Korean Circ J.  2022 Jul;52(7):485-495. 10.4070/kcj.2022.0093.

Strategies for Renal Protection in Cardiovascular Interventions

• Ali ZA
• Escaned J
• Dudek D
• Radhakrishnan J
• Galougahi KK

• KMID: 2530730
• DOI: http://doi.org/10.4070/kcj.2022.0093

Abstract

Coronary artery disease is highly prevalent in chronic kidney disease (CKD) and is a risk factor for contrast-associated acute kidney injury (CA-AKI), a complication of cardiovascular procedures that require contrast administration (e.g., coronary angiography, percutaneous coronary intervention [PCI]). CA-AKI has a major impact on morbidity, mortality, and healthcare resource utilization. The incidence of CA-AKI is particularly high in patients with pre-existing CKD, advanced age and comorbidities that increase the likelihood of CKD. The focus of the present review is to provide a brief overview on the assessment of the risk for and prevention of CA-AKI in patients undergoing angiography and PCI, including recognition of the important patient- and procedure-related factors that may contribute to CA-AKI. Preventive and treatment strategies, the mainstay of which is volume repletion by normal saline, are briefly discussed. The main focus of the review is placed on technical details of contrast minimization techniques, including ultra-low contrast angiography and zerocontrast PCI. Operator competence in such techniques is important to ensure that procedural challenges in patients with CKD, like vessel calcification, multivessel disease and complex anatomical subsets, are effectively addressed by PCI while minimizing the risk of CA-AKI.

Keyword

Chronic kidney disease; Coronary angiography; Percutaneous coronary intervention; Contrast-associated acute kidney injury; Contrast-induced nephropathy

Figure

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  Figure 1 Pathway for ultra-low contrast angiography and ultra-low or zero-contrast percutaneous intervention.ACS = acute coronary syndrome; AP = antero-posterior; CA-AKI = contrast-associated acute kidney injury; CCS = chronic coronary syndrome; CV = contrast volume; DES = drug-eluting stent; DM = diabetes mellitus; EKG = electrocardiogram; GFR = glomerular filtration rate; LAO = left anterior oblique; LCA = left coronary artery; LVEDP = left ventricular end-diastolic pressure; MAX = Medial dissection, Apposition, eXpansion; MLD = Morphology, Length, Diameter ; PCI = percutaneous coronary intervention.

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  Figure 2 Ultra-low contrast angiography in a patient with advanced chronic kidney disease (stage 5, estimated glomerular filtration rate 13 mL/min). (A) Radial access is avoided so that the radial artery is preserved for access for hemodialysis in the near future. Femoral access is performed using a combination of ultrasound to mark the common femoral bifurcation, a hemostat to mark the mid-femoral head using the micropuncture kit to gain access. (B) The left ventricular end diastolic pressure is measured to guide intravenous hydration. (C) Intracoronary injection of 10 mL of 0.9% heparinized normal saline. If the catheter is engaged, transient EKG changes will occur. Single view, low-magnification, non-panned angiograms of the right (LAO-cranial), circumflex (AP-caudal), and left anterior descending coronary arteries (AP-cranial) are obtained. Total contrast volume was 9.6 mL.AP = antero-posterior; LAO = left anterior oblique.

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  Figure 3 Ultra-low contrast angiography with adjunctive coronary physiology to resolve diagnostic ambiguity. (A) A patient with advanced chronic kidney disease (stage 5, estimated glomerular filtration rate 8 mL/min) undergoes ultra-low contrast angiography with contrast dilution, which suggests an ambiguous lesion in the proximal circumflex coronary artery (arrow). (B-C) Invasive coronary physiology is performed, without contrast-guidance, which excludes significant ischemia, with resting full-cycle ratio of 0.94.

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  Figure 4 Zero contrast percutaneous coronary intervention in a patient with advanced chronic kidney disease. (A) A road map from a previously performed ultralow contrast angiogram of the RCA with 3 mL contrast in the AP cranial view is projected. (B) Spot iFR of the distal vessel confirms significant ischemia (iFR 0.67). (C) Co-registration of iFR pullback with the angiographic silhouette of the guidewire reveals a focal flow-limiting stenosis in the mid RCA segment, while confirming that the proximal lesion (A*) is non-ischemic. (D) A reference segment distal to the lesion is identified manually and marked with cine angiography. (E) By co-registering the intravascular ultrasound system pullback with the guidewire, reference vessel measurements are performed at the distal reference segment, revealing a mean distal vessel size of 3.1 mm. (F) Following the same approach, a proximal, disease-free segment is identified, the length of lesion measured from the distal reference to this segment (yellow line) is 33.7 mm and mean proximal vessel size is 3.7 mm. (G-I) The stent is then deployed using co-registration, which may be automated (G), or manual (H), where the distal stent marker is aligned to the intravascular ultrasound transducer and a 3.0 mm by 33 mm drug eluting stent is deployed. (J) Using the advanced fluoroscopic device detection, the distal segment of stent is post-dilated pre-emptively with a 3.0 mm non-compliant balloon while avoiding the distal edge of the stent, and (K) the proximal segment of the stent with a 3.5 mm non-compliant balloon. (L) Stent expansion is assessed by measuring the manually identified minimal stent area (7.2 mm2) and comparing it with (M) the distal reference area (7.1 mm2), confirming >100% expansion. The distal and proximal stent edge were free of dissection (not shown). (N) A final spot iFR measurement confirms resolution of ischemia with pullback (O) confirming no need for further intra-stent optimization.AP = antero-posterior; iFR = instantaneous flow ratio; RCA = right coronary artery.

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  Figure 5 Techniques to increase safety of ultra-low or zero contrast percutaneous coronary intervention. (A) Baseline coronary angiogram. (B) Workhorse guide wires are bent at the tip with exaggerated curves to promote knuckling of the wire (white circles) and protect against distal wire perforation. (C) Dynamic coronary roadmap, a real-time, motion-compensated navigation system, can help prevent inadvertent wire passage into small vessels, which may track along the same course as the target vessel.

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