Zero contrast PCI tweetorial.
With prior good experience of ultra low contrast PCI we performed zero contrast PCI of RCA in a patient with CKD4 with h/o temp dialysis! EF20%, LIMA-LAD patent, No Grafts to PDA, OM with severe disease.
Pre RCA PCI iFR 0.85, post 1.01. A thread!👇
1. Practice lower contrast use in general.
2. Use <100 cc diagnostic+adhoc PCI to start & gain more experience.
3. Then move to low & very low contrast PCI to gain more confidence. (Have done several less than 10-15 cc PCI)
4. Use IVUS in every case to gain high confidence.
5. If IC doing peripheral work do 0 contrast work in leg first & gain confidence w IVUS result & correlate with CO2 final confirmation.
6. Watch angiogram for staged procedure several times on different days and memorize landmarks, Calcium, beds etc.
7. Take zoomed noncon Cine.
Engage guides without contrast during routine PCI. Watch for guide to dance with heart. A CTO technique to see if gear is moving in sync or out of sync to access if it’s in the right place.
Can inject saline to watch ecg charges as another confirmation test. However if guide is in sync and wire goes to vessel architecture, no need for saline injection.
Here is step by step video. #ZeroContrastPCI @mmamas1973 @jedicath @mirvatalasnag @DrDeepakKrishn1 @serioustaurean @Almanfi_Cardio @SripalBangalore @DKarmpaliotis @djc795 @HadyLichaaMD @DrRajeshG1 @DrJayMohan @drandrewsharp @stefan_harb @cardioPCImom @rickytiago
Total fluoro time 11 mins, total procedure time 45 mins. Two runs of iFR, 3 runs of IVUS & zero contrast.
Initial question was if we should treat just A, focal severe stenosis or treat like B, IVUS shows much longer plaque, went with near normal to normal which is C, final iFR shows it’s was probably right decision! Heavily Ca LM-LCx will be staged for ultra-low contrast PCI.
Looks like Twitter has compressed videos too much. Here is the GIFs:
Guide engagement:
Wire post engagement & dance in sync:
Here we went with 6F system, larger guide can accommodate IVUS with stent/balloon real-time and no need for marker wire in that case.
IVUS with co-registration if available will also help reduce some steps. Perform PCOUS 1-2h later then 6H later to confirm no effusion etc.
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