduction of Impella in the treatment of acute coronary syndrome [7, 8]. In addition, when combined with VA-ECMO, Impella offsets the drawbacks of VA-ECMO, particularly the increase in LV afterload [9]. Unfortunately, it is generally contraindicated in cases of acute aortic dissection owing to its intra-aortic placement, since the aortic structure is compromised in these cases. Yoshida et al. reported their experience regarding the use of Impella in cases of a dissected aorta [10], in which the ascending aorta and aortic arches had already been repaired. To the best of our knowledge, this is the first reported case in which Impella was used prior to aortic repair in a case of AAD.

In the current case, Impella was used before the AAD diagnosis. If AAD had been identified earlier, there might have been hesitation in employing this catheter pump because of the potential risk of exacerbating the condition or causing aortic rupture. However, a previous study reported that PCI with IABP support for AAD-related LMT malperfusion was performed without adverse events [6]. In our case, the Impella was successfully inserted through the true lumen into the LV, providing circulatory support that is superior to that of the IABP and comparable to that of a normal aorta. Additionally, its lower pulsatile pressure and its ability to pump blood directly from the LV into the true aortic lumen, rather than the pseudo lumen, may have helped prevent aortic rupture.

Considering this is a single case report, we are unable to recommend early PCI and Impella support for AAD patients with LMT malperfusion. However, it is crucial to recognize that emergency open-heart surgery has a poor prognosis in critical cardiac damage cases. Thus, this clinical approach may be considered in similar cases.