Abstract
A pivotal trial indicated that an initial invasive strategy did not improve the clinical outcomes in patients with moderate or severe ischemic heart disease and advanced chronic kidney disease (CKD) as compared with an initial conservative strategy. It is well known that contrast-induced nephropathy (CIN) is associated with worse prognosis after percutaneous coronary intervention (PCI). Minimum contrast PCI may lower the risk of CIN and improve the clinical outcomes of ischemic heart disease and advanced CKD. Here we report a case involving a 46-year-old woman with ischemic cardiomyopathy who was scheduled to start hemodialysis for end-stage diabetic nephropathy but exhibited improved renal function in accordance with the left ventricular function after PCI with an extremely low contrast dose. Accordingly, dialysis was not performed, and the patient did not require it for >2 years after coronary revascularization. The present case supports aggressive examination and revascularization for severe heart failure with an extremely low amount of contrast, even if the patient has complex coronary lesions and end-stage CKD.
< Learning objective: It is important to treat with aggressive examination and revascularization for severe heart failure with an extremely low amount of contrast, even if the patient has end-stage chronic kidney disease (CKD). The technique of catheterization with minimum contrast is required for a special patient group. Coronary revascularization with an extremely small amount of contrast medium could improve renal function in patients with end-stage CKD and severely ischemic cardiomyopathy.>
Introduction
Contrast-induced nephropathy (CIN) is the one of most serious complications of percutaneous coronary intervention (PCI), with a reported incidence of 57.3% in high-risk patients (Mehran risk score >16) . Little information was available regarding the risk of renal events after PCI for patients who have complex coronary lesions with high Syntax sore and end-stage nephropathy. A pivotal trial indicated that an initial invasive strategy did not improve the clinical outcomes in patients with moderate or severe ischemic heart disease and advanced chronic kidney disease (CKD) as compared with an initial conservative strategy . It is well known that CIN is associated with worse prognosis after PCI [ , ]. Minimum contrast PCI may lower the risk of CIN and improve the clinical outcomes of ischemic heart disease and advanced CKD. Here we report a case involving a 46-year-old woman with ischemic cardiomyopathy with very high Syntax sore (47) and CKD who was scheduled to start hemodialysis for end-stage diabetic nephropathy. Ultra-minimum contrast PCI for complex coronary lesions improved her renal function and delayed the initiation of hemodialysis by >2 years. In this report, we describe the clinical course and 2-year follow-up observations for our patient and present a review of the relevant literature.
Case report
A 46-year-old woman with a long history of type 2 diabetes mellitus (DM) presented to our cardiovascular center with dyspnea. She was diagnosed with DM at the age of 15 years and was receiving treatment since then. Because she did not exhibit insulin dependence and the anti-glutamic acid decarboxylase antibody was absent, she had been diagnosed with type 2 DM. At the age of 35 years, she developed diabetic nephropathy. Serum creatinine level was 1.64 mg/dl with estimated glomerular filtration rate (eGFR) 27.8 ml/min/1.73 m2 before 12 months. It gradually worsened and serum creatinine was 3.06 mg/dl with eGFR 14 one month before admission. Thus, her renal function worsened as the nephropathy approached the end stage. Consequently, she was scheduled for hemodialysis in the nephrology department before she presented for consultation at the cardiovascular center. Although the detailed data were not available regarding heart failure before admission, the present case had dyspnea on effort for a few years before presentation. New York Heart Association functional class (NYHA) was grade II, 18 months before and it gradually worsened. NYHA was IV on admission. Medical therapy included a diuretic and an antidiabetic agent.
Investigation
A 12-lead electrocardiogram exhibited low voltage at the limb lead and poor R wave progression from the V1 to V3 leads. A chest radiograph showed severe pulmonary congestion and cardiomegaly. The plasma B-type natriuretic peptide (BNP) and serum creatinine levels were 3202.5 pg/mL and 3.42 mg/dL, respectively, while the eGFR was 12 ml/min/1.73 m2 and the fractional excretion of urea nitrogen (FEUN) was 54.2%. On echocardiography, the left ventricular wall motion showed diffusely severe hypokinesis. Moreover, the ejection fraction was reduced to 20% and the estimated right ventricular systolic pressure was 50 mmHg. On the basis of all these findings, she was diagnosed with congestive heart failure and end-stage kidney disease.
Treatment
The patient’s heart condition was refractory to medications and did not improve despite adequate diuretic and vasodilator therapy. We decided to perform coronary angiography to determine the underlying cause, even though she had end-stage kidney disease. A minimum contrast dose was facilitated by the use of a low-profile catheter and biplane system, and a total volume of only 13.9 ml was injected. The angiography revealed 50% stenosis in the left main coronary artery, 90%–99% diffuse severe stenosis with delay in the left anterior descending artery, and 90% stenosis in the middle segment of the left circumflex artery. The right coronary artery showed no significant stenosis. Rentrop grade III collateral flow from right coronary artery to left anterior descending artery was observed. The Syntax score was extremely high (47); therefore, coronary artery bypass grafting was recommended. The patient strongly refused to undergo bypass surgery because of cosmetic aspects, the risk of perioperative complications, and the length of hospitalization. Accordingly, we scheduled ultra-minimum contrast PCI for the left coronary artery. The serum creatinine levels and the eGFR were 4.0 mg/dL and 10 ml/min/1.73 m2, respectively just before PCI. Normal saline was infused at 40 ml/h for 24 h before and after PCI. Revascularization of the left circumflex artery was performed first. PCI was completed without contrast; only the final selective angiography was performed with a small contrast volume of 1.9 ml. PCI for the diffusely severe stenosis in the left main coronary artery and left anterior descending artery was performed 3 days later. Stent implantation with optimal dilatation and apposition was confirmed on intravascular ultrasound. Once again, PCI was completed without contrast, and only the final angiography was performed with 3.2 ml of contrast. The details of the procedure are presented in Figs. 1 and 2 . The total volume of contrast used was 19 ml, including the volume used for diagnostic coronary angiography and complex PCI.
