During cardiology fellowship, my institution had a hand manifold system. I found it difficult to use at times, and it appeared to produce varying results with each patient. As someone who is left-handed, it took me slightly longer to feel comfortable using the system. Additionally, there was the constant worry of having an air embolism. I clearly remember my attendings questioning the quality of my injections.
Throughout my training, I was aware that contrast volume was linked to contrast-induced acute kidney injury (CI-AKI) from studying materials about heart catheterizations1-3. However, my attendings did not seem very concerned about this issue. I did not know our AKI rates, but I did know that from one case to the next, our contrast volume seemed to have a large variance. There have been various trials regarding this topic indicating that limiting contrast volumes, hydration before and after the procedure, as well as maintaining normal blood pressures lead to reduced AKI rates 4-6. AKI is a significant concern for cardiologists as it leads to longer hospital stays and increased morbidity and mortality for patients.
An Educational Experience
In my final year of cardiology training, I was introduced to the ACIST CVi Contrast Delivery System. I completed an elective month at another hospital, and in this one month, I was able to easily use the system and noticed reduction in the contrast volume I was using per case. The CVi system was easy to set up, and I was able to adjust the pressure, flow and amount of contrast delivered with the push of a button8-9. Being left-handed was not an issue because I could easily hold my catheter in place and inject at the same time. The ease of use and consistent reliability reduced my worry of an air embolism due to the detection system on the device, and ability to use less contrast (and therefore a reduction in CI-AKI) all made me a believer in the CVi system for my practice9-10.
Therefore, coming out of fellowship, I wanted to ensure the devices and techniques I was using would allow for as safe and efficacious outcomes as possible while also being easy to use on a repeated basis. Hand manifold had been the default, but I knew it was not the only method.
However, my first job post-fellowship was at a hospital system that only had the manifold system. We had monthly morbidity and mortality meetings with the cardiovascular service line and quarterly reviews to go over cath data, that included CI-AKI, hematomas, prolonged hospital stays and other outliers. In such reviews, it was discovered that we did have elevated AKI rates.
Cardiologists are consistently being evaluated by our quality measures, such as adverse events or hospital readmittance. I suspect this will become standard practice over time. Given this trend of evaluation, this provided me an opportunity to present my experience with the ACIST CVi along with the data behind reduction in contrast volume and AKI rates.9-11
My institution gathered data from each case including contrast dose, pre- and post-procedure fluids, and more. I systematically introduced observations and trends to my colleagues and superiors, presenting this and my personal experience with acute kidney injury and how it manifested in my patients.
After my presentation, the hospital invested in the ACIST CVi, and other physicians began to use the system. As we continued to have meetings, the physicians collectively noted a reduction in AKI rates. We were now able to meet the quality metric as set forth by our institution.
Ultimately, it was the collection and presentation of the physicians’ experiences as well as my own personal experience that helped convince my hospital to acquire and adopt the ACIST CVi system. I knew what metrics my hospital found most important and where the challenges were, so I made sure to capture that relevant information.
During my diagnostic heart catheterizations with the CVi system, I typically only used around 20 mL of contrast. (This includes taking at least two images of the right coronary artery and at least four of the left system.) Using the hand manifold, I remember coming out of diagnostic cases hearing that I used nearly 100 mL of contrast. Now, my average for interventional cases is around 60 or 70 mL of contrast, depending on the difficulty.
In addition to my reduction in use of contrast, I have also found value in the CVi system’s air column detection. This feature is designed to alert the clinician and stop the injection if air is detected12. To assist in change at your institution, it is imperative to present a problem followed by a solution. Whether CI-AKI, air embolism, or other concerns, present the data and let it tell the story.
Making the Transition
Our transition to ACIST happened to coincide with the beginning of the COVID-19 pandemic. Like many institutions, I was concerned about potential contrast shortages. We were constantly running out of different supplies and scrambled to get comparable replacements from different vendors. Luckily, we did not run out of contrast and could operate normally.
While we did not implement specific protocols to reduce contrast use, I did receive feedback from physicians following the installation of CVi, and they generally noticed a decline in their contrast volume used. I have been using the low volume setting options to deliver less contrast during my injections, and I do not believe it compromises the image quality. I had a difficult time trying to get other providers to reduce their settings, but my persistence enabled me to convince a few.
While our AKI rates have appeared to remain consistent with the institution’s goal, it has been a challenging journey for our hospital. After I introduced a new pre and post cath fluid protocol based on the Poseidon trial 7, we saw another drop in rates, which, of course, made the hospital happy. Physicians are continually linked to their outcomes, and the CVi system is beneficial to both personal statistics and outcomes of the collective institution. I personally think that the ACIST system increases patient and provider safety leading to better patient outcomes.
1. Rihal CS, Textor SC, Grill DE, Berger PB, Ting HH, Best PJ, Singh M, Bell MR, Barsness GW, Mathew V, Garratt KN, Holmes DR Jr: Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention. Circulation 105 :2259– 2264,2002
2. Gruberg L, Mintz GS, Mehran R, Gangas G, Lansky AJ, Kent KM, Pichard AD, Satler LF, Leon MB: The prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol 36 :1542– 1548,2000
3. McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW: Acute renal failure after coronary intervention: Incidence, risk factors, and relationship to mortality. Am J Med 103 :368– 375,1997
4. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. Catheterization and Cardiovascular Interventions. 82:E266–E355, 2013. 10.1002/ccd.23390
5. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International 2012.
6. Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, et al. 2014 ESC/EACTS guidelines on myocardial revascularization. EuroIntervention 10:1024–94, 2015. 10.4244/EIJY14M09_01
7. Brar SS, Aharonian V, Mansukhani P, Moore N, Shen AY, Jorgensen M, Dua A, Short L, Kane K. Haemodynamic‐guided fluid administration for the prevention of contrast‐induced acute kidney injury: the POSEIDON randomised controlled trial. Lancet. 2014; 383:1814–1823.
8. Minsinger KD, Kassis HM, Block CA. Meta-analysis of the effect of automated contrast injection devices versus manual injection and contrast volume on risk of contrast-induced nephropathy. Am J Cardiol. 2014;113(1):49-53.
9. Lehmann C, Hotaling M. Saving time, saving money: a time and motion study with contrast management systems. J Invasive Cardiol. 2005;17(2):118-121;quiz 122.
10. Call J, Sacrinty M, Applegate R, et al. Automated contrast injection in contemporary practice during cardiac catheterization and PCI: effects on contrast-induced nephropathy. J Invasive Cardiol. 2006;18(10):469-474.
11. Khoukaz S, Kern M, Bitar S, et al. Coronary angiography using 4 Fr catheters with Acisted power injection. Catheterization and Cardiovascular Interventions. 2001;52:393-398.
This article has been developed in conjunction with ACIST Medical Systems, Inc. (“ACIST”), who has compensated Dr. Alston for writing this blog. Opinions expressed during this presentation are not necessarily those of ACIST and reflect the personal and professional opinions of Dr. Alston.
The author’s experience and opinions regarding the use of ACIST products may not be interpreted or relied upon to support clinical claims or product comparison claims regarding ACIST and competitive devices. Individual experiences may vary.
ACIST Medical Systems, Inc. (“ACIST”) does not promote or encourage the use of its devices beyond their approved indications for use. The experiences discussed do not necessarily represent or predict clinical outcomes in other experiences, since individual results may vary. ACIST does not promote or encourage the use of its devices beyond their approved indications for use