Endovascular Therapy Using Diluted Contrast Medium for Critical Limb Ischemia in a Patient with Chronic Kidney Disease

Abstract

A high percentage of patients with critical limb ischemia have concurrent chronic kidney disease (CKD). However, endovascular therapy (EVT) can be problematic in CKD patients. Thus, we developed a method of EVT using digital subtraction angiography (DSA) with diluted contrast medium (low-concentration DSA), wherein DSA parameters were adjusted for diluted contrast angiography (1:10 dilution). Herein, we report the case of an 88-year-old woman with a foot wound and severe CKD. Her estimated glomerular filtration rate was 7.9 mL/minute/1.73 m 2. Therefore, EVT was performed with low-concentration DSA. Control angiography revealed total occlusion of the anterotibial and posterotibial arteries as well as severe stenosis of the peroneal artery. EVT with ballooning of the below-the-knee (BTK) lesions resulted in sufficient flow to the wound. Angiographic images of sufficient quality and visible wound blush were obtained with 1:10 diluted contrast medium. Because only 20 mL of contrast medium was required, renal function was preserved. EVT using DSA with diluted contrast medium was shown to be an effective BTK intervention in this CKD patient.

Ultra-Low-Dose Contrast Using Transluminal Renal Angioplasty: The ULTRA Study

“…Hayakawa et al demonstrated the efficacy of diluted contrast for lower-extremity endovascular therapy. 13 Using LC-DSA, they were able to dramatically reduce the amount of contrast required without using IVUS. Although the use of IVUS can reduce the contrast requirement in some cases, it is only useful for precise stent positioning.…”

“…One of the reasons why PTRA has failed to show effectiveness for renal function in RCTs is the use of a large amount of contrast media (up to approximately 125 mL), 12 and PTRA may be useful for selecting patients according to lesion severity and chronic kidney disease (CKD) degree. Endovascular therapy using diluted contrast has been suggested to prevent contrast-induced nephropathy (CIN) 13 ; however, the safety and efficacy of PTRA using reduced volumes of diluted contrast are unknown.…”