Zero contrast retrograde chronic total occlusions percutaneous coronary intervention: a case series

Invasive Management of Coronary Artery Disease in Advanced Renal Disease

Coronary artery disease (CAD) is highly prevalent in chronic kidney disease (CKD). CKD modifies the effects of traditional risk factors on atherosclerosis, with CKD-specific mechanisms, such as inflammation and altered mineral metabolism, playing a dominant pathophysiological role as kidney function declines. Traditional risk models and cardiovascular screening tests perform relatively poorly in the CKD population, and medical treatments including lipid-lowering therapies have reduced efficacy. Clinical presentation of cardiac ischemia in CKD is atypical, whereas invasive therapies are associated with higher rates of complications than in with patients with normal or near normal kidney function. The main focus of the present review is on the invasive approach to management of CAD in late-stage CKD, with an in-depth discussion of the findings of the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA)-CKD trial, and their implications for therapeutic approach and future research in this area. We also briefly discuss the existing evidence in the epidemiology, pathogenesis, diagnosis, and medical management of CAD in late-stage CKD, end-stage kidney disease (ESKD), and kidney transplant recipients. We enumerate the evidence gap left by the frequent exclusion of patients with CKD from randomized controlled trials and highlight the priority areas for future research in the CKD population.

Zero-Contrast Left Main Bifurcation PCI in an Elderly Patient with Chronic Kidney Disease

Patients with chronic kidney disease develop acute kidney injury (AKI) following percutaneous coronary intervention (PCI). We report a case highlighting the benefits of zero-contrast left main bifurcation PCI in an 82-year-old male with non-ST elevation myocardial infarction and contrast-induced AKI following coronary angiography. The patient was on routine follow-up, and he was stable and asymptomatic at nine months follow-up.

Zero-Contrast Multivessel Revascularization for Acute Coronary Syndrome in a Patient With Chronic Kidney Disease

Patients with chronic kidney disease are at elevated risk for adverse events after traditional coronary angiography and percutaneous intervention with contrast media. The case presented in this report highlights the potential benefits of zero-contrast multivessel percutaneous coronary intervention in a patient presenting with a non–ST-segment elevation acute coronary syndrome. (Level of Difficulty: Beginner.)

Successful revascularization of right coronary artery chronic total occlusion by the antegrade and retrograde approaches

The treatment of chronic total occlusion (CTO) of coronary arteries allowed for a remarkable improvement in success rates and is represented by the introduction of the "Hybrid algorithm". An inability to cross the occlusion with a guidewire is the most common cause of failure of CTO revascularization. As antegrade options are limited, intervention upon the extreme angulation of the coronary artery warrants a retrograde approach. Here, we report a 58-year-old man with symptoms of effort angina complicated with three-vessel disease and CTO of the right coronary artery (RCA). Left main artery bifurcation lesions were treated with systematic two-stent strategies and intervention upon RCA CTO after three months by means of a combination of the antegrade and retrograde approaches. The RCA was eventually revascularized by the implantation of stents, and no adverse events were observed during hospitalization.

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

Contrast-induced nephropathy is a serious complication after intravascular administration of iodinated contrast media and is associated with numerous adverse outcomes. Its prevalence is particularly high in patients with multiple comorbidities who undergo coronary angiography and percutaneous coronary intervention (PCI). Currently, the only effective method to prevent contrast-induced kidney injury is adequate hydration and a reduction of contrast volume during the intervention. Recently, new approaches aiming to minimize contrast usage have been proposed, i.e., ultra-low contrast angiography and zero-contrast PCI. However, neither tutorials for these techniques nor reviews of their outcomes exist in the literature, and therefore dissemination of these approaches among the interventional community may be limited. This article presents a step-by-step description on how to perform ultra-low coronary angiography and zero-contrast PCI, which should help invasive cardiologists to adopt these techniques in daily practice. A review of clinical studies, case series and single case reports regarding these methods is also provided. Despite the promising results, such procedures still require some improvements and confirmation of their effectiveness as well as safety in large clinical studies. This article aims to spread these new techniques throughout the interventional community, which is paramount for their further development and wider utilization.