Long-term outcomes after transcatheter aortic valve replacement with minimal contrast in chronic kidney disease

Low Contrast Strategies in TAVR: Feasibility and Outcomes to Prevent Renal Injury in Chronic Kidney Disease

BACKGROUND

Contrast volume is a major risk factor for acute kidney injury (AKI) in patients with chronic kidney disease (CKD) after TAVR. Use of a low-contrast (LC) protocol in TAVR may reduce AKI without impacting other clinical outcomes.

METHODS

TAVR patients with Stage 3b or worse CKD between 2015 and 2020 were grouped into LC and normal-contrast (NC). LC was defined as TAVR procedure contrast use (mL) less than estimated glomerular filtration rate (eGFR, mL/min/1.73 m2). The primary outcome was AKI, defined as creatinine elevation > 200% or ≥ 0.3 mg/dL from baseline. Secondary outcomes were 30-day mortality, length of stay, paravalvular leak at 30 days, new dialysis requirement, major vascular complication, re-admission, bleeding, and a composite primary endpoint of secondary outcomes. We performed a propensity-matched analysis, compared cohort outcomes, and stratified outcomes by AKI severity.

RESULTS

Four hundred thirty-seven patients were analyzed. The LC group (n = 173) were more commonly male and had a lower baseline eGFR (31 vs. 33, p = 0.03) than the NC group (n = 264). After propensity-matching, AKI occurred less frequently in LC patients than in the NC patients (17.9 vs. 28.3%, p = 0.0217). There were no inter-group differences in mortality, new dialysis requirement, major vascular complications, bleeding, or re-admissions.

CONCLUSIONS

In TAVR patients with CKD, LC volume was associated with reduced risk of AKI, supporting a LC approach for TAVR in CKD patients.

AIMS

We sought to evaluate the outcomes of a LC versus normal-contrast dose strategy in TAVR amongst patients with CKD.

Distal radial approach: a review on achieving a high success rate

INTRODUCTION

The transradial approach is the standard for percutaneous coronary intervention (PCI). Moreover, to lead to the evolution of PCI, a new approach site was developed, namely the distal radial approach (dRA).

ANATOMY AND VESSEL DIAMETER

The vessel diameter of the distal radial artery is smaller than that of the forearm radial artery; hence, use of 1 Fr size or a sheath with a thinner outer diameter is recommended. Ultrasound examination before the procedure provides useful information on this matter.

PUNCTURE

There are two approaches to puncture: proximal site puncture of the distal radial artery and distal site puncture. Based on anatomical characteristics, the puncture angle is large on the former and small on the latter. Although a learning curve for the dRA puncture is needed, the use of ultrasound facilitates the process.

HEMOSTASIS

Using a hemostatic device dedicated to the dRA simplifies observation after PCI. Hemostatic devices for the conventional radial approach or simple bandage with an elastic band can be useful. Usually, less hemostasis time is needed for the dRA compared with the conventional radial approach.

SUCCESS RATE

Studies have shown high success rates of the dRA (approximately 88-99.5%).

ADVANTAGES AND DISADVANTAGES

Advantages of the dRA are patient comfort, short hemostasis time, less restraint for the patients after PCI, and easy observation at the ward. Disadvantages are the learning curve required for the puncture and the small diameter of the distal radial artery.

CONCLUSION

The dRA is a new approach site for PCI. Further research is warranted for the selection of suitable patients to undergo PCI through the dRA.