A prospective study on the incidence of contrast-associated acute kidney injury after recanalization of chronic total coronary occlusions with contemporary interventional techniques

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Highlights

  • CA-AKI is a major procedural complication in patients undergoing complex PCI such as the recanalization of a CTO

  • In a large cohort of 1924 procedures the incidence of CA-AKI was 5.6%, in patients with CKD it increased to about 20%.

  • Patient-related risk factors were higher age, diabetes, LVEF<40%, pre-existing CKD, as well as preprocedural anaemia.

  • Procedural risk factors were longer procedures, and the risk of perforation, but not the contrast medium volume.

  • It should be tested in further studies whether correcting anaemia in patients at highest risk could reduce CA-AKI.

Abstract

Background

Contrast-associated acute kidney injury (CA-AKI) is a potential risk associated with the percutaneous coronary interventions (PCI) for chronic total coronary occlusions (CTO). This study should evaluate the incidence of CA-AKI in an era of advanced strategies of recanalization techniques and identify modifiable determinants.

Methods

We analysed 1924 consecutive CTO procedures in 1815 patients between 2012 and 2019. All patients were carefully monitored at least up to 48 h after a CTO procedure for changes in renal function.

Results

The incidence of CA-AKI was 5.6%, but there was no relation to the technical approach such as frequency of the retrograde technique, intravascular ultrasound or radial access. Procedures with CA-AKI had longer fluoroscopy times (37.6 vs 46.1 min; p = 0.005). The major determinants of CA-AKI were age, presence of diabetes and reduced ejection fraction, as well as chronic kidney disease stage ≥2, serum haemoglobin, and fluoroscopy time. Contrast volume or contrast volume/GFR ratio were not independent determinants of CA-AKI. Periprocedural perforations were more frequent in CA-AKI patients (11.3 vs 2.3%; p < 0.001), and in-hospital mortality was higher (2.8 vs 0.4%; p < 0.001).

Conclusions

CA-AKI was associated with the risk of in-hospital adverse events. Established patient-related risk factors for CA-AKI (age, diabetes, preexisting chronic kidney disease, low ejection fraction) were confirmed in this study. In addition, the length of the procedure, coronary perforations and low preprocedural serum haemoglobin were risk factors that might be preventable in patients at high risk for CA-AKI.

Introduction

The advances in percutaneous coronary interventions (PCI) for chronic total occlusions (CTO) have led to success rates that are close to those in non-occlusive lesions, but the risk of radiation related injury and the high utilization of contrast medium remain limiting factors with potential risk of contrast-associated acute kidney injury (CA-AKI) [1,2]. In a meta-analysis of studies on CTO PCI the prevalence of CA-AKI appears to be in a range of 2.4–18.1%, but only 20% of studies looked at CA-AKI at all, and not all of those followed the patients for at least 48 h or used a uniform definition for CA-AKI [3]. There are developments in the strategic approach to CTOs which even allow zero contrast medium interventions [4], but this is not universally applicable, as in general, the contrast medium usage is higher than for PCI of non-occlusive lesions [5,6].

On one hand, recent guidelines advise not to exceed a ratio of contrast medium volume relative to the glomerular filtration rate (GFR) of 3.7 [7], on the other hand the direct relation of contrast volume to CA-AKI has not been shown in some studies of complex PCI [8,9]. As contemporary CTO technique have developed rapidly over the past years with the option of reducing contrast volume with intravascular ultrasound imaging (IVUS), but also becoming more complex with a high share of retrograde procedures, we assessed a consecutive series of patients with monitoring of renal function to determine patient-related and procedure-related risk factors after contemporary CTO PCI.

Section snippets

Study concept

This study is a single-centre prospective registry conducted for quality control of CTO PCI. All patients undergoing PCI for one or more CTOs between 2012 and 2019 were included. Out of a total of 19393 procedures, 12 (0.62%) were performed in patients on chronic haemodialysis which are excluded from the subsequent analysis leaving 1927 procedures, 26 of them (1.3%) were PCI for two CTOs in one procedure. Three patients (all with CKD stage < 2) died during or immediately after the procedure

Clinical and procedural characteristics of patients with and without CA-AKI after CTO PCI

We analysed 1924 procedures performed in 1815 patients. Each procedure was considered separately regarding the possible incidence of CA-AKI. During the eight-year study period 93 patients underwent a second procedure (5.1%), 16 patients had a third or fourth procedure (0.9%). Only one patient experienced CA-AKI on two separate occasions. The hydration protocol was applied invariably during this study period, adjusted for LV function, without adverse effects of congestive heart failure or the

Discussion

This study presents one of the largest series of CTO PCI with prospective evaluation of CA-AKI using contemporary recanalization techniques with almost half of them done by the retrograde approach. The incidence of CA-AKI was 5.6%. Preventive measures of continuous fluid substitution were routinely applied [13,14,20], and contrast volume limited as technically feasible. Notably, there was no close relation between contrast medium volume and CA-AKI incidence which supports recent discussions

Conclusion

This study showed an incidence of CA-AKI after CTO PCI is in the range of 5–6% with contemporary recanalization techniques with limited use of contrast and routine use of a hydration protocol. Some of the well-established patient related risk factors were confirmed but contrast volume or the CV/GFR ratio were not independent determinants. Anaemia and long procedures were factors with high impact on the incidence of CA-AKI which should receive special attention. Even though not always

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