Feasibility and safety of noncontrast percutaneous coronary intervention in patients with complicated acute coronary syndrome

Absolute zero-contrast percutaneous coronary interventions: An intravascular ultrasound-guided case series and literature review

PURPOSE

Contrast media (CM)-associated adverse effects including mainly acute kidney injury and hypersensitivity reactions still remain a significant treatment burden to vulnerable patients requiring percutaneous coronary intervention (PCI). The complete omission of CM administration accompanied by intravascular ultrasound (IVUS) guidance may offer an appropriate revascularization treatment.

METHODS

We hereby present a case series of four patients with challenging coronary lesions and relative/absolute contraindications to CM use [(hypersensitivity reaction owning to CM, history of contrast-induced acute kidney injury, solitary kidney, or advanced chronic kidney disease (CKD)] who underwent absolute zero-contrast IVUS-guided PCI following a predetermined protocol.

RESULTS

The initial diagnostic angiography was reviewed for landmark identification, and multiple guidewires created a metallic road map providing additional landmarks and protected side branches. IVUS imaging was performed to determine lesion length, reference segments and landing zones, assess stent expansion/apposition and identify major complications. All procedures were successfully completed without any CM administration, renal function deterioration, pericardial effusion, or stent edge dissection.

CONCLUSIONS

We demonstrated the feasibility of absolute zero-contrast IVUS-guided PCI in patients with complex coronary lesions susceptible to CM-associated adverse effects. Since the safety of this strategy is well-documented in patients with CKD and challenging lesions morphology even in acute settings, evidence-based validation of this approach is capable of changing the otherwise conservative treatment of vulnerable patients where even minimum doses of CM may have detrimental effects.

SUMMARY FOR THE ANNOTATED TABLE OF CONTENTS

Patients with vulnerable renal function as well as former hypersensitivity reaction to contrast media encounter a significant treatment burden regarding coronary artery disease. Zero-contrast IVUS-guided strategy based on a predetermined protocol provides a feasible alternative approach in patients susceptible to contrast media-associated adverse effects even in the presence of complex coronary lesions.

Clinical impact of noncontrast percutaneous coronary intervention in patients with acute coronary syndrome

PURPOSE

Contrast-induced acute kidney injury (CI-AKI) is one of the common serious complications of percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). This study aimed to assess the significance of noncontrast strategy in the setting of ACS.

METHODS

CI-AKI was defined as an increase in serum creatinine of ?0.5 mg/dL or ?1.25 times from the baseline. One-year worsening renal function (WRF) was defined as an increase of ?0.3mg/dL in serum creatinine from the baseline after PCI.

RESULTS

Of 250 ACS patients, 81 were treated with noncontrast PCI. The average doses of contrast medium in the noncontrast and conventional groups were 17 (9?22) ml and 150 (120?200) ml, respectively. CI-AKI was observed in 4 patients (5%) in the noncontrast group and 29 patients (17%) in the conventional group. Noncontrast PCI was associated with a lower incidence of CI-AKI (adjusted odds ratio, 0.26;95% confidence interval [CI], 0.08?0.82). The bootstrap method and inverse probability weighting led to similar results. CI-AKI was associated with a higher incidence of 1-year WRF (adjusted hazard ratio, 2.30;95% CI, 1.12?4.69), while noncontrast PCI was not.

CONCLUSIONS

Noncontrast PCI was associated with the lower incidence of CI-AKI in ACS patients. J. Med. Invest. 69 : 57-64, February, 2022.

Ultra-low contrast, complex left main coronary intervention case series using novel intravascular ultrasound technology

Background

Contrast-induced nephropathy (CIN) in patients with chronic kidney disease (CKD) carries a high morbidity and mortality. Ultra-low contrast percutaneous coronary intervention (ULPCI) has previously been described. Complex left main (LM) ULPCI using two-stent strategy guided by novel intravascular ultrasound (IVUS) co-registration software has not been described. We report a series of complex LM ULPCI using IVUS co-registration.

Case Summaries

Five patients with estimated glomerular filtration rate ≤20 mL/min who presented with stable angina or non-ST segment elevation acute coronary syndrome underwent percutaneous coronary intervention (PCI). The patients previously had diagnostic angiography performed as a separate procedure. Successful LM ULPCI was performed in all patients with a provisional and two-stent bifurcation strategies. These were complex procedures, some of which required haemodynamic support and rotational atherectomy.

Discussion

This report describes the first ULPCI using a dedicated two-stent LM bifurcation strategy and using rotational atherectomy and IVUS co-registration. This technology facilitated complex PCI in this high-risk patient group with minimal contrast use (≤6 mL) with optimal results and no patients developed acute kidney injury after intervention. The adaptation of ULPCI to daily practice in patients at risk of CIN will improve treatment for this underserved patient group.

IVUS-Guided Zero-Contrast PCI in CKD Patients: Safety and Short-Term Outcome in Patients with Complex Demographics and/or Lesion Characteristics

Background. Percutaneous coronary intervention (PCI) in patients with significant renal dysfunction is challenging because of the lesion characteristics and the risk of contrast-induced acute kidney injury (CI-AKI). With the advent of intravascular ultrasound- (IVUS-) guided zero-contrast PCI, outcomes have improved considerably. Objective. To assess the safety and short-term outcomes of IVUS-guided zero-contrast PCI in chronic kidney disease (CKD) patients with complex demographics or lesion morphology. Methods. Patients who underwent IVUS-guided zero-contrast PCI at a tertiary center, from November 2019 to May 2020, were included in this prospective analysis. Clinical characteristics, procedural data, and follow-up data were collected and analyzed. Results. A total of 15 patients (27 vessels), all men (mean age, 70.0 ± 11.0 years), underwent zero-contrast PCI. The mean estimated glomerular filtration rate (eGFR) and serum creatinine were 30.8 ± 7.3 mL/min/1.73 m2 and 2.6 ± 1.3 mg/dL, respectively. The mean BMC2 risk for dialysis was 2.1 ± 1.1%, mean SYNTAX score was 20.3 ± 10.3, and mean left ventricular ejection fraction (LVEF) was 42.4 ± 11.6%. Four patients (26.6%) underwent left main coronary artery (LMCA) PCI including one LMCA bifurcation. One patient underwent chronic total occlusion PCI. Technical and procedural success were 100% without any periprocedural complications. No major adverse cardiovascular events (MACE) were reported, and no patient required dialysis within three months of follow-up. Conclusion. Zero-contrast PCI guided by IVUS is safe in coronary artery disease (CAD) patients with moderate-to-severe CKD. High procedural success without complications can be achieved even in cases with complex clinical characteristics and lesion morphology.