Coronary angiography is the third leading cause of acute kidney injury (AKI) among hospitalized patients.1,2 Several risk factors for the development of contrast-induced nephropathy (CIN) have been identified, including diabetes mellitus, chronic kidney disease, and heart failure.3,4 CIN is associated with a variety of adverse clinical outcomes such as increased mortality, cardiovascular events, and prolonged hospitalization.5
Prevention of CIN is key in patients undergoing cardiac catheterization. Adequate hydration both pre- and post-procedure can decrease its incidence, but poses a challenge particularly in patients with congestive heart failure, as hydration can cause decompensation.
Additionally, significantly minimizing or eliminating radio-contrast media use can prevent CIN.6
Herein, we describe a case of percutaneous coronary intervention (PCI) of a right coronary artery (RCA) with zero radio-contrast use, and PCI of the distal left main coronary artery (LM) into the left anterior descending artery (LAD) using minimal radio-contrast use, facilitated by the SyncVision Precision Guidance System (Philips).
A 70-year-old female with a history of hypertension, type 2 diabetes mellitus, and chronic kidney disease stage 4 underwent coronary angiogram for evaluation of Canadian Cardiovascular Society class 3 angina. Cardiac catheterization was performed via a right femoral approach due to severe right radial artery spasm. The coronary angiogram showed severe lesions in the distal LM, proximal LAD, and mid RCA (Figures 1-2). A total of 30 cc of contrast was used. Intervention was not performed in order to minimize contrast. The patient also stated she did not want to undergo dialysis at any point. She was referred to us for staged low-contrast, multivessel PCI using the SyncVision Precision Guidance System.
We first intervened in the RCA. The RCA was selectively engaged with a 6 French Judkins right (JR) 4 guide catheter and wired with a Runthrough (Terumo) guidewire into the posterior descending artery. No contrast was used. The images from the diagnostic coronary angiogram were printed, and used for a reference to facilitate engagement and wiring of the coronaries without contrast use. Next, intravascular ultrasound (IVUS) was advanced to the distal RCA and we started to record. A slow pullback was performed under continuous fluoroscopy at 15 frames per second until the IVUS catheter was in the guide catheter. At this point, fluoroscopy and IVUS recording were stopped, and a 3-second “dry” (no contrast) cinematography was performed (Figure 3). SyncVision co-registered the location of the IVUS image on the dry cinematography. We were then able to navigate the vessel to obtain the healthy proximal and distal vessel diameter, minimal luminal area (MLA), and lesion length. With this SyncVision data available on the right side of the screen, a 3.0 x 30 mm drug-eluting stent (DES) was landed in the geographic location under live fluoroscopy (Figures 4-7). The stent was post-dilated with a 3.5 mm non-compliant (NC) balloon. Post-stenting IVUS was performed again, which showed excellent stent apposition and lesion coverage (Video 1, see below).
Intervention of the LM and LAD lesions was performed next. The LM was selectively engaged with a 7 French Extra Backup (EBU) 3.5 guide catheter, and a Runthrough guidewire was used to wire into the distal LAD. Again, no contrast was used since the diagnostic images were used as a reference. Similar to the RCA, IVUS pullback under continuous fluoroscopy followed by a 3-second “dry” (no contrast) cinematography was performed (Figure 8). SyncVision co-registration allowed us to determine the proximal and distal reference diameters, MLA, and lesion length (Figures 9-11). The distal LM into the mid LAD was stented with a 3.0 x 34 mm DES, the proximal stent was post-dilated with a 4.0 mm NC balloon. Post-PCI IVUS showed excellent results. Up to this point, no contrast was used; however, since this was a LM intervention and we “jailed” the left circumflex, 2 final images were obtained in the anteroposterior (AP) caudal and cranial projections (Figure 12); 12 cc of contrast was the total use for the entire case. The patient was discharged same day, and was doing very well at 1-week follow-up. Her renal function has remained stable.
We believe that contemporary PCI should routinely utilize IVUS guidance. IVUS use during PCI is associated with decreased target vessel failure and cardiac death.7,8 While IVUS improves outcomes, matching up the IVUS image with the angiogram image can be challenging. The SyncVision Precision Guidance System addresses this challenge, because it co-registers the angiogram and IVUS images so that the operator can see both images on one screen. SyncVision allows for determination of artery healthy-to-healthy landing zones, proximal and distal reference vessel diameter, and lesion length, resulting in optimal stent selection and landing.
SyncVision co-registration is performed in 4 steps:
- Advance the IVUS catheter to the distal healthy reference segment.
- Begin recording and perform a slow IVUS catheter pullback under fluoroscopy at 15 frames/second.
- When the catheter is in the guide catheter, stop recording and go off fluoroscopy.
- Perform a cinematography angiogram. A “dry” cine can also be performed, as we did, in order to conserve contrast. If a no-contrast cine is performed, it is important that the patient remain in the same position throughout the process.
For best results, the catheter tip and guidewire should be clearly visible. The artery should be imaged in a view that is off the spine and diaphragm, both of which could impede co-registration.
With the use of the SyncVision Precision Guidance System, we believe that nearly every PCI can be performed with <20 cc of contrast use. This is a gamechanger, especially for patients with CKD. By utilizing minimal contrast, patients with CKD can be discharged the same day with less concern for the development of CIN. Same-day discharge is not only cost effective, but may be safer for patients in the current Covid pandemic, and has been shown to be safe even after the most complex interventions.9
Disclosures: Nachiket Patel reports he is a consultant for Philips. Drs. Jost, Barry, Lipskind and Heuser report no conflicts of interest regarding the content herein.
The authors can be contacted via Nachiket Patel, MD, FACC, FACP, FSCAI, Clinical Assistant Professor of Medicine – University of Arizona College of Medicine, at email@example.com.
- Barrett BJ, Parfrey PS. Clinical practice. Preventing nephropathy induced by contrast medium. N Engl J Med. 2006; 354(4): 379-386.
- Patel N, Baker SM, Walters RW, et al. Serum hyperchloremia as a risk factor for acute kidney injury in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention. Proc (Bayl Univ Med Cent). 2016; 29(1): 7-11.
- McCullough PA, Wolyn R, Rocher LL, et al. Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Am J Med. 1997; 103(5): 368-375.
- McCullough PA, Stacul F, Becker CR, et al. Contrast-Induced Nephropathy (CIN) Consensus Working Panel: executive summary. Rev Cardiovasc Med. 2006; 7(4): 177-197.
- James MT, Samuel SM, Manning MA, et al. Contrast-induced acute kidney injury and risk of adverse clinical outcomes after coronary angiography: a systematic review and meta-analysis. Circ Cardiovasc Interv. 2013; 6(1): 37-43.
- Gupta RK, Bang TJ. Prevention of contrast-induced nephropathy (CIN) in interventional radiology practice. Semin Intervent Radiol. 2010; 27(4): 348-359.
- Zhang J, Gao X, Kan J, et al. Intravascular ultrasound versus angiography-guided drug-eluting stent implantation: the ULTIMATE trial. J Am Coll Cardiol. 2018; 72(24): 3126-3137.
- Choi KH, Song YB, Lee JM, et al. Impact of intravascular ultrasound-guided percutaneous coronary intervention on long-term clinical outcomes in patients undergoing complex procedures. JACC Cardiovasc Interv. 2019; 12(7): 607-620.
- Sawant AC, Seibolt L, Distler E, et al. Safety and feasibility of same-day discharge after percutaneous coronary intervention for chronic total occlusion: a single center observational cohort study. Coron Artery Dis. 2019; 30(7): 549-550.