By Lorenzo Azzalini MD PhD MSc, Interventional Cardiology Division San Raffaele Hospital, Milan, Italy for foroepic.org

1. Zero-CIN approach in patients
with advanced CKD undergoing PCI
Lorenzo Azzalini, MD PhD MSc
Interventional Cardiology Division
San Raffaele Hospital, Milan
Italy

2. Patients with advanced CKD undergoing PCI
suffer a high risk of CIN and dialysis
Tsai et al. JACC Cardiovasc Interv. 2014 Jan;7(1):1-9.

3. How to minimize CIN risk when performing
PCI in patients with advanced CKD
Strategies:
IVUS or OCT (dextran)
FFR
Diluted contrast

4. Ultra-low contrast angiography & PCI
Coronary angiogram and subsequent
PCI can be performed with low contrast
media use:
1. Injection of contrast using a 3 ml
syringe with diluted contrast media
2. Biplane high quality angiography
3. Liberal IVUS use
4. Avoid puff testings
Nayak et al. Catheter Cardiovasc Interv. 2010 Jun 1;75(7):1076-83.

5. MOZART trial
83 patients (normal renal function or
mild CKD) randomized to IVUS-guided
PCI vs angio-guided PCI
IVUS allowed markedly lower contrast
media volume
Mild increase in procedural time
The study was underpowered to detect
differences in clinical events; anyway,
no difference was reported in technical
success of the procedure
IVUS-guided PCI appears to be a promising strategy
in patients at high risk of CIN, due to marked
reduction in contrast volume use
Mariani et al. JACC Cardiovasc Interv. 2014 Nov;7(11):1287-93.

6. MOZART trial
Technical precautions:
1. Planning: know the patient; know the angio
2. Small-diameter guiding catheters
3. Small-volume syringes of diluted contrast (50%)
4. Every drop of contrast must be used in angio
(not fluoro); avoid “tests”
5. High res/high frame rate acquisitions
Mariani et al. JACC Cardiovasc Interv. 2014 Nov;7(11):1287-93.

7. Zero-contrast PCI with FFR + IVUS
• Anatomy- and physiology-based PCI may be used in order to completely avoid contrast injection
• Use recent coronary angiogram (performed with ultra-low contrast precautions) as reference
• Wires are placed in major side branches to create a roadmap for PCI
• FFR and IVUS are performed at baseline and to assess final result
• IVUS is performed instead of angiography at every major procedural step
(baseline, predilatation, stenting, etc.)
Ali et al. Eur Heart J. 2016 Oct 21;37(40):3090-3095.

8. Zero-contrast PCI with FFR + IVUS
31 high risk patients were treated with this approach
Ali et al. Eur Heart J. 2016 Oct 21;37(40):3090-3095.

9. Zero-contrast PCI with FFR + IVUS
Ali et al. Eur Heart J. 2016 Oct 21;37(40):3090-3095.

10. Zero-contrast PCI with OCT
Dextran-based OCT-guided PCI:
The use of dextran instead of contrast to achieve
blood flushing to perform OCT has anecdotally
been described to perform zero-contrast PCI
OCT has higher resolution and faster pullback
compared with IVUS
Karimi Galougahi et al. Eur Heart J. 2016 Apr 1;37(13):1059.

11. Dextran-based OCT
• Very good correlation between dextran- and contrast-based OCT
• Excellent image quality with dextran
• Multiply results by 1.117 (areas) or 1.057 (lengths)  dextran has
different refractive properties compared with contrast
Frick et al. Catheter Cardiovasc Interv. 2014 Nov 1;84(5):727-31.

12. Imaging- and physiology-guided PCI in severe CKD patients
IVUS
Pros Cons
FFR
OCT
with
dextran
• More consolidated track among
interventionalists
• Solid outcome data
• Slow to perform (especially since
multiple IVUS runs are needed)
• Best possible image quality
• Very fast to perform
• Less experience among
interventionalists
• Need to load automated injector
with dextran
• Very solid outcome data
(baseline FFR)
• Easy to perform and interpret
• Uncertain role of post-PCI FFR
(little evidence)
• Needs blind wiring with “clumsy” wire

13. Ultra low-contrast PCIZero-contrast PC
Pros
Cons
• Zero risk of CIN
• “Cooler” (media, research)
• Safer (perforations and
dissections are diagnosed)
• Much quicker
• Undetected coronary perforation
• Very time-consuming and
cumbersome
• CIN risk minimized but still
present