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
- 9907 reads
David E. Allie, MD, Chris J. Herbert, RT, RCIS, and Craig M. Walker, MD
Recently, our group reported our 64-channel infrainguinal validation study with a revised protocol.38,39 The revised protocol was used for 60 consecutive patients with severe infrainguinal disease. Protocol revisions included the automated trigger being lowered from the mid-chest to 1 cm above the aortic bifurcation in the distal aorta. The automated trigger Hounsfield units were increased from 180H to 250H with a 5-second scan delay. The contrast volume was reduced from 125 cc to 70 cc (Isovue, BRACCO Diagnostics, Princeton, New Jersey) with a 40 cc NS bolus chase. All other parameters remained unchanged. In concept, we were resetting the system to “delay or slow down” to better acquire infrapopliteal images. The resolution quality and post-processing imaging time were improved and validated when compared to 60 matched patients. This protocol has allowed us to minimize and optimize contrast exposure in our PAD patients, especially those with infrainguinal disease (Figures 4A and 4B).
The mortality and morbidity of CIN is significant and likely underappreciated. The potential for increased CIN morbidity during PPI is unknown; therefore, the need for strategies to optimize contrast exposure in the treatment of PAD is likely greater than during PCI. The rapid adoption of MDCTA and the proliferation of endovascular and surgical treatments of PAD underscore the need for optimizing novel strategies designed to preserve renal function. Several such novel strategies, utilizing the ACIST Injection System, TRT, and revised MDCTA protocols, hold promise in optimizing contrast utilization and preventing CIN when treating PAD.
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.