LETTERS FROM READERS
Dynamic Coronary Roadmap in Real Practice

Dynamic Coronary Roadmap en la práctica real

  • JUAN M. PÉREZ ASOREY, 1  ORCID logo 
  • JOAQUÍN PÉREZ ASOREY, 2  ORCID logo 
  • 1  Interventional Cardiologist. Chief Resident, Interventional Cardiology, Favaloro Foundation, Buenos Aires.
  • 2  Cardiologist. Fellowship en Hemodinamia y Cardiología Intervencionista, Fundación Favaloro, Ciudad de Buenos Aires

Rev Argent Cardiol 2025;93:477-478. https://doi.org/10.7775/rac.v93.i6.20962

Correspondence: Juan M. Pérez Asorey, Av. Pres. Manuel Quintana 49, Buenos Aires. Email: jmperez@ffavaloro.org


2025 ©Revista Argentina de Cardiología

Licencia Creative Commons  Creative Commons Atribution-NonCommercial-Sharelike 4.0 Internacional
Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons
 
 

Contrast-induced nephropathy (CIN) remains a significant complication after percutaneous coronary intervention (PCI), particularly in elderly patients, diabetics, or those with preexisting chronic kidney disease. (1,2)

A significant body of evidence demonstrates a direct, dose-dependent association between the administered contrast volume and the risk of acute kidney injury. (1-3) In this context, total contrast volume is no longer a purely technical parameter but has become a relevant clinical variable that can be monitored and optimized during percutaneous procedures. (2,3)

In recent years, different strategies have been developed to reduce the contrast volume load during PCI. Low-contrast PCI, the systematic use of intravascular imaging, and the incorporation of software for navigation and planning have proven to be effective tools for reducing unnecessary injections and optimizing decision-making during the procedure. (4) Likewise, from an institutional perspective, excessive contrast media use increases direct costs for materials and indirect costs derived from renal complications, length of hospital stays, and use of complementary tests, with a negative impact on the efficiency of the healthcare system. (2,3)

In this context, Abud et al. evaluated the impact of the Dynamic Coronary Roadmap (DCR) as a tool to reduce the total contrast volume during PCI. This observational, retrospective, single-center study included 480 patients and compared DCR-guided procedures with conventional angiography. The authors demonstrated a significant reduction in the total contrast volume and in the volume used specifically during PCI, with no differences in radiation dose or serum creatinine levels between the two groups. (5)

The study provides relevant local evidence and underscores the concept that incorporating navigation tools can contribute to a more rational use of contrast media, primarily by reducing redundant injections and improving procedure planning. However, from a constructive perspective, it is important to contextualize these findings. Although the absolute reduction in contrast volume observed (20--30 mL) was statistically significant, it did not translate into measurable clinical changes, decreases in creatinine levels, or reduction of adverse kidney events. Furthermore, this is a single-center study with highly experienced operators, where baseline contrast volumes are already low, which could limit the magnitude of the incremental benefit of DCR.

In conclusion, DCR is presented as a useful tool within a comprehensive strategy to reduce contrast volume, particularly in high-risk patients. The study by Abud et al. represents a valuable contribution to this field and paves the way for future multicenter studies aimed at better defining its clinical impact in selected populations.

 

Ethical considerations

Not applicable.

Conflicts of interest

None declared.

(See authors' conflict of interests forms on the web).

 
 

REFERENCES

1. Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol 2004;44:1393-9. https://doi.org/10.1016/j.jacc.2004.06.068
2. Mehran R, Dangas GD, Weisbord SD. Contrast-Associated Acute Kidney Injury. N Engl J Med 2019;380:2146-55. https://doi.org/10.1056/NEJMra1805256
3. Azzalini L, Kalra S. Contrast-Induced Acute Kidney Injury-Definitions, Epidemiology, and Implications. Interv Cardiol Clin 2020;9:299-309. https://doi.org/10.1016/j.iccl.2020.02.001
4. Azzalini L, Laricchia A, Regazzoli D, Mitomo S, Hachinohe D, Bellini B, et al. Ultra-Low Contrast Percutaneous Coronary Intervention to Minimize the Risk for Contrast-Induced Acute Kidney Injury in Patients With Severe Chronic Kidney Disease. J Invasive Cardiol 2019;31:176-82. https://doi.org/10.25270/jic/18.00331
5. Abud MA, Villa F, Paganini IL, Cóggiola J, De Brahi JP. Reduction in contrast use through the application of Dynamic Coronary Roadmap in coronary angioplasty. Rev Argent Cardiol 2025;93:358-63. https://doi.org/10.7775/rac.es.v93.i5.20941

 
 

AUTHORS' REPLY

Firstly, we would like to thank Dr. Pérez Asorey for his critical reading and constructive feedback on our work, as well as for the conceptual framework he provides on the clinical relevance of contrast-induced nephropathy and the need for strategies to optimize the total volume administered during percutaneous coronary interventions (PCIs).

We agree that the absolute magnitude of the reduction in the contrast agent used must be interpreted in context. In our cohort, the group guided by Dynamic Coronary Roadmap (DCR) showed a significant reduction in total contrast volume (median 120 mL vs. 140 mL). In turn, after adjusting for clinical and procedural variables, the estimated reduction was 37.3 mL per patient (95% CI: 24.3--50.5 mL). We acknowledge that a reduction of this magnitude may seem "incremental" in individual terms; however, we believe that its potential value is expressed in the context of (i) institutional strategies for continuous improvement (reduction of redundant injections, among others) and (ii) higher-risk subgroups, where every mL counts.

We understand that a key point for interpretation is that the DCR group included a significantly higher proportion of complex PCIs (39.6% vs. 17.6%). In other words, DCR was more commonly used in more demanding scenarios, where, in actual practice, contrast consumption is substantially higher. The fact that the reduction persists (and remains after multivariable adjustment) suggests a relevant signal of the tool's operational benefit in more complex anatomies and therapeutic strategies.

Regarding the absence of differences in renal function, we share this cautious interpretation. Although CIN was defined in the protocol as an increase in creatinine within 48--72 hours, the comparison presented was based on changes in creatinine levels measured prior to discharge. Moreover, the study was not powered to detect infrequent clinical outcomes. In this context, we consider it reasonable that a single-center observational study does not show "hard" clinical changes, even with a consistent reduction in contrast media, especially when baseline contrast volumes are already relatively low.

In conclusion, we interpret DCR as a valuable complementary tool within a comprehensive low-contrast PCI strategy, and we agree on the need for future multicenter studies (ideally prospective and regional) focused on populations at higher renal risk, with standardized creatinine measurement in the 48--72 h window and assessment of renal and economic outcomes.

Sincerely yours,

Marcelo A. Abud, Facundo Villa, Ignacio L. Paganini,
Javier Cóggiola, Juan P. De Brahi
San Gerónimo Cardiovascular Institute
Endovascular Therapy Service
 
 

HTML generado desde un xml-jats a través de la plantilla jats-rac.xsl  por  RevisCiencia.  El motor utilizado es Apache Software Foundation (Xalan XSLTC).