Contrast-induced nephropathy after peripheral vascular intervention: Long-term renal outcome and risk factors for progressive renal dysfunction.

OBJECTIVE: Contrast-induced nephropathy (CIN) is a frequently used quality outcome marker after peripheral vascular interventions (PVIs). Whereas the factors associated with CIN development have been well documented, the long-term renal effects of CIN after PVI are unknown. This study was undertaken to investigate the long-term (1-year) renal consequences of CIN after PVI and to identify factors associated with renal function deterioration at 1-year follow-up. METHODS: From 2008 to 2015, patients who had PVI at our institution (who were part of a statewide Vascular Interventions Collaborative) were queried for those who developed CIN. CIN was defined by the Collaborative as an increase in serum creatinine concentration of at least 0.5 mg/dL within 30 days after intervention. Preprocedural dialysis patients or patients without postprocedural creatinine values were excluded. Preprocedural, postprocedural, and 1-year serum creatinine values were abstracted and used to estimate glomerular filtration rate (GFR). ΔGFR was defined as preprocedural GFR minus 1-year GFR. Univariate and multivariate analyses for ΔGFR were performed to determine factors associated with renal deterioration at 1 year. RESULTS: From 2008 to 2015, there were 1323 PVIs performed; 881 patients met the inclusion criteria. Of these, 57 (6.5%) developed CIN; 47% were male, and 51% had baseline chronic kidney disease. CIN resolved by discharge in 30 patients (53%). Using multivariate linear regression, male sex (P = .027) and congestive heart failure (P = .048) were associated with 1-year GFR decline. Periprocedural variables related to 1-year GFR decline included percentage increase in 30-day postprocedural creatinine concentration (P = .025), whereas CIN resolution by discharge (mean, 13.1 days) was protective for renal function at 1 year (P = .02). A post hoc analysis was performed with 50 PVI patients (randomly selected) who did not develop CIN, comparing their late renal function with that of the CIN group stratified by the periprocedural 30-day variables. Patients with CIN resolution at discharge had similar 1-year renal outcomes to non-CIN patients, whereas the CIN-persistent (at discharge) patients had greater renal deterioration at 1 year compared with non-CIN patients (P = .016). CONCLUSIONS: Male sex and congestive heart failure are risk factors for further renal function decline in patients developing CIN after PVI. The magnitude and duration of increase in creatinine concentration (CIN persistence at discharge) correlated with late progressive renal dysfunction in CIN patients, suggesting that early-resolving CIN is relatively benign.

Incidence and prognosis of vascular complications after percutaneous placement of left ventricular assist device.

OBJECTIVE: Mechanical assist devices have found an increasingly important role in high-risk interventional cardiac procedures. The Impella (Abiomed Inc, Danvers, Mass) is a percutaneous left ventricular assist device inserted through the femoral artery under fluoroscopic guidance and positioned in the left ventricular cavity. This study was undertaken to assess the incidence of vascular complications and associated morbidity and mortality that can occur with Impella placement. METHODS: We used a prospective database to review patients who underwent placement of an Impella left ventricular assist device in our tertiary referral center from July 2010 to December 2013. Patient demographics, comorbidities, interventional complications, and 30-day mortality were recorded. RESULTS: The study included 90 patients (60% male). Mean age was 66 years (range, 17-97 years). Hypertension was found in 69% of the patients, 37% were diabetic, 57% had a history of tobacco abuse, and 65% had chronic renal insufficiency. The median preprocedure cardiac ejection fraction was 30%. Most (87%) had undergone coronary artery intervention. Cardiogenic shock was documented in 67 patients (74%). The Impella was placed for an average of 1 day (range, 0-5 days). At least one vascular complication occurred in 15 patients (17%). Acute limb ischemia occurred in 12 patients; of whom four required an amputation and six required open or endovascular surgery. Other complications included groin hematomas and one pseudoaneurysm. All-patient 30-day mortality was 50%, which was not significantly associated with vascular complications. Female sex and cardiogenic shock at the time of insertion were associated with vascular complications (P = .043 and P = .018, respectfully). CONCLUSIONS: Vascular complications are common with placement of the Impella percutaneous left ventricular assist device (17%) and are related to emergency procedures. Vascular complications in this high-risk patient population frequently lead to withdrawal of care. These data provide quality improvement targets for left ventricular assist device programs.