Automated Contrast Injection and Targeted Renal Therapy: Strategies to Prevent Contrast-Induced Nephropathy (FULL TITLE BELOW)
- Volume 3 - Issue 3 - May/June 2006
- Posted on: 9/5/08
- 0 Comments
- 10743 reads
David E. Allie, MD, Chris J. Herbert, RT, RCIS, and Craig M. Walker, MD
The role of CIN and perioperative ARF during vascular and cardiac surgical procedures likewise remains poorly defined. Strategies for contrast optimization and CIN prophylaxis will become increasingly important to the surgeon as increasing numbers of surgeons acquire catheter-based skills. Interestingly, contrast administration < 48 hours before coronary artery bypass (CABG) is a known, independent, preoperative predictor of worsening RI, but no guidelines exist for optimal renal protection in CABG performed within 72 hours of angiography.12,15 In fact, the association and incidence of CIN during cardiac surgery is unknown, and likely underestimated and a major contributing factor to a significant number of patients with worsening RI and ARF after cardiac surgery yearly. Loc et al. has shown that the 1-year mortalities after CABG are significantly higher (p < 0.0001) in patients with mild RI (11.1%) versus no RI (3.8%).15 The clinical implications become significant when considering that approximately 18% of the U.S. population (> 50 million) has some degree of RI and 14% of the approximately 750,000 patients undergoing cardiac surgical procedures have preoperative RI, and therefore are at risk for perioperative ARF.15–17
A heightened awareness of CIN and RI will become increasingly important in the treatment of aortic aneurysmal disease with endovascular aneurysm repair (EVAR) now available for thoracic (TAA) and abdominal aortic aneurysms (AAA). It is estimated that 10% of every male in the U.S. > 70 years old is harboring a AAA, and that there are approximately 1,000,000 AAAs that remain untreated.17,18 Approximately 30% of those 100,000 treated yearly undergo EVAR (30,000), and therefore will require contrast exposure.17,18 With the widespread acceptance of MDCTA, and AAA screening expected to be reimbursed in certain patient populations, it is anticipated that an increasing number of AAAs will be diagnosed yearly, and therefore treated with EVAR. Interestingly, the FDA has recently approved a novel, miniature implantable device capable of remote, radio-frequency monitoring of the AAA (or even TAA) sac pressure after EVAR. The EndoSure Wireless AAA Pressure Sensor (CardioMEMS, Inc., Atlanta, Georgia) would have the potential to significantly decrease the number of contrast studies currently recommended for EVAR follow up.
The incidence of RI after catheter-based AAA EVAR is also associated with preoperative RI and high post-procedure mortality.19,20 ARF is reported after 2–6% of infrarenal open AAA repairs, and is significantly higher in TAA.19–21 Worsening RI after EVAR is the third most commonly experienced morbidity and few reports exist implicating CIN as a prevalent etiology.19–21 Worsening RI post-EVAR has been reported from 6–39%.19–21 Carpenter et al. reported a 20% incidence of preop RI in 98 EVAR cases with an average volume of intraoperative contrast use of 152 cc (35–420 cc), underscoring the potential for intraoperative-induced CIN.22 Permanent RI was reported at 16% in this series, despite the liberal use of MRA and gadolinium. With the rapid adoption of MDCTA for the treatment of patients with TAA, AAA and PAD, the additional 75-mL to 125-mL of contrast volume required will further mandate the surgeon to develop strategies to minimize CIN.
Multiple strategies have been proposed for the prevention of CIN in PCI but few have strong supporting data. Randomized trials have demonstrated the importance of 0.9% saline infusions before and after contrast exposure in decreasing CIN.23,24 The infusion rates have varied between 1–3 mL/kg/hr for 6-12 hours after contrast exposure. Isotonic sodium bicarbonate solution started one hour before contrast exposure was recently associated with a 2% versus 17% incidence of CIN in a high-risk patient population when randomized to 0.9% saline.25 Further trials are being structured to validate the role of serum and urine alkalinization in the prevention of CIN. The role of N-acetylcysteine (NAC) in CIN prevention remains uncertain, with inconsistent results reported with regards to both the route and dose of administration.26 Interestingly, Barret and Parfay, recently reporting a review of strategies to reduce CIN, stated that NAC and IV sodium bicarbonate were “not generally recommended unless efficacy was confirmed by further trials.”26 Most cath lab protocols now incorporate some form or combination of 0.9% saline, sodium bicarbonate and NAC for CIN prevention, especially in the high-risk patient, despite a lack of validating data.
Intuitively, increasing renal blood flow and renal medullary vasodilatation would seem protective against CIN, since the proposed etiology of injury in CIN is an acute toxic injury induced by severe medullary vasoconstriction and critical cellular hypoxia. Fenoldopam (FEN) (Corlopam, Abbott Laboratories, Abbott Park, Illinois) is a short-acting, selective dopamine-1 agonist and vasodilator that is the only agent shown to increase both renal cortical and medullary blood flow.27 The initial favorable clinical reports of systemic IV-FEN administration in reducing CIN in PCI were not reduplicated in the randomized CONTRAST trial.28
Unfortunately, IV-FEN has a first-pass renal metabolism and can cause systemic hypotension at mild to moderate systemic doses. Therefore, it has been theorized that the CONTRAST trial results were secondary to an inability to deliver therapeutic doses directly to the renal medulla. Direct high-dose intrarenal (IR) infusion of FEN, in concept, has the potential to deliver selective high-dose renal vasodilatation and increased medullary blood flow without systemic hypotension, with the potential to reduce CIN in both the cath lab and surgical suites.
1. Yost, ML. Peripheral Arterial Disease: A Report by The Sage Group. 2004; Vol. II. 2. U.S. Department of Health and Human Services. National Center for Health Statistics. National Hospital Discharge Survey: Annual Summary with Detailed Diagnosis and Procedure Data. Data from the National Hospital Discharge Survey. Series 13. 1983–2000. 3. Mayfield JA, Reiber GE, Maynard C, et al. Trends in lower limb amputation in Veterans Health Administration, 1989-1998. J Rehabil Res Dev 200;37(1):23–30. 4. Rihal CS, Textor SC, Grill DE, et al. Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention. Circulation 2002;52:409–416. 5. MacNeill BD, Harding SA, Bazari H, et al. Prophylaxis on contrast-induced neuropathy in patients undergoing coronary angiography. Cathet Cardiovasc Interv 2003;60:458–461. 6. Baker CSR, Wragg A, Kmar S, et al. A rapid protocol for the prevention of contrast-induced renal dysfunction: The RAPPID study. J Am Coll Cardiol 2003:41:2114–2118. 7. Arakawa K, Suzuki H, Naitoh M, et al. Role of adenosine in the renal response to contrast medium. Kidney Int 1996;49:1199–1206. 8. Heyman SN, Rosen S, Brezis M. Radiocontrast neuropathy: Paradigm for the synergism between toxic and hypoxic insults in the kidney. Exp Nephrol 1994;2:153–157. 9. McCullough PA, Woln R, Rocher LL, et al. Acute renal failure after coronary intervention: Incidence, risk factors, and relationship to mortality. Am J Med 1997;103:368–375. 10. Gruberg L, Mehran R, Dangas G, et al. Acute renal failure requiring dialysis after percutaneous coronary interventions. Cathet Cardiovasc Intervent 2001;52:409–416. 11. Levey AS, Beto jA, Coronado BE, et al. Controlling the epidemic of cardiovascular disease in chronic renal disease: What do we know? What do we need to learn? Where do we go from here? National Kidney Foundation Task Force on Cardiovascular Disease. Am J Kidney Dis 1998;32:853–906. 12. Mehran R, Aymong ED, et al. A simple score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: Development and initial validation. J Am Coll Cardiol 2004;44:1393–1399. 13. Allie DE, Hebert C, Walker CM, et al. Critical limb ischemia: A global epidemic. A clinical analysis of current treatment unmasks the clinical and economic costs of CLI. Eurointervention 2005;1:75–84. 14. Parfrey PS, Griffiths SM, et al. Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. A prospective controlled study. N Engl J Med 1989;320:143–149. 15. Lok CE, Austin PC, Tu JV, et al. Impact of renal insufficiency on short- and long-term outcomes after cardiac surgery. Am Heart J 2003;148:430–438. 16. Stallwood MI, Grayson AD, Scawn ND, et al. Acute renal failure in coronary artery bypass surgery: Independent effect of cardiopulmonary bypass. Ann Thorac Surg 2004;77:968–972. 17. Mangano CM, Diamondstone LS, Ramsay JG, et al. Renal dysfunction after myocardial revascularization: Risk factors, adverse outcomes, and hospital resource utilization. The Multicenter Study of Perioperative Ischaemic Research Group. Ann Intern Med 1998;128:194–203. 18. Matsumura J, Brewster D, Makaroun M, Naftel D. A multicenter controlled clinical trial of open versus endovascular treatment of abdominal aortic aneurysm. J Vasc Surg 2003;37:262–271. 19. Powell RJ, Roddy SP, Sumpio BE, et al. Effect of renal insufficiency on outcome following infrarenal aortic surgery. Am J Surg 1997;174:126–130. 20. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm. Part II. Variables predicting morbidity and mortality. J Vasc Surg 1989;9:437–447. 21. Haddad F, Grennburg RK, Ouriel K, et al. Fenestrated endovascular grafting: The renal side of the story. J Vasc Surg 2005;181–190. 22. Carpenter JP, Fairman RM, Baum RA, et al. Endovascular AAA repair in patients with renal insufficiency: Strategies for reducing adverse renal events. Cardiovasc Surg 2001;9:559–564. 23. Mueller C, Buerkle G, Buettner HJ, et al. Prevention of contrast media-associated nephropathy: Randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med 2002;162:329–336. 24. Taylor AJ, Hotchkiss D, Morse RW, McCabe J. PREPARED: Preparation for Angiography in Renal Dysfunction: A randomized trial on inpatient vs. outpatient hydration protocols for cardiac catheterization in mild-to-moderate renal dysfunction. Chest 1998;114:1570–1574. 25. Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: A randomized controlled trial. JAMA 2004;291:2328–2334. 26. Barrett BJ, Parfrey PS. Preventing nephropathy induced by contrast medium. N Engl J Med 2006 354;4:379–386. 27. Stone GW, Roxana M. Pharmacologic prevention of contrast-induced nephropathy. J Invasive Cardiol 2005;17:9C–14C. 28. Stone GW, McCullough PA, et al. Fenoldopam mesylate for the prevention of contrast-induced nephropathy: A randomized controlled trial. JAMA 2003;290:2284–2291. 29. Teirstein P, Madyoon H, Mathur V, et al. Effects of targeted renal delivery of fenoldopam on renal function and systemic blood pressure in patients undergoing cardiac catheterization: A randomized, placebo controlled trial (in press). Am J Cardiol 2006:4. 30. Cohen M, Fearon W, Weisz G, et al. Use of a new bifurcated renal infusion catheter for clinical management of high risk angiography patients: data from the Be-RITE! National Registry. Abstract #603.29. Presented at the Cardiovascular Revascularization Therapies Meeting in Washington, D.C, March 28-31, 2005. 31. Srodon P. Contrast nephropathy in lower limb angiography. Ann R Coll Surg Engl 2003;85:187–191. 32. Goldstein JA, Kern M, Wilson R. A novel automated injection system for angiography. J Interv Cardiol 2001;14:147–152. 33. Khoukaz S, Kern MJ, Bitar SR, et al. Coronary angiography using 4 Fr catheters with acisted power injection: A randomized comparison to 6-Fr manual technique and early ambulation. Catheter Cardiovasc Interv 2001;52:393–398. 34. Chahoud G, Khoukas S, El-shafei A, et al. Randomized comparison of coronary angiography using 4 Fr catheters: 4-Fr manual versus “Acisted” power injection technique. Catheter Cardiovasc Interv 2001;53:221–224. 35. Anne G, Gruberg L, Huber A, et al. Traditional versus automated injection contrast system in diagnostic and percutaneous coronary interventional procedures: Comparison of the contrast volume delivered. J Invasive Cardiol 2004;16:360–362. 36. Holton M. Ergonomics Revisited: Carpal Tunnel Syndrome. Potential or Real Problem for Cath Lab Personnel? Cath Lab Digest 2005;13(March):50–53. 37. Allie DE, Hebert CJ, Walker CM. Multidetector Computed Tomography Angiography: Two decades of evolution in this imaging modality have produced some powerful and unprecedented options. Endovascular Today 2004, 20–28. 38. Allie, DE, Hebert CJ, Lirtzman MD, et al. 64-Channel Multidetector Computed Tomography in Non-Cardiac Vascular Disease: A Validation Study in the Treatment of Femoral, Popliteal, and Infrapopliteal Disease. Abstract. Cardiovascular Imaging 2005. 33rd Annual Meeting & Scientific Sessions of the North American Society of Cardiovascular Imaging (NASCI) in Amelia Island, Florida, October 11, 2005. 39. Allie DE, Hebert CJ, Lirtzman MD, et al. Lower Contrast Volume with Minor Protocol Changes Enhance 64-Channel CTA Imaging in Peripheral Vascular Disease. Poster. Cardiovascular Imaging 2005. 33rd Annual Meeting & Scientific Sessions of the North American Society of Cardiovascular Imaging (NASCI) in Amelia Island, Florida, October 8–11, 2005.