ZERO Contrast Peripheral Vascular Interventions: A New Frontier

S. Halabi, M. Sabir, S. Arikupurathu, M. S. Dallal, S. Abbas, F. Saab, J. Mustapha

Purpose: Chronic kidney disease (CKD) is associated with significantly higher incidence of peripheral vascular disease (PVD). An important part of therapy includes peripheral vascular interventions (PVIs) requiring contrast media use. Contrast-induced acute kidney injury is a complication of vascular interventions and is responsible for serious adverse outcomes such as deterioration of renal function, necessity for dialysis, prolonged hospitalization, and increased mortality rate. We present a case of zero-contrast PVI using multiple innovative techniques.

Materials and Methods: A 69-year-old woman with a history of type 2 diabetes, hypertension, hyperlipidemia, and CKD (stage V) presented because of a nonhealing ulcer on the dorsal aspect of the right foot. The patient underwent an angiogram 8 months earlier where she underwent therapy to the right superficial femoral, popliteal, and anterior tibial artery. The patient had known occlusion of the proximal posterior tibial artery (PT), which was not treated because of advanced CKD. Because of lack of meaningful healing in the foot ulcer and the patient’s reluctance to initiate dialysis, amputation was recommended by the podiatry team. The decision was made to attempt revascularization of the PT using intravascular ultrasound (IVUS) guidance, CO2 angiography, and extravascular ultrasound (EVUS) with the goal of zero contrast use.

Results: Ultrasound-guided PT access was obtained followed by placement of a 4/5 slender sheath. An 0.018-inch wire was advanced using the JENALI technique crossing the occlusion of the PT. A combination of EVUS and CO2 angiography as used to confirm crossing of the PT occlusion. IVUS was used to assess wire position, plaque morphology, and severity and size of the vessels. Atherectomy and balloon angioplasty therapy were used to treat the PT. IVUS was completed, which confirmed excellent luminal gain without dissections. A final CO2 angiography run confirmed flow in the PT. EVUS was completed showing biphasic flow in the PT. On further follow-up, the patient had excellent clinical improvement and remained dialysis free.

Conclusions: The increased prevalence of PVD and CKD mandates that vascular operators continue to find innovative solutions to treating patients with advanced disease and preserving their residual limited kidney function. We present a case in which multiple innovative solutions were used to help revascularize a patient using zero contrast.