Percutaneous Coronary Intervention During the Shortage of Iodinated Contrast: An Interview With Zachary M. Gertz, MD

Dr Zachary M. Gertz shares background and insights on his article, “Percutaneous Coronary Intervention During the Shortage of Iodinated Contrast.”

Transcript:

Hi, I'm Dr Zachary Gertz, from Virginia Commonwealth University, where I'm the director of our Cath lab. I'm here to discuss my paper, “Percutaneous Coronary Intervention During the Shortage of Iodinated Contrast.”

00:22: What were the key clinical concerns you and your colleagues had at the onset of the iodinated contrast shortage?

I think, like all of us, we were worried that we would not have enough contrast to do our procedures and take care of our patients.

00:37: Your study found no change in acute kidney injury despite reduced contrast volumes. How should interventionalists interpret this finding when considering contrast-use thresholds in everyday practice?

Well, I think it's important to remember that we've all internalized the importance of limiting contrast. So, just because our study didn't show that a reduction in contrast led to a reduction in acute kidney injury doesn't mean that there isn't the potential for contrast to cause acute kidney injury. I think the important finding from our study is that we are probably all doing a really good job of mitigating excessive contrast use in our patients when we do coronary interventions.

00:13: What were some of the operational or procedural challenges encountered across hospitals during the shortage, particularly in maintaining PCI volumes, while reducing contrast usage?

So we were a bit surprised that actually the PCI volumes didn't seem to go down at the hospitals we studied. This may be because PCI is an important procedure, and the operators just did not feel that there were patients that could be put off. We did notice a reduction in complex interventions, which suggests that perhaps the operators were trying to limit how much contrast was used per patient.

01:48: Given your findings, what additional research do you think is needed to define the minimum contrast doses for different patient subgroups or procedural complexities?

To know the minimum amount of contrast we'd have to test different modalities that can be used to replace contrast. One of the surprising findings from our study was that there was not an increased use in intravascular imaging, including optical coherence tomography or intravascular ultrasound. We would have hypothesized that with less ability to take pictures during the procedures with contrast, there would have been more intracoronary imaging to look for edge dissections or well-expanded stents. It's possible that operators just used other methods, perhaps just routine post-dilatation of stents instead of looking at a cineangiogram first to decide whether it was necessary.

I think research in the future can continue to look at whether there are any other opportunities to replace contrast. But one important thing we learned from this study is that even when there is a contrast shortage, we were able to take care of all of our patients.

02:57: Is there anything else you'd like to share with our audience?

I think it's important to continue to think about acute kidney injury; just because a small reduction in contrast didn't lead to reductions in measurable acute kidney injury doesn't mean we should stop with those efforts. I think we have probably all learned a lot from the contrast shortage that we can take further. I know, in our Cath lab, we switched to routine 5-French diagnostic catheters instead of 6-French, and we found that we saved contrast that way, and a lot of those lessons that we learned should be carried into the future. And I think when we talk about acute kidney injury, it's important to remember that it does still happen, and we can still predict it. In our study, the biggest predictor of acute kidney injury after a cardiac catheterization was being at high risk, which is sort of a good sign—it tells us that the patients that we think are going to have acute kidney injury are probably the ones who will have it, which means we've been able to identify them. And we should continue to target that population with interventions that can reduce it.