Imaging- and physiology-guided percutaneous coronary intervention without contrast administration in advanced renal failure: a feasibility, safety, and outcome study

Abstract

Aims: The feasibility, safety, and clinical utility of percutaneous coronary intervention (PCI) without radio-contrast medium in patients with advanced chronic kidney disease (CKD) are unknown. In this series, we investigated a specific strategy for 'zero contrast' PCI with the aims of preserving renal function and preventing the need for renal replacement therapy (RRT) in patients with advanced CKD.

Methods and results: A total of 31 patients with advanced CKD [creatinine = 4.2 mg/dL, inter-quartile range (IQR) 3.1-4.8, estimated glomerular filtration rate = 16 ± 8 mL/min/1.73 m²] who had clinical indication for PCI based on a prior minimal contrast coronary angiogram were included. Zero contrast PCI was performed at least 1 week after diagnostic angiography using real-time intravascular ultrasound (IVUS) guidance, with pre- and post-PCI measurements of fractional flow reserve and coronary flow reserve to confirm physiological improvement. This approach resulted in successful PCI, no major adverse cardiovascular events and preservation of renal function without the need for RRT within a follow-up time of 79 days (IQR 33-207) in all patients.

Conclusion: In patients with advanced CKD who require revascularization, PCI may safely be performed without contrast using IVUS and physiological guidance with high procedural success and without complications.

Keywords: Chronic kidney disease; Contrast-induced nephropathy; Coronary physiology; Intravascular ultrasonography; Percutaneous coronary intervention.

Figure 1

Ultra-low contrast coronary angiography followed by staged percutaneous coronary intervention with zero contrast. Cine images recorded at the initial angiography using ultra-low contrast volume are displayed on adjoining screen during the staged percutaneous coronary intervention (A) and used to guide catheter engagement, coronary guide wire placement in the left anterior descending artery, diagonal branch, and the circumflex artery, thus creating a metallic silhouette of the left coronary system (B). Intravascular ultrasound imaging of the left anterior descending artery is performed with proximal reference diameter (≈4.5 mm) (1), minimal luminal area (3.71 mm²) (2), and distal reference diameter (≈4.0 mm) (3) measured for selection of the appropriate pre-dilation balloon and stent sizes. The co-registered dry cine image of intravascular ultrasound transducer placed at the distal reference (C) is used to guide the percutaneous coronary intervention. Following preparation of the lesion and deployment of a 3.5 × 38 mm drug-eluting stent (D), intravascular ultrasound is repeated to assess the result, to determine the proximal (9.6 mm²) (4) and distal (7.7 mm²) (6) reference areas, and to guide post-dilation of under-expanded segments to achieve the pre-determined MSA, defined as >90% of the mean of the proximal and distal reference areas, (7.9 mm²) (5).