WASHINGTON–New research presented at the 2024 Transcatheter Cardiovascular Therapeutics (TCT) conference in Washington, DC, challenges a preconceived notion within interventional cardiology: that injecting contrast during percutaneous coronary procedures inherently increases the risk of propagating coronary dissections.
Copublished in JSCAI, “Can Contrast Injections Cause or Propagate Coronary Injuries?: Insights From Vessel and Guiding Catheter Hemodynamics,” investigates the changes in peak systolic pressures within coronaries generated during contrast injections and their potential to propagate coronary dissections hydraulically.
“While manual or pump-guided injections generate high pressures within the catheter, we found that these pressures dissipate significantly upon exiting the catheter, resulting in minimal transmission into the coronary vessels. The risk of propagating an existing dissection was minimal if the dissection was distal to the catheter,” said coauthor Daniel Chamie, MD, PhD, director of intravascular imaging at the Yale University School of Medicine. “Conversely, dissections proximal to the catheter pose a higher risk due to significant pressure increases during injection. Clinicians are advised to avoid injections in such scenarios.”
To conduct the study, clinicians at four centers located in Brazil, London, and Mexico, monitored intracoronary pressures at distal, mid, and proximal locations, at the catheter tip, and inside the catheter in patients undergoing physiological assessments using pressure wires typically employed for coronary physiology measurements. The research included stented and nonobstructive vessels to ensure unimpeded transmission of coronary pressures.
The study's findings have important implications for clinical practice. While the study supports the safe use of additional angiographic views when those are needed for clarifying a distal dissection, the researchers cautioned that clinicians should be mindful of contrast volume and avoid injections when proximal dissections are suspected. When intracoronary imaging is needed, optical coherence tomography (OCT) could be a safe option if the suspected dissection is not close to the catheter.
The authors also advise that contrast injections be avoided when coronary pressures are damped or ventricularized and highlight the research results do not apply to chronic total occlusion procedures where interventional equipment is often extraluminal in the vessel structure. In chronic total occlusion percutaneous coronary intervention (CTO PCI), injection of contrast media into a closed extraluminal compartment could increase the risk of extending a subintimal/intramural hematoma by exposing the false lumen to above-average pressures.
“Overall, our findings provide reassurance that using OCT or additional angiographic views to clarify diagnoses is safe when dissections are distal to the catheter. Our data do not apply to damped or ventricularized coronary pressures or to CTO PCI. With that in mind, clinicians should always be mindful of contrast volume,” Chamie said.
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