Coronary stent positioning under live IVUS guidance in low contrast percutaneous coronary interventions: The live IVUS stenting technique

Selected in Catheterization and Cardiovascular Interventions by M. Alasnag

Thanks to a case report, find out more about the technical steps by which imaging can be used to precisely position the stents and reduce contrast use.

Reviewer

Mirvat Alasnag

@mirvatalasnag

Interventional cardiologist / Cardiologist

Jeddah, Saudi Arabia

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My Comment

Why this study? – the rationale/objective

It is well established that renal dysfunction portends worse cardiovascular outcomes in those who develop contrast-related acute kidney injury¹.

Percutaneous coronary intervention (PCI) using low or zero contrast technique has been proposed previously and demonstrated in the MOZART (Intravascular Ultrasound Guidance to Minimize the use of Iodine Contrast in Percutaneous Coronary Intervention) trial².

This was a small trial (83 patients) that examined total contrast use, in-hospital outcomes, and cardiovascular events at 4 months in those undergoing intravascular ultrasound (IVUS) vs angiography only guided revascularization.

In this trial, the volume of contrast was lower with IVUS guidance and outcomes were similar for in-patients and at 4 months.

Similarly, Ali et al reported a series of 31 patients with advanced chronic kidney disease in whom zero contrast PCI was employed had successful PCI, no major adverse cardiovascular events, and preserved renal function up to 79 days³.

Lichaa, in his article, describes a case report that serves as a proof of concept detailing the technical steps by which imaging can be used to precisely position the stents and reduce contrast use.

How was it executed? – the methodology

After a diagnostic angiogram revealed three-vessel disease, an emergent heart team decision recommended proceeding with PCI in a patient who presented with an acute coronary syndrome and had advanced kidney disease.

The plan was to treat the culprit vessel (right coronary artery) first and stage the left system in one week.

The sheath was upsized to 8 French and IVUS was used to guide the PCI by determining the lesion length and vessel size.

Simultaneous delivery of the IVUS catheter and predilation balloon and subsequently the drug-eluting stent permitted precise positioning after which the IVUS catheter and its wire were withdrawn and the stent was deployed.

The vessel was rewired and IVUS catheter advanced once again for postdilation.

What is the main result?

The procedure was successful with a total contrast volume of only 7 ml.

Lichaa demonstrated the feasibility of simultaneously introducing an IVUS catheter with a stent delivery system in a guiding catheter which was generally 7 or 8 French depending on the manufacturer.

Critical reading and the relevance for clinical practice

The demonstration by Lichaa and the other previous publications seem to be more of a proof of concept noting feasibility and safety.

More importantly, however, is the applicability of these techniques in higher-risk patients. Although the inclusion criteria of the MOZART trial included cardiogenic shock and advanced kidney disease, the majority were low-risk individuals with prior PCI (26 %) and CABG (14.6 %), and ACS (14.6 %) and creatinine clearance < 60ml / min / m² (48.8 %). Similarly, Ali et al included few patients with prior revascularization and mean age of 66 years.

As for the simultaneous IVUS, this is a single case report for what appears to be focal disease of the right coronary artery. The feasibility of this technique in more complex interventions such as bifurcations, small vessels, and those requiring atherectomy remains unanswered.

It will be difficult to perform simultaneous IVUS unless it is limited to the dilatation and stenting, but not the atherectomy.

As the author notes, the need for a larger sheath is a drawback particularly in the case of small radial arteries.

The radial artery size can be assessed by ultrasound, and conversion to femoral access may be necessary.

A concern of the simultaneous IVUS technique is rewiring the vessel before postdilatation to deliver the IVUS catheter. It is conceivable that the wire is advanced behind the struts. It may be useful to use fluoroscopy to perform 1:1 postdilatation before rewiring, IVUS imaging and potentially further optimizing the implanted stent with bigger postdilatation balloons.

Finally, long-term renal and cardiovascular outcomes are difficult to extrapolate from such limited series particularly in higher-risk patients who require staged or multiple revascularizations.

Whether combination of techniques can be employed to reduce risk is unknown. For example, Mehran et al reported lower contrast volume use and no difference in renal outcomes using the AVERT device designed to limit the delivery of excess contrast during angiography⁴.

Another example is Azzalini et al's protocol that described low contrast with IVUS and dextran with optical coherence tomography and reported lower acute kidney injury in these patients⁵. These included complex diseases such as chronic total occlusions, bifurcations, and atherectomy.

References

1. Sun G, Chen P, Wang K, Li H, Chen S, Liu J, He Y, Song F, Liu Y, Chen JY. Contrast-Induced Nephropathy and Long-Term Mortality After Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction. Angiology. 2019 Aug;70(7):621-626. doi: 10.1177/0003319718803677. Epub 2018 Oct 15. PMID: 30317864.
2. Mariani J Jr, Guedes C, Soares P, Zalc S, Campos CM, Lopes AC, Spadaro AG, Perin MA, Filho AE, Takimura CK, Ribeiro E, Kalil-Filho R, Edelman ER, Serruys PW, Lemos PA. 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 Nov;7(11):1287-93. doi: 10.1016/j.jcin.2014.05.024. Epub 2014 Oct 15. PMID: 25326742; PMCID: PMC4637944.
3. Ali ZA, Karimi Galougahi K, Nazif T, Maehara A, Hardy MA, Cohen DJ, Ratner LE, Collins MB, Moses JW, Kirtane AJ, Stone GW, Karmpaliotis D, Leon MB. Imaging- and physiology-guided percutaneous coronary intervention without contrast administration in advanced renal failure: a feasibility, safety, and outcome study. Eur Heart J. 2016 Oct 21;37(40):3090-3095. doi: 10.1093/eurheartj/ehw078. Epub 2016 Mar 7. PMID: 26957421; PMCID: PMC6279210.
4. Mehran R, Faggioni, Chandrasekhar J, et al. Effect of a contrast modulation system on contrast media use and the rate of acute kidney injury after coronary angiography. JACC Cardiovasc Interv. 2018 Aug 27; 11(16): 1601-1610.
5. Azzalini L, Laricchia A, Regazzoli D, et al. Ultra-low contrast percutaneous coronary intervention to minimize the risk for contrast-induced acute kidney injury in patients with severe chronic kidney disease. J Invasive Cardiol. 2019 Jun; 31(6): 176-182.