Ultra-Low Contrast Volume for Patients with Advanced Chronic Kidney Disease Undergoing Coronary Procedures

Abstract

Background/Aims: Contrast induced nephropathy (CIN) is associated with adverse clinical outcomes in patients undergoing coronary interventions, particularly in patients with advanced chronic kidney. The study was aimed to assess the real-life feasibility and safety of ultra-low volume coronary procedures in patients with advanced chronic kidney disease. Methods: A prospective study that included patients with an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m²) was conducted. Coronary procedures were performed using an ultra-low contrast volume technique. Results: The 30 patients had a mean eGFR of 31.8(±8) mL/min/1.73 m². Indications for coronary angiography were non-ST elevation myocardial infarction (63.3%), unstable (20%), and stable angina pectoris (16.7%). Median contrast volume for diagnostic coronary angiography was 13 mL (interquartile ranges [IQR] 12–14.9), and an additional 13 mL (IQR 8.8–14.3) for percutaneous coronary intervention (PCI). In 3 patients (10%), a ≥25% increase was demonstrated in serum cystatin C levels 48 h following the procedure. None of the patients demonstrated a ≥25% increase in serum creatinine levels at 48 h. Following 6 months, no patient required renal replacement therapy or unplanned coronary intervention. Conclusions: In patients with advanced chronic kidney disease, the ultra-low contrast technique is feasible and effective and can be used safely without a significant deterioration in renal function. This technique may increase the utilization of PCI in high-risk coronary patients with chronic kidney disease.

Remote ischemic preconditioning reduces the incidence of contrast‐induced nephropathy in patients undergoing coronary angiography/intervention: Systematic review and meta‐analysis of randomized controlled trials

“…30 The efficient and judicious use of CM through "ultra-low contrast technique" has been described to be feasible, effective, and safe; this technique involved use of small catheters without side-holes and approach to minimize CM injection. 32 Another approach thought to reduce the risk of CIN is by using iso-osmolar CM (iodixanol), however, current evidence does not show the superiority of iso-osmolar CM compared to low-osmolar CM. 33 A randomized controlled trial also showed that radial access has a lower risk of AKI compared to femoral access, which might be elucidated by reduction of bleeding events, renal circulation embolization, or by a combination of both mechanisms.…”

“…Dextran may also be used in OCT‐guided PCI which seemed to be non‐nephrotoxic if administered <100 ml 30 . The efficient and judicious use of CM through “ultra‐low contrast technique” has been described to be feasible, effective, and safe; this technique involved use of small catheters without side‐holes and approach to minimize CM injection 32 . Another approach thought to reduce the risk of CIN is by using iso‐osmolar CM (iodixanol), however, current evidence does not show the superiority of iso‐osmolar CM compared to low‐osmolar CM 33 .…”

Clinical Outcome of Low Dose Contrast during Percutaneous Coronary Intervention in Patients with Moderate to Severe Kidney Impairment

“…The most common indication was NSTEMI (25 patients) followed by stable angina pectoris (5 patients), and 16 patients underwent subsequent coronary angioplasty. CIN occurred in 3 patients increase in serum cystine level but not on creatinine levels 48 h following coronary procedure [20].…”

“…Group (A): which included [20] whose cv/gfr ratio < 2. Group (B): which included [21] patients in whom cv/gfr ratio > 2 but still < MACD.…”

Ultra-low contrast coronary angiography and zero-contrast percutaneous coronary intervention for prevention of contrast-induced nephropathy: step-by-step approach and review

“…Recently, one prospective study and another retrospective analysis showed that ultra-low contrast techniques guided by only angiography (without IVUS and OCT) is feasible and can safely be used in patients with CKD [26, 27]. These single arm studies showed that contrast dose might be reduced to a median volume of 13 to 15.2 ml for diagnostic angiography and 13 to 17.1 ml for PCI, which was associated with a low rate of CIN [26, 27]. Although this approach is cheaper compared with IVUS- or OCT-guided procedures, there are some concerns about its long-term outcomes, i.e., whether ultra-low contrast PCI without intravascular imaging ensures optimal results.…”