Author + information
- Received February 25, 2019
- Revision received April 4, 2019
- Accepted April 23, 2019
- Published online September 11, 2019.
- Marcel Almendarez, MDa,b,
- Hitinder S. Gurm, MDc,
- José Mariani Jr., MDd,e,f@mariani_jr,
- Matteo Montorfano, MDa,
- Emmanouil S. Brilakis, MD, PhDg@esbrilakis,
- Roxana Mehran, MDh@Drroxmehran and
- Lorenzo Azzalini, MD, PhD, MSca,∗ (, )@lorenzo2509
- aInterventional Cardiology Division, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
- bInterventional Cardiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
- cDivision of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- dDepartment of Interventional Cardiology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
- eHospital Israelita Albert Einstein, São Paulo, Brazil
- fSanta Casa de São Paulo, São Paulo, Brazil
- gCenter for Advanced Coronary Interventions, Minneapolis Heart Institute, Minneapolis, Minnesota
- hInterventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- ↵∗Address for correspondence:
Dr. Lorenzo Azzalini, Interventional Cardiology Division, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy.
• The incidence of contrast-induced acute kidney injury (CI-AKI) is particularly high (>25%) in patients with advanced chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI), and has been associated with increased risk for in-hospital dialysis and mortality.
• Implementing contrast-sparing protocols may reduce the risk for CI-AKI in patients with advanced CKD undergoing coronary angiography and PCI.
• Additional components of an ultra-low-contrast-volume PCI protocol include strong reliance on intravascular imaging, device-based interventions, and ancillary measures.
• Prospective (ideally randomized) studies should evaluate whether the implementation of the procedural recommendations discussed herein can lead to decreased rates of CI-AKI, need for dialysis, and mortality in high-risk patients undergoing PCI.
Contrast-induced acute kidney injury (CI-AKI) is a potentially serious complication following coronary angiography and percutaneous coronary intervention (PCI). The incidence of CI-AKI is particularly high in patients with advanced chronic kidney disease (defined as an estimated glomerular filtration rate <30 ml/min/1.73 m2). Although much effort has been dedicated to the identification and implementation of preventive measures for this complication at the pre-intervention stage, much less has been investigated on the procedural strategies and techniques to decrease the risk of CI-AKI during PCI. The mainstay of such approaches relies on the minimization of contrast volume by means of specific strategies or dedicated devices. Invasive imaging, such as intravascular ultrasound or non–contrast-based optical coherence tomography, is another pillar of any ultra-low-contrast-volume PCI protocol. Finally, an array of miscellaneous ancillary measures can be implemented to decrease the risk of CI-AKI, which includes the use of radial access, remote ischemic conditioning, and hemodynamic support in high-risk patients. The present review analyzes the technical aspects as well as the scientific evidence supporting these novel techniques, with the goal to improve the outcomes of patients at high risk for CI-AKI undergoing PCI.
- chronic kidney disease
- contrast-induced acute kidney injury
- contrast-induced nephropathy
- intravascular ultrasound
- optical coherence tomography
- percutaneous coronary intervention
Dr. Gurm received honoraria for consulting from Osprey Medical; and research funding from the National Institutes of Health and Blue Cross Blue Shield of Michigan. Dr. Brilakis received consulting/speaker honoraria from Abbott Vascular, the American Heart Association (associate editor of Circulation), Boston Scientific, Cardiovascular Innovations Foundation (board of directors), CSI, Elsevier, GE Healthcare, InfraRedx, and Medtronic; research support from Regeneron and Siemens; is a shareholder of MHI Ventures; and is on the board of trustees of the Society of Cardiovascular Angiography and Interventions. Dr. Mehran has received institutional research grant support from The Medicines Company, Bristol Myers-Squibb, AstraZeneca, Abbott Vascular, Bayer, Beth Israel Deaconess, CSL Behring, DSI, Medtronic, Novartis Pharmaceuticals, OrbusNeich, Osprey Medical, PLC/Renal Guard, and Lilly/Daiichi Sankyo; is on the advisory board for Janssen (Johnson & Johnson), Medtelligence, and PLx Opco/PLx Pharma; serves on a data and safety monitoring board for Watermark Research Partners; and has received consulting fees and honoraria from Abbott Vascular, AstraZeneca, Boston Scientific, Covidien, CSL Behring, Medscape/WebMD, Siemens Medical Solutions, Philips/Volcano/Spectranetics, Roivant Sciences, Sanofi, Bracco Group, Janssen (Johnson & Johnson), and Merck. Dr. Mehran’s spouse is a consultant for Abiomed and The Medicines Company. Dr. Azzalini has received honoraria from Abbott Vascular, Guerbet, Terumo, and Sahajanand Medical Technologies; and research support from ACIST Medical Systems, Guerbet, and Terumo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 25, 2019.
- Revision received April 4, 2019.
- Accepted April 23, 2019.
- 2019 American College of Cardiology Foundation
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