ABSTRACT: A 78-year-old male presented with exertional chest pain and renal dysfunction. Diagnostic coronary angiogram revealed severe subtotal occlusion in intermediate left anterior descending artery. We conducted percutaneous coronary intervention (PCI) and selective angiography with a thrombus aspiration catheter from the proximal part of the lesion using a contrast volume of only 2.5 ml. After marking the optimal location by intravascular ultrasonography, we inserted a stent. Selective coronary angiography revealed good expansion. We could complete PCI using a contrast volume of only 5 ml in total. This strategy might be effective in preventing contrast-induced nephropathy.
J INVASIVE CARDIOL 2011;23:E232–E234
Key words: selective coronary angiography, aspiration catheter, contrast-induced nephropathy, percutaneous coronary intervention
Case Report. A 78-year-old man presented with exertional chest pain when he was referred to our hospital. The hematologic test showed renal dysfunction (blood urea nitrogen = 32.0 mg/dl; creatine = 2.55 mg/dl).
The patient was admitted and coronary angiography was performed on the following day after hydration with 0.9% saline at 1 ml/kg/hour. Subtotal occlusion of the intermediate left anterior descending artery (LAD) was observed (Figure 1). In total, 25 ml contrast medium was used. The blood test did not show further deterioration of the renal function.
Revascularization was considered appropriate. The patient was hospitalized and PCI was performed the following day after hydration. Angiography by guide catheter was not performed. By referring to the diagnostic angiography, a Runthrough® guidewire (Terumo Medical, Somerset, New Jersey) was advanced into the diagonal artery and bifurcated immediately before the lesion. Following this step, by an Eliminate® aspiration catheter (Terumo Europe, Leuven, Belgium), selective coronary angiography was performed from the proximal part of the lesion using a contrast volume of 2.5 ml (Figure 2). Subsequently, a second Runthrough® guidewire was advanced through the lesion in the LAD using a Finecross® microcatheter (Terumo Medical). Passage of the guidewire through the true lumen could be confirmed via the sensation conveyed to the fingertips, as well as by the observation that the wire easily passed through the side branch distal to the lesion. The lesion was dilated using a 2.25 × 10 mm Ryujin® balloon catheter (Terumo Europe), and then, intravascular ultrasonography (IVUS) was performed to mark the optimal location (Figure 3). After a 3.0 × 18 mm Xience V stent (Abbott, Abbott Park, Illinois) was placed, we confirmed by IVUS that the artery was free from dissection and hematoma. After re-crossing to the diagonal artery and LAD using the Runthrough® guidewires (Terumo Medical), we performed simultaneous dilation with a 2.25 × 10 mm Ryujin® (Terumo Europe) and a 3.5 × 10 mm bpi® balloon catheter (Kaneka, Osaka, Japan). IVUS confirmed satisfactory dilatation of the stent, no malapposition, no dissection or hematoma at both edges, and no damage of the left main trunk caused by the guide catheter. Finally, selective coronary angiography was performed using the Eliminate® aspiration catheter (Terumo Medical) with a contrast volume of 2.5 ml, and satisfactory result was confirmed (Figure 4). The total amount of contrast medium during the procedure was 5 ml.
Discussion. PCI has been reported to worsen the prognosis if CIN has occurred.1–5 To avoid worsening of the prognosis, preventing CIN is critical. The most important precaution should be to minimize the use of contrast medium.6,7
In the present case, several measures were taken to minimize the contrast volume. Preprocedure coronary angiography was not performed and selective coronary angiograms using an aspiration catheter and IVUS images were completely utilized. An aspiration catheter, which does not require the removal of the guidewire before the selective angiogram, offers sufficient luminal space to obtain satisfactory angiograms and may be the optimal device for the present purpose. We could obtain satisfactory images to assess the lesion using an aspiration catheter with a contrast volume as small as 2.5 ml without strong resistance. PCI using a smaller contrast volume could be performed safely taking these measures.
- The guidewire must be manipulated carefully to prevent it from erroneously entering a false lumen or producing dissection. In addition, we have to confirm the guidewire can easily enter a side branch after the lesion, and therefore, it must be confirmed at this stage that the wire is in the true lumen.
- After dilatation, careful observation of the patient’s symptoms and ECG changes as well as IVUS evaluation are needed to determine if there is flow-limiting dissection, distal embolism, or side-branch occlusion.
- After completion of the maneuver, careful IVUS evaluation is indispensable to identify any entry-site injury caused by the guide catheter.
If these precautions are fully understood, performing selective coronary angiography using an aspiration catheter in combination with IVUS may be effective in reducing the use of contrast medium to prevent CIN.
Conclusion. We experienced a patient with severe subtotal occluded lesion in intermediate LAD and renal dysfunction. During PCI, we performed selective coronary angiography using a thrombus aspiration catheter in combination with IVUS. The procedure was completed successfully while using only a 5 ml total amount of contrast medium. The approach described herein may be useful in preventing CIN.
- 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.
- Rihal CS, Textor SC, Grill DE, et al. Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention. Circulation 2002;105:2259-2264.
- Gruberg L, Mintz GS, Mehran R, et al. The prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol 2000;36:1542-1548.
- Senoo T, Motohiro M, Kamihata H, et al. Contrast-induced nephropathy in patients undergoing emergency percutaneous coronary intervention for acute coronary syndrome. Am J Cardiol 2010;105:624-628.
- Marenzi G, Lauri G, Assanelli E, et al. Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 2004;44:1780-1785.
- Kane GC, Doyle BJ, Lerman A, et al. Ultra-low contrast volumes reduce rates of contrast-induced nephropathy in patients with chronic kidney disease undergoing coronary angiography. J Am Coll Cardiol 2008;51:89-90.
- Mehran R, Aymong ED, Nikolsky E, et al. A simple risk score for prevention of contrast-induced nephropathy after percutaneous coronary intervention. Development and initial validation. J Am Coll Cardiol 2004;44:1393-1399.
From the Department of Cardiology, Naganoken Koseiren Shinonoi General Hospital, Nagano, Japan.
Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The author reports no conflicts of interest regarding the content herein.
Manuscript submitted January 25, 2011, provisional acceptance given February 18, 2011, final version accepted March 3, 2011.
Address for correspondence: Norihiko Shinozaki, MD, Department of Cardiology, Naganoken Koseiren Shinonoi General Hospital, 666-1 Ai, Shinonoi, Nagano, Japan, E-mail: email@example.com