2019/1/24

Efficacy and safety of EVT by diluted contrast angioplasty for CKD patients

1 Asahi General Hospital, Cardiology, Chiba, Japan,2Radiology

◎Naoki Hayakawa1，Noriyoshi Ohki2, Yuhei Kasai1 ,Noriyuki Ishibashi1 ,

Masataka Arakawa 1 ,Satoshi Hirano1 , Takahiko Kanamori1 ,Junichi Kamoshida1，

Sandeep Sakkya1，Kotaro Miyaji1，Syunichi Kushida1，Junji Kanda1

Disclosure

Speaker name:

Naoki Hayakawa

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

ㇾ I do not have any potential conflict of interest

Introduction• Endovascular therapy (EVT) for patients with CKD can be problematic

because of the risk of contrast-induced nephropathy (CIN).

• Various methods for preventing CIN have been reported. However there were no consensus.

• Carbon dioxide angiography can reduce the amount of contrast, but this method is associated with serious complications and poor imaging quality in the BTK.

• We made a digital subtraction angiography (DSA) program with a specialized diluted contrast. We named this method Low Concentration DSA(LC-DSA) 4)5) .

5)N Ohki , et al. LC-DSA:2016 CVIT

6)N Hayakawa, et al. 2017 CVIT

1) Romano G, et al. Eur Heart J. 2008; 29: 2569-2576

2) Fung JW, et al. Am J Kidney Dis 2004;43:801-808

3)S Kariya, et al. Ann Vasc Surg,2010;24(7):845-850

4) Fujihara M, et al. Catheter Cardiovasc Interv 2015; 85: 870-7

Periph DSA LC-DSA

UnSub. Lut normal +

Sub. Lut. ++ ++

Contrast 1.0 4.5

Brightness 0 0

Edge gain 3 1

Edge Kernel small Large

Set parameters

Equipment：PHILIPS Allura Xper FD10, AZURION 7C20M

Frame rate 3fps or 1fps

Iodine contrast medium

300mg/ml

Dilution medium 5% glucose

Dilution rate 10%

Setting／Injection method

Manual／Hand use

LC-DSA protocol

-The Concept of LC-DSA-

・Adjusted DSA parameters：10% diluted contrast was almost equivalent to CO2 in vitro.

・Pre-set diluted contrast comprised 10 mL contrast medium and 90 mL 5% glucose(10% diluted).

LC-DSA CO2-DSA

• LC-DSA imaging

• Injection site is Pop A (from diagnostic 4Fr

• catheter)

• Iodine contrast medium dilution rate : 10%

• Exposure frame rate : 3 f/s.

• We could see BTK and BTA vessels and small

channels well.

ATA

PTA

PA

BK(prox) BK(mid) BK(dis) BTA

Representative Imaging

A B C

Normal DSA100% contrast>5.0ml

Normal DSA10% contrast<1.0ml

LC DSA10% contrast<1.0ml

Comparison of normal DSA vs LC-DSA

・87 years old male CLI case.・Pre eGFR was 48.0 ml/min/1.73mm2・Angiography showed total occlusion of ATA from proximal.・The patient didn’t feel any pain from the diluted contrast shot.・We could identify main vessels and small channels well.

Representative Case

・CLI case, target lesion was ATA CTO.・We performed parallel wire technique with Crusade PAD.・Finally we could pass the lesion and confirm the wire was in the true lumen by diluted DSA.・The imaging quality was fully acceptable even if we perform these complex procedure.

Total contrast:20mLFluoro times:51.3minDAP:15.5 Gycm2eGFR 48.0→60.4SPP(dorsal) 19→68

EVT using LC-DSA

6) Hayakawa N, et al. Int Heart J. 2018 Nov20.doi:10.1536/ihj.18-125

Our data of LC-DSA intervention

・We analyzed 122 CKD (eGFR<45ml/min/1.73m2) patients who were performed EVT during June 2012 to November 2017 retrospectively.

・We classified two groups, 63 patients who were performed on LC-DSA(LC-DSA group) and 59 patients who had the normal contrast(Control group).

・We excluded aorto-iliac lesion and hemodialysis patients.

LC-DSA (n=63) Control (n=59) P value

Age 74.9±10.7 74.9±9.4 0.75

Male 50(79.4%) 35(59.3%) 0.016

HT 60(95.2%) 57(96.6%) 0.7

DM 56(88.9%) 45(76.3%) 0.06

DL 50(79.4%) 47(79.7%) 0.97

CAD 41(65.1%) 31(52.5%) 0.16

CVD 25(39.7%) 8(13.6%) 0.0009

Smoking 43(68.3%) 28(47.5%) 0.02

CLI 35(55.6%) 40(67.8%) 0.14

Number of lesions 1.44±0.71 1.49±0.82 0.96

CTO 41(65.1%) 34(57.6%) 0.39

Success 62(98.4%) 57(96.6%) 0.06

Result-clinical characteristics-

• Clinical characteristics were almost similar in both groups.

• The rate of male and CVD were higher in LC-DSA group than control group.

• CLI was over 50% and CTO was over 50% in both groups.

LC-DSA (n=63) Control (n=59) P value

Pre eGFR 29.4±8.5 34.8±8.5 0.0095

Post eGFR 33.6±13.7 35.9±10.6 0.75

Absolute change of eGFR

4.25±4.7 1.24±6.9 0.005

Pre Cre (mg/dL) 2.09±1.2 1.53±0.7 0.0006

Post Cre (mg/dL) 1.94±1.1 1.54±0.8 0.056

Absolute change of Cre(mg/dL)

-0.16±0.2 0.007±0.34 0.0078

CIN 0(0%) 7(11.9%) 0.001

Worsening renal function

5(7.94%) 23(38.9%) <0.0001

Result-renal function, CIN-

CIN:absolute increase Cre≧0.5mg/dL, or relative increase ≧25% measured 2 to 5 days after EVT

• The incidence of CIN was significantly lower in LC-DSA group (rate was 0% !!).

• Absolute change of eGFR and creatinine were greater(improve) in LC-DSA group.

LC-DSA (n=63) Control (n=59) P value

Pre ABI 0.68±0.17 0.62±0.18 0.08

Post ABI 0.87±0.19 0.85±0.2 0.58

Total contrast volume(ml)

30.0±14.6 117.9±52.8 <0.0001

Per shot(ml/shot) 1.38±0.85 7.08±3.04 <0.0001

Procedual success(%) 100 96.6 0.23

Number of reshot 1.09±1.85 0.05±0.29 <0.0001

Complication(%) 0 1.7 0.48

Fluoro time(min) 37.8±22.8 52.0±38.6 0.1

Cumlative DAP(Gycm2) 40.1±25.7 32.8±31.2 0.009

Result-Procedural characteristics-

• Total contrast medium and per shot contrast medium were significantly lower in LC-DSA group.

• There were no difference about procedual success and complication.

• The cumulative DAP was greater in LC-DSA group than control, but its value seemed to be acceptable.

DAP:dose area product

Discussion-Efficacy and Safety of LC-DSA

Efficacy Safety・We can reduce the amount of contrast medium.

・We could get acceptable imaging even if BTK and BTA lesions.

・There were no complications about LC-DSA.

・The rate of CIN was very low (0%!).

・The amount of fluoro seemed to be acceptable.

Diluted contrast angioplasty with using LC-DSA

Strong Point・We don’t need any special technique and devices .

Conclusion

• EVT by diluted contrast DSA is effective and safety for treating CKD patients with infrainguinal lesions.

• Low Concentration DSA(LC-DSA) has a possibility of being useful for treating CKD patients.

2019/1/24

Efficacy and safety of EVT by diluted contrast angioplasty for CKD patients

1 Asahi General Hospital, Cardiology, Chiba, Japan,2Radiology

◎Naoki Hayakawa1，Noriyoshi Ohki2, Yuhei Kasai1 ,Noriyuki Ishibashi1 ,

Masataka Arakawa 1 ,Satoshi Hirano1 , Takahiko Kanamori1 ,Junichi Kamoshida1，

Sandeep Sakkya1，Kotaro Miyaji1，Syunichi Kushida1，Junji Kanda1