Seeing With the Mind's Eye: Zero Contrast High-Risk PCI
Presenter
Salman A. Arain, MD, FSCAI, UTHealth-McGovern Medical School, Houston, TX
Salman A. Arain, MD, FSCAI, UTHealth-McGovern Medical School, Houston, TX
Title:
Seeing With The Mind's Eye - Zero Contrast High Risk PCI
Introduction:
A 65 year old man with known CAD and ischemic heart disease (EF 25%) presents with decompensated CHF and acute on chronic renal insufficiency (Cr 2.2 at baseline and 4 after diuresis). The patient is a Jehovah's witness and refused CABG in the past. His last documented EF was 40-45% 12 months prior to the current hospitalization. A nuclear scan shows viable tissue in the anterior and lateral walls - 85% of the LV is viable. An updated LHC shows CTO of the proximal LAD, complex disease in the LCX involving multiple OM branches and a patent RCA. The patient is deemed to be at high risk of complications from CABG and is referred for a high risk PCI.
Clinical Case:
The patient is undergoes percutaneous revascularization utilizing a low contrast technique and Impella back up if needed. Both the LAD and LCX are treated with
zero contrast PCI. 1. The LCX is addressed first. The various branches are wired with soft-tipped wires under fluoro guidance to 'map' the LCX. Angioplasty is performed at multiple sites including a bifurcation. IVUS is used to better define the LCX anatomy and determine and optimal bifurcation treatment strategy. The LCX and OM branches are treated with multiple DES. A final angiogram is performed using 5 cc of contrast. 2. The LAD CTO is then addressed. The occlusion is crossed using antegrade wire escalation under fluoro and angiographic guidance. Multiple soft tipped wires are used to confirm re-entry into the true lumen distally and to map the LAD in a similar fashion to the LCX. Angioplasty is performed within the proximal LAD and IVUS is used to define the anatomy. The LAD is treated with two DES using IVUS guidance. A final angiogram is performed using additional 5 cc of contrast. Final angiography is performed bringing the total contrast delivery to 15 cc. The patient makes an uneventful recovery. His creatinine improves to 2.8 prior to discharge and his improves to 35% at follow up.
Discussion:
This case highlights several challenges associated with PCI in 'high risk' patients with CAD: low EF with a risk of hemodynamic compromise, renal insufficiency and a high risk of worsening renal function, and anatomic complexity (e.g. CTOs, calcification, bifurcation lesions) necessitating the use of advanced techniques. The intervention uses contemporary low contrast techniques to achieve complete revascularization in a single setting. Important teaching points include: - Review of risk factors associated with contrast induced nephropathy in high risk patients - Zero contrast techniques including 'dry road mapping' with wires and use of IVUS - Treatment of bifurcations with zero contrast - tools and tips for success - Treatment of CTOs with zero contrast - strategies for success - Discussion of hemodynamic support during high risk PCI - current indications and device selection