Recent clinical trial has recommended zero-contrast percutaneous coronary intervention (PCI) in patients with coincident coronary artery disease and advanced chronic kidney disease (CKD). Although its safety and feasibility have been reported in patients with chronic coronary syndrome, few studies have addressed patients with complex high-risk conditions. This article reports on short-term renal and cardiovascular events in patients with complex conditions who underwent zero-contrast PCI, especially those with acute coronary syndrome.

All patients were prospectively enrolled in the authors’ fractional flow reserve (FFR) registry, nine of whom with advanced CKD underwent zero-contrast PCI to avoid contrast exposure. Descriptive analysis was used to reveal the complexity of the patients’ conditions and describe events up to 30 days’ follow-up. Renal events were defined as the initiation of incident hemodialysis or a 25% increase in serum creatinine levels. Cardiovascular events included target vessel failure, repeat myocardial infarction, hospitalization for heart failure, and mortality, all of which are reported separately.

Nine patients (mean age, 71 years [20% female]) who underwent 14 zero-contrast PCI procedures were included in this study. The mean estimated glomerular filtration rate was 15 mL/min/1.73 m²; 57% of patients presented with acute coronary syndrome and 21% with heart failure. The mean left ventricular ejection fraction was 50%, and approximately four-fifths experienced heart failure symptoms during PCI, with a median left ventricular end-diastolic pressure of 27 mmHg. All patients exhibited multi-vessel coronary artery disease, and 22% underwent left main bifurcation PCI. The PCI success rate was 93%, with failure in one of two PCI procedures for chronic total occlusion. Intravascular ultrasound was used in all patients and 86% of procedures involved concomitant FFR assessment. The median pre-PCI FFR was 0.51, and the post-PCI FFR was < 0.80 in 31%. All patients were discharged alive, although 18% experienced renal events. One (11%) patient was re-hospitalized for heart failure; however, no patients experienced other cardiovascular events.

Zero-contrast PCI was feasible and safe in patients with concomitant advanced CKD and/or other complex high-risk conditions, and the risks for short-term renal and cardiovascular events were acceptable. Nevertheless, further trials evaluating its efficacy are warranted.