contrast saving strategies for btk recanalisation with the
TRANSCRIPT
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Contrast saving strategies for BTK recanalisation with the
ARROW GPScath
Costantino Del Giudice - Marc Sapoval Service de radiologie oncologique et vasculaire Interventionnelle HEGP, Paris.
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Disclosure
Speaker name:
Costantino Del Giudice
I have the following potential conflicts of interest to report:
Consulting (Medtronic, Teleflex)
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
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The incidence of radiocontrast-induced acute kidney injury is as high as 50% for patients with multiple
risk factors1
Why reduce contrast injection?
1) Goldfarb et al. Mayo Clin Proc. 2009;84(2):170-179 2) Mehran et al. Kidney International (2006) 69, S11–S15
Fixed (non-modifiable) risk factors Modifiable risk factors Older age Volume contrast medium Diabetes mellitus Hypotension Pre-existings renal failure Anemia and blood loss Advanced congestive heart failure Dehydratation Low LVEF Low serum albumin level <35 g/l Acute myocardial infarction ACE inhibitors Cardiogenic shock Diuretics Renal transplant Non-steroidal anti-inflammatory drugs Nephrotoxic antibiotics IABP
The incidence of CIN in patients with underlying chronic kidney disease is extremely high, ranging from 14.8 to 55% The incidence of CIN in diabetic patients varies from 5.7 to 29.4%
Patients with contrast induced nephropathy have an increased length of hospital stay and higher rates of in-hospital cardiovascular events, in hospital mortality Rihal et al. Circulation. 2002;105:2259-2264
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1) Optimize patients hemodynamic - avoid dehydration - anaemia treatment
2) Optimize medical treatment - if possible eliminate ACE inhibitors - if possible minimize diuretics - avoid non-steroidal anti-inflammatory
and antibiotics 3) Avoid periprocedural imaging with nephrotoxic contrast medium
Strategies to reduce risk of CIN PREPROCEDURAL CARE
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Strategies to reduce risk of CIN PROCEDURAL CARE
1) Use of iso-osmolar contrast media (290 mOsm/kg)
2) Reduce the contrast media volume
3) Pharmacological interventions (N-acetylcysteine, ascorbic acid, and
statins)
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Importance to reduce contrast media
The risk of RCIN is minimal in patients receiving < 100 mL contrast1 The only predictor of RCIN in patients with pre-existing CKD was volume of contrast administered2
V/eGFR ratio ≥ 2.39 was a significant and independent predictor of CIN3 1) McCullough et al. Am J Med 1997; 103: 368-375
2) Kane GC et al. J Am Coll Cardiol 2008; 51:89-9 3) Liu Y et al. Int Urol Nephrol 2012; 44:221-229
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Contrast saving strategies in BTK
If above the knee disease is excluded in pre-procedural imaging:
- reduce above the knee angiographic control - perform angiographic control with a road-mapping injecting only 1-2 cc of contrast medium - go straight to BTK level
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GPScath balloon BTK recanalization should be performed using a 2-in-1 technique using a GPScath balloon in order to limit the contrast volume
GPScath balloon is an innovative multipurpose balloon that combine angioplasty and target injection system in one device
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GPScath balloon – 2 in 1 technique
A switch allows the control of a Visio Valve located proximal to the balloon
In “balloon mode”, inflation of a high-pressure semicompliant angioplasty balloon is performed as with standard inflation device.
In “fluid delivery mode”, delivers fluids, such as contrast, without losing access or needing to adjust wire position. A selective antegrade angiography is possible with only 1-2 cc of contrast
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Previous experience in SFA lesion using GPScath balloon
GPS (38 lesions)
Control (31 lesions)
P
Chronic total occlusions, n %
6 (15.8) 2(6.5) ns
Procedure, n % Intraluminal Subintimal
33 (86.8)
5 (13.2)
29 (93.5)
2 (6.5)
ns
ns
Need to change balloon, n %
5 (13.2) 3 (9.7) ns
Balloons movements, n % 1.5±2.0 2.1±1.3 ns
Catheter exchange 0 0.26±0.7 0.02
Stent, n % 16 (42.1) 10 (32.3) ns
Primary end-point, n% 33 (86.8) 28 (90.3) ns
Mean Balloon diameter, mm±SD
5.34±079 5.31±0.51 ns
Mean Balloon length, mm±SD
41.3±7.1 35.9±25.8 ns
Time procedure, min±SD 6.7±8.9 7.1±4.6 ns
Contrast Volume, ml±SD 14.7±15.8 26.2±17.6 0.006
Total dose, Gy 8480±14400 10777±12905 ns
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Case
Female 69 yo Diabetic Chronic Renal failure Forefoot TEXAS III C ulcer
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Case
GPScath balloon 2,5x150 mm
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Case
Tapered tip profil designed to cross the toughest lesions
“balloon mode” inflation at 15 atm of the occluded vessels
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Case
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Case Before
After
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Case Male 52 yo Atrial Fibrillation Hypertension Acute limb ischemia 5 month ago Rest pain Rutherford IV Occlusion of ATA, ATP Desert foot
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Case
Recanalization of ATA with a 0.014 Abbot Command guidewire supported by a GPScath ballon 2.5x80 mm Angiographic control with 2 cc contrast medium
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Case Dilatation of the occluded ATA Angiographic control from GPScath balloon
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Case
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Case
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Conclusions
The best strategy to prevent RCIN is reduce the amount of contrast GPScath ballons allows to perform selective angiography reducing the amount of contrast for each control (1-2 cc x injection) and to reduce the procedure time with the 2 in 1 technique Associated to CO2 Angiography could improve outcomes in these kind of patients
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THANK YOU FOR THE ATTENTION