Safety and feasibility of intravascular ultrasound guided zero-contrast percutaneous coronary intervention–A prospective study
Introduction
Contrast induced acute kidney injury (CI-AKI) is a concern for interventional cardiologists (IC) and they often defer percutaneous coronary intervention (PCI) due to fear of CI-AKI. CI-AKI results in permanent degradation of renal function, renal replacement therapy (RRT), and complications ranging from prolonged hospitalization to death. Mannitol, furosemide, acetylcysteine, ascorbic acid, dopamine, fenoldopam and statins failed to prevent CI-AKI [1,2]. The only proven method to avoid CI-AKI is adequate periprocedural hydration of the patient [3]. Amongst the risk factors of CI-AKI, reduction of the contrast volume is the only modifiable factor. In contrast, chronic kidney disease(CKD), congestive heart failure, hypotension, anemia, age > 75 years and diabetes mellitus are non-modifiable [4]. Previous studies calculated the maximum safe limit of contrast volume as 2 to 3.7 times of estimated glomerular filtration rate(eGFR) [[5], [6], [7], [8], [9]]. MOZART (Minimizing cOntrast utiliZation With Intra vascular ultrasound Guidance in coRonary angioplasTy) study demonstrated that aggressive use of intra-vascular ultrasound (IVUS) based strategy can dramatically reduce the contrast volume during PCI [10]. The standard techniques of reducing contrast volume as described by Nayak et al. are meticulous pre-procedural planning based on diagnostic angiography, use of reference images, small caliber catheters, small volume syringes, diluted contrast, high-resolution cine angiography, avoidance of catheters with side holes, and not exceeding contrast volume-to-eGFR ratio of 2 [11].
The coronary sinus (CS) aspiration method failed to aspirate contrast completely during coronary angiography or PCI. Non-CS drainage of the coronary circulation, ineffective balloon occlusion of the CS in large CS patients, and aortic sinus reflux of contrast during injection into the coronary artery were the reasons for failure [12]. Systemic removal of contrast agent immediately after completion of the diagnostic or therapeutic procedure by hemodialysis did not show benefit. Nevertheless, hemofiltration after PCI prevents CI-AKI in patients who had baseline creatinine ≥ 4 mg/dl [13,14].
IVUS identifies plaque morphology, lumen area, vessel dimensions, landing zones for stent, stent diameter and length, under expansion, mal-apposition, edge dissection, intramural hematoma and tissue prolapse. Hence IVUS can be used as an alternative tool to angiography during PCI. Ali et al. published the first series of zero-contrast PCI with IVUS and coronary physiology guidance and established a standard reproducible protocol. In that series, fractional flow reserve (FFR) and coronary flow reserve (CFR) were used as physiological guidance to assess coronary flow [15]. As CFR is not available in India; coronary flow estimation is impossible without the angiogram during PCI. We describe a technique of coronary flow assessment using IVUS in this study. We hypothesized that PCI is feasible without contrast using IVUS guidance alone, without further coronary physiology to rule out slow-flow or no-flow at the end of PCI.
Section snippets
Study design and population
This single-center prospective feasibility study aimed to assess the feasibility of zero-contrast PCI with only IVUS guidance without coronary physiology. Patients were screened based on inclusion and exclusion criteria (supplement). Two independent operators analyzed the coronary angiograms for the feasibility of zero-contrast PCI. A team of three IC, who had experience in intracoronary imaging performed a trial run of two cases. At least one was available during every procedure of the study.
Results
From June 2019 to April 2021, 254 patients at risk of CI-AKI underwent coronary angiograms were screened for this study. Out of that, 133 patients were suitable for PCI. Ninety-three participants met the exclusion criteria, and 13 participants were unwilling to consent. Thus 27 participants were enrolled in the study. The study was initially planned for 50 vessels within 12 months. But, the study was extended for a period of additional ten months due to slow enrollment. Fifty-seven participants
Discussion
Mariani et al. described the concept of using IVUS to reduce the contrast volume in 2014. MOZART trial was a randomized controlled trial that compared the total contrast volume required for PCI between angiogram guided (n = 42) vs. IVUS guided (n = 41) groups. The amount of contrast per stent implanted in the study was 13 ml (7.1,20.0) in IVUS guided group against 40.5 ml (25.7,48.3) in angiogram guided group. The contrast was used during guide catheter engagement, stent positioning, and final
Conclusions
This prospective study shows that zero-contrast PCI is safe and feasible in selective coronary anatomies. IVUS guidance alone is sufficient without the need for additional FFR or CFR guidance to rule out slow-flow or no-flow at the end of PCI. The short-term clinical outcomes are good. While using this technique, slow-flow, geographical miss and intraprocedural thrombus were the possible complications. Contrast may be needed to tide over the crisis. IVUS being mandatory, stent optimization was
Funding
None.
Declaration of Competing Interest
The authors do not have conflict of interest.
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All authors of this article take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.