Imaging and Physiology to Guide Venous Graft Interventions Without Contrast Administration in Advanced Renal Failure

J INVASIVE CARDIOL 2017;29(11):E163-E165.

Key words: PCI, chronic kidney disease, coronary artery bypass graft, intravascular ultrasonography, coronary physiology  

Patients with previous coronary artery bypass grafting and advanced chronic kidney disease (CKD) are considered high risk for revascularization. In addition to native coronary artery angiography, additional contrast is required to visualize the bypass conduits, increasing the risk of contrast-induced nephropathy (CIN) and need for renal replacement therapy. As a result, despite the need for revascularization, these patients are frequently under-treated.¹ There is evidence in the literature that intravascular ultrasound (IVUS)-guided interventions reduce the amount of contrast and its associated risk of CIN.² We recently described intravascular imaging and physiology-guided percutaneous coronary intervention (PCI) without contrast administration in advanced CKD.³ Here we describe step-by-step “zero-contrast” saphenous vein bypass graft (SVG) intervention using a modified technique.  

•    Ultra-low contrast angiography, defined as contrast volume/estimated glomerular filtration rate <1, is performed. 

•    The left ventricular end-diastolic pressure is used to guide hydration.

•    Imaging- and physiology-guided PCI is performed 1 week after angiography. 

•    Guide-catheter engagement is confirmed by the entry of a workhorse guidewire into the SVG. 

•    A pressure wire capable of measuring pressure and flow is used to record the baseline fractional flow reserve (FFR) and coronary flow reserve (CFR).

•    Near-infrared spectroscopy (NIRS)/IVUS (Infraredx) is used for assessment of reference vessel sizing, stent landing zones, and plaque composition with stent length based on the distance between the two reference areas, ensuring complete lesion coverage. 

•    The NIRS/IVUS catheter is re-advanced, manually marking the landing zones by “dry” cine angiograms for co-registration.

•    An embolic protection device is considered for high lipid-core burden index (LCBI).^4,5 LCBI_4mm is a quantitative summary metric of the total lipid-core plaques detected over any 4 mm segment of vessel relative to total length of the pullback.

•    Following stent deployment, NIRS/IVUS identifies areas of under-expansion and postdilation is performed to optimize PCI results. 

•    Final FFR confirms resolution of ischemia and CFR the absence of slow flow with improved absolute flow. 

References  

1.    Dangas G, Iakovou I, Nikolsky E, et al. Contrast-induced nephropathy after percutaneous coronary interventions in relation to chronic kidney disease and hemodynamic variables. Am J Cardiol. 2005;95:13-19.

2.    Mariani J Jr, Guedes C, Soares P, et al. Intravascular ultrasound guidance to minimize the use of iodine contrast in percutaneous coronary intervention: the MOZART (Minimizing cOntrast utiliZation With IVUS Guidance in coRonary angioplasTy) randomized controlled trial. JACC Cardiovasc Interv. 2014;7:1287-1293.

3.    Ali ZA, Karimi Galougahi K, Nazif T, et al. Imaging- and physiology-guided percutaneous coronary intervention without contrast administration in advanced renal failure: a feasibility, safety, and outcome study. Eur Heart J. 2016;37:3090-3095.

4.    Goldstein JA, Maini B, Dixon SR, et al. Detection of lipid-core plaques by intracoronary near-infrared spectroscopy identifies high risk of periprocedural myocardial infarction. Circ Cardiovasc Interv. 2011;4:429-437.

5.    Stone GW, Rogers C, Hermiller J, et al; FilterWire EXREI. Randomized comparison of distal protection with a filter-based catheter and a balloon occlusion and aspiration system during percutaneous intervention of diseased saphenous vein aorto-coronary bypass grafts. Circulation. 2003;108:548-553.

From the ¹Division of Cardiology, Center for Interventional Vascular Therapy, New York-Presbyterian Hospital & Columbia University, New York, New York; and the ²Cardiovascular Research Foundation, New York, New York.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Stone reports grants from the Cardiovascular Research Foundation; personal fees from Velomedix, Toray, Matrizyme, Miracor, TherOx, Reva, V-wave, Vascular Dynamics, Ablative Solutions, Neovasc, Medical Development Technologies; equity/options from the MedFocus family of funds, Guided Delivery Systems, Micardia, Vascular Nonotransfer Technologies, Cagent, Qool Therapeutics, Caliber, Aria, the Biostar family of funds; consultant on prasugrel patent litigation paid for by Lupin Pharmaceuticals. Dr Maehara reports payment for independent CEC, core lab, and statistical analysis to the Cardiovascular Research Foundation. Dr Ben-Yehuda reports grant funds from St. Jude Medical. Dr Ali reports personal fees from St. Jude Medical, Acist Medical, and CSI; grant funds from St. Jude Medical. Dr Mintz reports grant funds from St. Jude and Boston Scientific; personal fees from Boston Scientific and Acist Medical. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript accepted May 22, 2017.

Address for correspondence: Ziad A. Ali, MD, DPhil, Division of Cardiology, Center for Interventional Vascular Therapy, New York-Presbyterian Hospital and Columbia University, 161 Fort Washington Ave, New York, NY 10032. Email: zaa2112@columbia.edu