Title:
Low contrast PCI for multivessel in-stent restenosis
Introduction:
Patients with CKD who develop contrast induced nephropathy (CIN) have worse outcomes. Several techniques can be used prior to and during PCI to minimize contrast use and reduce risk of developing CIN.
Clinical Case:
A 65 year old man presented with in SCAI stage C cardiogenic shock and NSTEMI. Comorbidities includes recent PCI with "6 stents” at outside hospital 6 months prior (on ticagrelor and aspirin), ischemic cardiomyopathy with LVEF 30-35% and functional mitral regurgitation, hypertension, DM2, hyperlipidemia, history of cerebellar stroke, and CKD. He was managed with inotropes and diuresis. A right heart catheterization performed after a few days showed elevated filling pressures with postcapillary pulmonary hypertension and normal cardiac output. Coronary angiogram showed prior stents in the left main into distal LAD, proximal Lcx, and proximal OM1 with severe in-stent restenosis (ISR) of the mid and distal LAD, proximal Lcx, and proximal OM1, and diffuse calcified atherosclerotic disease of the RCA with mid 90% stenosis. Patient was deemed high risk for CABG and high risk PCI was offered. Impella-assisted PCI was performed with IVUS guidance, which showed severe stent under expansion as mechanism of ISR. The ostial Lcx was noted to be unstented. Despite aggressive balloon angioplasty, there were areas of under expansion in the mid LAD and ostial LCx that required intravascular lithotripsy. Finally, reverse culotte stenting was performed from the left main into the Lcx, with a total contrast use of 17cc.
Discussion:
Some techniques to minimize contrast use as in this case include use of prior angiogram images and coronary calcification / stents as a roadmap for the arterial course, saline injection to confirm catheter engagement, use of intravascular imaging, and use of higher frame rate and StentViz technology.