Rethinking Percutaneous Coronary Intervention: The Era of Ultra-Low-Contrast Intervention

Iodinated contrast remains a key component of percutaneous coronary intervention, yet it poses a significant risk for contrast-associated acute kidney injury (CA-AKI), particularly in patients with chronic kidney disease (CKD). This review summarizes the evidence, procedural workflow with stepwise approach including clinical implications of ultra-low-contrast PCI (ULC-PCI). We reviewed recent literature describing strategies for contrast reduction, imaging and physiology-guided PCI, and subsequent clinical outcomes. ULC-PCI incorporates techniques such as intravascular imaging (IVUS/OCT), fractional flow reserve (FFR/iFR), and dynamic coronary roadmap imaging to safely reduce contrast exposure while maintaining procedural quality. It, thus, represents a paradigm shift toward a safer, precision-guided revascularization. Broader implementation requires structured training in this aspect and further outcome validation.