Minimal contrast use in carotid stenting: avoiding contrast pitfalls.

ABSTRACT

BACKGROUND: The progression of endovascular approaches to vascular disease has led to an increasing volume of procedures requiring iodinated contrast media. Accordingly, the potential for contrast-induced nephropathy (CIN) also continues to increase. Hypotension, independent of contrast use, is a well-described cause of acute renal dysfunction and an important factor in endovascular procedures complicated by hypotension. CIN is the third leading cause of hospital-acquired acute renal failure, accounting for 12% of cases, and the frequency of CIN in coronary angiography ranges from 5% in patients with mild renal insufficiency to 50% in those with severe renal dysfunction and diabetes. Prior carotid trials have demonstrated that patients with dialysis-dependent renal failure had a stroke, death and myocardial infarction rate of 28.6%. CIN is an economic burden with increased morbidity, length of hospitalization, chronic renal impairment and higher mortality. Multiple pharmacological agents have been studied as prophylaxis to CIN, but none have been shown to be beneficial, including a recent meta-analysis of 13 randomized N-acetylcysteine trials showing inconclusive efficacy. The preprocedural avoidance of nephrotoxic drugs, iso- or low-osmolar contrast, reduced volume contrast and additional intravenous fluids are all recommended as strategies in reducing the risk of CIN.