Training Slides_Protocol v.2.0CKD

ISCHEMIA-CKD TrialOptimal Revascularization Therapy

Training Slides_Protocol v.2.0CKD

Goal

Revascularization of all ischemic myocardial segments (detected by non-invasive imaging or by fractional flow reserve (FFR) testing) within 4 weeks after treatment assignment while minimizing the risk of contrast induced acute kidney injury (AKI)

Training Slides_Protocol v.2.0CKD

Risk of Contrast Induced Acute Kidney Injury

McCullough et al. J Am Coll Cardiol 2008;51:1419–28

Exponential increase in the risk of contrast induced AKI with eGFR <40

Acute kidney injury (AKI) was defined as serum creatinine increase of 25% and/or 0.5 mg/dl

Training Slides_Protocol v.2.0CKD

Mantra to prevent contrast induced AKI

Hydration!! Hydration!! Hydration!!

Use ultra low-volume contrast protocol for cath and PCI

Use IVUS-guided PCI Cath and PCI can be done with as little as 20-30

cc of contrast Avoid nephrotoxic agents

Consider staged procedure as needed

Training Slides_Protocol v.2.0CKD

Hydration

Protocol used in POSEIDON trial: Initiate 3mL/kg/h of normal saline IV, for at least 1 h

prior to angiography Measure LVEDP prior to contrast administration Adapt infusion rate based on LVEDP measurement

as follows: 5 mL/kg/hr for LVEDP < 13 mm Hg 3 mL/kg/hr for LVEDP of 13 mm Hg to 18 mm Hg 1.5 mL/kg/hr for LVEDP > 18 mm Hg

Continue fluid administration for 4 hours post procedure

Training Slides_Protocol v.2.0CKD

Hydration

Simplified protocol based on LVEF (expert opinion):

Patients with preserved EF IV 0.9% NS at 1 cc/kg/hour for 12 hours pre- and

post-procedure

Patients with EF<40% IV 0.45% NS at cc/cc replacement (match urine

output to maintain euvolemia) for 12 hours pre- and post-procedure

Training Slides_Protocol v.2.0CKD

Ultra-low volume contrast techniques

Use small diameter catheters (i.e., 5–6 F) without side-holes

All contrast injections require simultaneous cine angiogram, i.e., ‘‘no dye without the cine’s eye’’

Limit the volume of contrast injected to 1–2 cm3 per injection using a 3-cm3 syringe

During PCI, prior to exchange of devices such as balloon catheters, remove contrast from the guide catheter by back bleeding contrast out of the ‘‘Y’’ connector

Training Slides_Protocol v.2.0CKD

Ultra-low volume contrast techniques

If available, display previous angiographic images alongside active fluoroscopy screen as a reference to use as guidance during guide wire, balloon, stent and ultrasound passage

Absolutely no contrast ‘‘puffing’’/test injections during the procedure

Use IVUS liberally for pre-PCI assessment of the lesion, selection of therapeutic modalities, and post-PCI result assessment (IVUS guided PCI)

Training Slides_Protocol v.2.0CKD

Ultra-low volume contrast techniques

Use biplane angiography when available

Avoid ventriculography Pre-procedure statins if not already on statin therapy

Use iso- or low-osmolar contrast media (besides iohexol and ioxaglate)

Hold diuretics pre-procedure in euvolemic participants and those unlikely to have heart failure precipitated by administration of radiocontrast media

Avoid nephrotoxic agents prior to the procedure and at least 48 hours post procedure

Training Slides_Protocol v.2.0CKD

CABG vs. PCI

Low SYNTAX score (0-22): PCI or CABG

Intermediate SYNTAX score (23-33): CABG preferred

High SYNTAX score (>33): CABG strongly preferred

Consult ‘Heart-kidney’ team (Non invasive cardiologist, interventionalist, surgeon, and nephrologist) as needed

Decision should also be based on renal transplant considerations for the participants based on local practices

Training Slides_Protocol v.2.0CKD

Other Aspects of ORT

Given the increased risk of restenosis, the use of DES is favored in participants with advanced CKD (such as everolimus and zotarolimus-Resolute)

Emphasis on ischemia guided revascularization (decreases volume of contrast used)

For antiplatelet/anticoagulant choice, FFR use, stent choice, deployment technique and other aspects of ORT- please refer to ORT slideset/MOO for the main ISCHEMIA trial