Zero-contrast percutaneous coronary intervention of saphenous vein graft in a patient with chronic renal failure

Zero-contrast percutaneous coronary intervention (PCI) is a new technique for preventing contrast-induced nephropathy (CIN) [1]. Recently, some complex procedures have been performed with this approach, including PCI of the left main [2], chronic total occlusion [live case at CTO Summit 2017, New York] and intervention of calcified lesions using rotational atherectomy [3]. Herein, we present a case of zero-contrast PCI of a saphenous vein graft (SVG) in a patient with chronic renal failure (estimated glomerular filtration rate, eGFR: 25.84 ml/min/1.73 m2) who was admitted to our hospital due to non-ST-segment elevation myocardial infarction. Coronary angiography revealed: chronic occlusions of right coronary artery (RCA), left anterior descending artery (LAD) and SVG to obtuse marginal branch (OM); critical stenosis of OM; significant stenosis of SVG-RCA (Figure 1 A); and patent left internal mammary artery graft to LAD. First, urgent PCI of the OM was carried out, then 4 days later we performed PCI of the SVG-RCA. However, in order to protect renal function the second intervention was done without contrast administration. After careful analysis of previous angiograms and all surrounding anatomical details, an MPA guiding catheter (which best fitted the anatomy of the graft) was placed into the ostium of the SVG-RCA. To engage it, we followed a surgical clip within the occluded SVG-OM which superimposed on the ostium of the SVG-RCA, and the correct catheter position was confirmed by introducing a Sion Blue guidewire (Asahi) to the distal portion of the RCA (Figure 1 B). Then intravascular ultrasound examination (IVUS) identified the lesion in reference to overlying ribs. Once an embolic protection device, Spider FX 4.0 mm (Medtronic), had been placed distally to the lesion, a repeated IVUS examination determined proximal and distal landing zones for stent implantation in relation to the ribs and protection device (Figures 1 C, D).
A drug-eluting stent, Orsiro 4.0/18 mm (Biotronik), was implanted according to the position of ribs (Figure 1 E) and post-dilatation with a balloon Trek 4.0/20 mm was performed. The IVUS examination confirmed good stent expansion and no edge dissection. After removal of the protection system, one single injection of 5 ml of contrast (Visipaque, GE Healthcare) was done in order to document the final result and lack of complications (Figure 1 F). The whole procedure lasted 50 min and the total radiation dose was 1418 mGy....


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