Purpose: Chronic kidney disease is associated with significantly higher incidence of peripheral vascular disease (PVD). An important part of therapy includes peripheral vascular interventions (PVI) requiring contrast media use. Contrast-induced acute kidney injury is a complication of vascular interventions and is responsible for serious adverse outcomes such as deterioration of renal function, necessity of dialysis, prolonged hospitalization and increased mortality. We present a case of Zero Contrast peripheral vascular intervention utilizing multiple innovative techniques.
Material and Methods: 69-year-old female with a history of Diabetes Mellitus Type II, hypertension, hyperlipidemia, chronic kidney disease (stage V) presented due to a non-healing ulcer on the dorsal aspect of the right foot. Patient underwent an angiogram 8 months ago where she underwent therapy to the right superficial femoral, popliteal and anterior tibial artery. Patient had known occlusion of the proximal posterior tibial artery (PT) which was not treated due to advanced CKD. Due to lack of meaningful healing in the foot ulcer and patient’s reluctance to initiate dialysis, amputation was recommended by the podiatry team. Decision was made to attempt revascularization of the PT utilizing IVUS guidance, CO2 angiography, extra vascular ultrasound (EVUS) with the goal of Zero contrast use.
Results: US guided PT access was obtained followed by placement of a 4/5 slender sheath. An 0.018 wire was advanced using the JENALI technique crossing the occlusion of the PT. A combination of EVUS and CO2 angiography were used to confirm crossing of the PT occlusion. IVUS was used to assess wire position, plaque morphology, severity and size of the vessels. Atherectomy and balloon angioplasty therapy were use to treat the PT. IVUS was completed which confirmed excellent luminal gain without dissections. A final CO2 angiography run confirmed flow in the PT. EVUS was completed showing biphasic flow in the PT. On further follow up, patient had excellent clinical improvement and she remained dialysis-free.
Conclusions: The increased prevalence of peripheral vascular disease and chronic kidney disease mandates that vascular operators continue to find innovative solutions to treating advanced disease and preserving residual limited kidney function. We present a case where multiple innovative solutions were used to help revascularize a patient using zero contrast.