Iodinated Contrast Media Allergy in Patients Hospitalized for Investigation of Chest Pain

Absolute zero-contrast percutaneous coronary interventions: An intravascular ultrasound-guided case series and literature review

PURPOSE

Contrast media (CM)-associated adverse effects including mainly acute kidney injury and hypersensitivity reactions still remain a significant treatment burden to vulnerable patients requiring percutaneous coronary intervention (PCI). The complete omission of CM administration accompanied by intravascular ultrasound (IVUS) guidance may offer an appropriate revascularization treatment.

METHODS

We hereby present a case series of four patients with challenging coronary lesions and relative/absolute contraindications to CM use [(hypersensitivity reaction owning to CM, history of contrast-induced acute kidney injury, solitary kidney, or advanced chronic kidney disease (CKD)] who underwent absolute zero-contrast IVUS-guided PCI following a predetermined protocol.

RESULTS

The initial diagnostic angiography was reviewed for landmark identification, and multiple guidewires created a metallic road map providing additional landmarks and protected side branches. IVUS imaging was performed to determine lesion length, reference segments and landing zones, assess stent expansion/apposition and identify major complications. All procedures were successfully completed without any CM administration, renal function deterioration, pericardial effusion, or stent edge dissection.

CONCLUSIONS

We demonstrated the feasibility of absolute zero-contrast IVUS-guided PCI in patients with complex coronary lesions susceptible to CM-associated adverse effects. Since the safety of this strategy is well-documented in patients with CKD and challenging lesions morphology even in acute settings, evidence-based validation of this approach is capable of changing the otherwise conservative treatment of vulnerable patients where even minimum doses of CM may have detrimental effects.

SUMMARY FOR THE ANNOTATED TABLE OF CONTENTS

Patients with vulnerable renal function as well as former hypersensitivity reaction to contrast media encounter a significant treatment burden regarding coronary artery disease. Zero-contrast IVUS-guided strategy based on a predetermined protocol provides a feasible alternative approach in patients susceptible to contrast media-associated adverse effects even in the presence of complex coronary lesions.

Pharmacist-led iodinated contrast media infusion risk assessment service

Background: With the increasing development of medical imaging, the use of iodinated contrast media has become more widespread. Adverse reactions caused by iodinated contrast media have drawn much attention. Despite this, there is still a lack of unified standards for the safe infusion process of iodinated contrast media in clinical practice both domestically and internationally. Objectives: Establishing a risk management service system to better predict the risks associated with iodinated contrast media infusion, reduce the incidence of adverse reactions and minimize patient harm. Method: A prospective interventional study was carried out from April 2021 to December 2021 at Nanjing Drum Tower Hospital in China. During this study, a service system was established to manage the risks associated with the infusion of iodinated contrast media. Personalized risk identification and assessment were performed by a pharmacist-led multidisciplinary team before iodinated contrast media infusion. Early warning, prevention, and adverse reaction management were performed according to different risk levels during and after infusion. Results: A multidisciplinary team led by pharmacists was established to evaluate the risks associated with infusion of iodinated contrast media. A total of 157 patients with risk factors related to the iodinated contrast media were screened out, which prevented 22 serious adverse events and enhanced the quality of medical care. All participants expressed high satisfaction with the service. Conclusion: Through practical exploration, the pharmacist-led multidisciplinary team can provide advance warning and effectively limit the risks of adverse reactions caused by iodinated contrast media to a preventable and controllable level. This approach serves as a valuable reference for developing strategies and schemes to reduce the incidence of such reactions. Therefore, we encourage the implementation of this intervention in other areas of China.

Clinical impact of allergy and pre-medication in CT studies with low-osmolality intravenous iodinated contrast media

AIM

To evaluate the occurrence and severity of allergic reactions to iodinated contrast media (ICM), including associated risk factors and the impact of pre-medication.

MATERIALS AND METHODS

Data on patients who had experienced allergic reactions during outpatient computed tomography (CT) examinations between January 2014 and September 2018 were analysed retrospectively. Response severity was assessed according to validated criteria. A control group was selected among individuals who underwent CT during the study period and did not experience allergic reactions.

RESULTS

Screening of 36,920 CT studies revealed 74 (0.2%) individuals with systemic reactions to ICM. No significant differences in patient characteristics were found among patients who experienced mild (n=54), moderate (n=17), or severe (n=4) reactions. Previous ICM allergy was reported in 10 patients (13.3%). Patients with a history of ICM allergy had mild (9/10) or moderate (1/10) reactions, with one individual showing decreased intensity of the allergic response compared to a previous event. Within the control group, four patients (4%) had previous ICM allergy. In these individuals, lack of allergic reactions could not be attributed to pre-medication. All patients with severe reactions did not have a prior history of ICM allergy.

CONCLUSION

Severe allergic reactions to ICM are rare, lack significant risk factors, and do not appear to be impacted by pre-medication. The findings presented herein highlight the need for prospective work that will re-evaluate the yield of pre-medication protocols.

Complications during chronic total occlusion percutaneous coronary intervention: a sign- and symptom-based approach to early diagnosis and treatment

Coronary chronic total occlusions (CTO) are frequently found in patients undergoing coronary angiography. Despite their high prevalence and indication for revascularization in a relevant proportion of cases, CTO recanalization is attempted only in a minority of cases. This is due to higher risk of procedural complications compared to non-CTO interventions and because the CTO-PCIs are the most complex procedures in interventional cardiology. In particular, the perceived higher risk of complications during CTO intervention might discourage new operators from engaging in this challenging field. The aim of this work is to review the potential complications of CTO percutaneous coronary intervention, and to provide an algorithmic, sign- and symptom-based approach to facilitate early recognition and effective management.

Zero-contrast percutaneous coronary intervention for chronic total occlusions guided by intravascular ultrasound with ChromaFlo mode: a case report

Background

Contrast agent allergy may result in severe adverse events that prevent the use of percutaneous coronary intervention (PCI) in some patients, especially for those with complex lesions.

Case summary

We describe a 59-year-old man who presented with the multi-vessel disease and suffered from contrast allergy. The patient refused to have coronary artery bypass grafting surgery, thus two-stage PCI procedures without iodinated contrast media were performed after a detailed discussion with the heart team, including a chronic total occlusion (CTO) lesion in the proximal left anterior descending artery. The intravascular ultrasound (IVUS) was used for finding the entry point of the proximal fibre cap, and assessing the lesion, thereby marking the positions of the proximal and distal edges of the stent. After PCI, stent expansion and subtle edge dissection or incomplete apposition were confirmed by IVUS and ChromaFlo imaging. Zero-contrast PCI was done successfully without any complication.

Discussion

This case report illustrates the feasibility and safety of performing CTO-PCI without contrast agent in carefully and well prepared selected patients.

Emergent Premedication for Contrast Allergy Prior to Endovascular Treatment of Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Management of contrast media allergies may lead to treatment delays in patients with acute ischemic stroke undergoing endovascular therapy. The optimal premedication strategy remains unclear. The aim of this report was to analyze our experience with emergent administration of premedication regimens before endovascular therapy.

MATERIALS AND METHODS

We retrospectively reviewed prospective data for all patients undergoing endovascular therapy from 2012 to 2019 at an academic comprehensive stroke center. Records of patients with documented contrast allergy were reviewed and analyzed. Data collected included stroke risk factors and characteristics, historical contrast reaction details, premedication regimens administered, and signs or symptoms of allergic reaction developing post-endovascular therapy. Hospital arrival time to endovascular therapy was compared with that in those who did not have a history of contrast allergy.

RESULTS

We analyzed 1521 patients undergoing endovascular therapy; 60 (4%) had documented contrast allergies and constituted the study cohort. The median age was 73 years (interquartile range, 66-81 years), and 65% were women. The median time from premedication to contrast was 24 minutes (interquartile range, 0-36 minutes). Forty-three patients (72%) proceeded directly to endovascular therapy; in 17 patients, the first contrast exposure was CTA. Time from hospital arrival to endovascular therapy was not slower for patients with documented allergies (96 versus 134 minutes, P = .32). No patients experienced a contrast media reaction.

CONCLUSIONS

In a single-institution cohort study of 60 consecutive patients with documented contrast allergies undergoing endovascular therapy with emergent premedication en route to (or in) the neuroangiography suite, no patients experienced allergic symptoms. This pragmatic approach may be safe for patients who have documented contrast media allergies.

The Journal of Allergy and Clinical Immunology: In Practice 2018 Highlights

A large number of clinically impactful studies and reviews were published in this journal in 2018. This article provides highlights of the original research published in 2018 issues of The Journal of Allergy and Clinical Immunolgy: In Practice on the subjects of anaphylaxis, asthma, dermatitis, drug allergy, eosinophilic disorders, food allergy, immune deficiency, rhinitis, and urticaria/angioedema and mast cell disorders. Within each topic, practical aspects of diagnosis and management are emphasized. Treatments discussed include lifestyle modifications, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help readers consolidate and use this extensive and practical knowledge for the benefit of patients.