Acute Kidney Injury in High-Risk Percutaneous Coronary Intervention Supported by IABP Versus V-A ECMO: A Pilot Prospective Study

Abstract

Background:

Acute kidney injury (AKI) is a frequent and clinically-significant complication after high-risk percutaneous coronary intervention (HR-PCI). Temporary mechanical circulatory support (MCS) is increasingly used to maintain hemodynamic stability during complex PCI. However, comparative prospective data on the renal effects of intra-aortic balloon pump (IABP) versus veno-arterial extracorporeal membrane oxygenation (V-A ECMO) remain extremely limited. The aim of this study was to compare the incidence and determinants of AKI within 48 hours after HR-PCI supported by IABP versus V-A ECMO in a prospective pilot cohort.

Methods:

This single-center prospective observational study (2019–2025) included adult patients undergoing scheduled HR-PCI with planned prophylactic MCS using either IABP or V-A ECMO. Patients with cardiogenic shock, ST-segment elevation myocardial infarction (STEMI), urgent MCS deployment, chronic kidney disease stages 4 to 5 (CKD), or pre-existing AKI were excluded. The primary endpoint was AKI within 48 hours, defined by the Acute Kidney Injury Network criteria. Secondary endpoints included hemodynamic parameters, lactate dynamics, transfusion requirements, and procedural characteristics.

Results:

Seventy-eight patients were included (V-A ECMO, n = 36; IABP, n = 42). Acute kidney injury occurred in 44.4% of patients supported with V-A ECMO and 21.4% of those treated with IABP (p=0.029). In univariate analysis, diabetes mellitus (DM) (p=0.027), lower baseline estimated glomerular filtration rate (p=0.022), lower postprocedural hemoglobin (p=0.016), more positive fluid balance (p=0.001), and packed red blood cell transfusion (p=0.045) were associated with AKI. In multivariable regression, independent predictors of AKI were DM (odds ratio [OR]=2.92; 95% confidence interval [CI]=0.87–9.87; p=0.024) and PRBC transfusion (OR = 2.66; 95% CI = 0.84–8.43; p=0.036), whereas the type of MCS did not remain an independent factor.

Conclusions:

In this prospective pilot study, V-A ECMO support during HR-PCI was associated with more than a twofold higher rate of AKI compared with IABP, although V-A ECMO did not remain an independent predictor after adjustment. Diabetes mellitus, hemoglobin dilution, transfusion exposure, and fluid overload appear to substantially contribute to AKI risk in this population.

Clinical Impact

This prospective study highlights that V-A ECMO support during high-risk PCI is associated with a substantially higher incidence of early acute kidney injury compared with IABP, although not independently after adjustment. These findings underscore the importance of careful patient selection and individualized choice of mechanical circulatory support. For clinicians, the results emphasize the need for proactive renal protection strategies, including strict fluid balance control, minimization of transfusions, and optimization of hemoglobin levels. The study introduces a clinically relevant perspective by focusing on modifiable peri-procedural factors rather than device selection alone. Ultimately, this approach may help reduce AKI risk and improve outcomes in high-risk PCI populations.