Low contrast PCI of Anomalous coronary artery in a young male with Advanced Stage4 CKD.

Background: Percutaneous coronary intervention (PCI) in patients with advanced chronic kidney disease (CKD) is particularly challenging due to the elevated risk of contrast-induced nephropathy and increased procedural complexity. These risks are further amplified in the presence of anomalous coronary anatomy, which demands careful technique and strategic planning.

Case Presentation: We present the case of a 39-year-old male with advanced CKD Stage 4 secondary to biopsy-proven focal segmental glomerulosclerosis (FSGS). His medical history included hypertension, hyperlipidemia, hyperuricemia, and a strong family history of ischemic heart disease. He reported typical exertional chest pain and dyspnea for three months, with notable worsening over the previous week. Clinical examination was unremarkable. ECG demonstrated normal sinus rhythm, and echocardiography revealed concentric left ventricular hypertrophy (LVH) with preserved systolic function (LVEF 60%). A treadmill stress test showed strongly positive evidence of inducible ischemia. After multidisciplinary consultation with nephrology, urgent coronary angiography with ad hoc PCI was scheduled, supported by peri-procedural dialysis.

Intervention: Coronary angiography was performed via right radial access using limited projections to reduce contrast exposure. Findings revealed a right-dominant coronary system with an anomalous right coronary artery (RCA) arising from the non-coronary sinus, exhibiting a critical 90% mid-segment stenosis. A low-contrast PCI strategy was employed using a Judkins Right 3.5 guide catheter and a BMW guidewire. Lesion crossing and pre-dilatation were achieved primarily through tactile guidance with minimal reliance on contrast. A 3 × 38 mm drug-eluting stent was successfully deployed, followed by post-dilatation with a non-compliant balloon. Total contrast volume was restricted to just 30 cc. Optimal stent expansion was achieved without complications. The patient remained hemodynamically stable and underwent scheduled dialysis both before and after the procedure.

Conclusion: This case highlights that low-contrast PCI can be performed safely and effectively in patients with advanced CKD and challenging coronary anatomy when supported by careful pre-procedural planning, appropriate hardware selection, and tailored procedural adjustments. Although intracoronary imaging (IVUS/OCT) is ideal for minimizing contrast use, meticulous technique can achieve successful outcomes even in resource-limited environments.

Credit: Case managed and reported by Dr. Shaikh Swalehin, Consultant Interventional Cardiologist, Bahrain Specialist Hospital.