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Novel Technique For Reduced Contrast Administration During Computed Tomography Angiography (CTA) In Patients With Chronic Kidney Disease And Concomitant Complex Aortic Aneurysms
Clayton J. Brinster, MD, Andrew Rivera, MD, Kundanika Lakkadi, MS, BSA, Hernan Bazan, MD, W. Charles Sternbergh III, MD, Samuel Money, MD;
Ochsner Health, NEW ORLEANS, LA, USA
Objectives: Patients with advanced chronic kidney disease (CKD) and coexisting complex aortic pathology present a unique challenge. Administration of the standard contrast volume required in these patients for diagnostic CTA, essential for pre-operative planning, increases the risk of accelerated renal failure. We report a novel approach to reduce intravenous contrast dosage during CTA in this situation utilizing a trans-radial aortic catheter.
Methods: Patients with thoracoabdominal, pararenal, and juxtarenal aortic aneurysms requiring intervention and presenting with CKD stage IIIb or IV (glomerular filtration rate (GFR), 16 to 44) were included. In each case, a straight flush catheter (facilitated removal without re-wiring or angiography) without radiopaque makers (avoids radiogenic scatter) was placed in trans-radial fashion and positioned proximally to respective aortic pathology. Patients were transported to a radiology suite, and CTA performed. For thoracoabdominal aneurysms, 40cc of contrast and for juxta- and pararenal aneurysms, 30cc of contrast were administered with each respective CTA. Standard contrast volume for CTA is 100cc. A standard injection rate of 4cc/second with an 8-10 second delay was used. Catheters were removed and a trans-radial band placed without the need to return to the angiographic suite. Concurrent intravenous hydration was undertaken in all patients. GFR values were obtained a minimum one month after CTA.
Results: Fifteen patients were identified. The average age was 76, and 12/15 (80%) were men. Average pre-CTA GFR was 29. CKD stage IIIB 7/15 (47%) and 8/15 (53%) stage IV patients were included. Average post-CTA GFR was 29. No individual patient demonstrated a significantly increased GFR post-CTA. Detailed aortic, visceral branch, and access vessel images were sufficient for complex, three-dimensional, endovascular planning in all cases. No access site complications occurred.
Conclusions: This initial series demonstrates that trans-radial CTA generates detailed images and preserves renal function in patients with CKD IIIb and IV, with no significant change in post-scan GFR seen in any patient. Imaging in all patients was adequate for complex, 3-D endovascular planning despite the use of 60-70% less contrast per scan. Although the trans-radial CTA approach has not been previously described, the widespread availability of required equipment, familiarity of trans-radial access among vascular surgeons, and lower access site risk compared to transfemoral access make the technique generalizable and straightforward to achieve in this uniquely vulnerable patient population.
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