Gadolinium-based coronary angiography in patients with contraindication for iodinated x-ray contrast medium: a word of caution

Adverse Events Associated with Intra-Arterial Administration of Gadolinium-Based Contrast Agents: A Systematic Review and Meta-Analysis

PURPOSE

To determine the risk of immediate hypersensitivity reactions (HRs), contrast-associated acute kidney injury (CA-AKI), nephrogenic systemic fibrosis (NSF), and gadolinium retention associated with use of intra-arterial gadolinium-based contrast agents (GBCAs).

MATERIALS AND METHODS

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from 1988 (GBCAs approved for clinical use) to March 2021 for studies reporting adverse events associated with intra-arterial administration of GBCAs. The number of adverse events and GBCA administrations were used to calculate incidence in individual studies, and results across studies were pooled using random-effects meta-analysis.

RESULTS

There were 72 studies (patients = 1,221) that reported on HR, 59 studies (patients = 1,142) that reported on CA-AKI, and 6 studies (patients = 291) that reported on NSF. No studies reported gadolinium retention as an outcome. Based on 5 events and 1,451 GBCA administrations, the incidence of HR per 100 administrations was 0.95 (95% CI, 0.52-1.51). Based on 90 events and 1,318 GBCA administrations, the incidence of CA-AKI per 100 administrations was 5.94 (95% CI, 3.92-8.34). Based on 7 events and 361 GBCA administrations, the incidence of NSF per 100 Group I GBCA administrations was 4.72 (95% CI, 0.35-13.70). There were no unconfounded NSF events after Group II GBCA administration.

CONCLUSIONS

HRs to intra-arterial administration of GBCAs are rare, with no serious reactions. Limited data demonstrate a higher-than-expected rate of CA-AKI; however, multiple confounding factors were noted. Thus, any causative link of CA-AKI to GBCA remains controversial. Also, severe physiologic reactions (including life-threatening arrhythmias) during coronary angiography have been reported.

Adrenal vein sampling with gadolinium contrast medium in a patient with florid primary aldosteronism and iodine allergy

We describe a 35-year-old woman who was allergic to iodine contrast medium and was diagnosed with primary aldosteronism (PA) based on functional confirmatory tests. She was suspected to have unilateral PA because of marked hypertension, spontaneous hypokalemia, high plasma aldosterone, reduced plasma renin activity, and a right hypodense adrenal tumor. She wanted to become pregnant and requested adrenalectomy instead of medical treatment with mineralocorticoid receptor antagonists. Localization of PA by adrenal vein sampling (AVS) was necessary, but angiography with iodine contrast medium was not possible because of her allergy. AVS was performed using gadolinium contrast agent (gadoterate meglumine) instead of iodine, in combination with computed tomography angiography (CTA). In AVS, before and after adrenocorticotropin (ACTH) loading, 12 blood samples were drawn from the right adrenal vein, left adrenal central vein, left adrenal common duct, left and right renal veins, and the lower inferior vena cava with only 5 mL of gadolinium medium. There were no complications during AVS. Examination revealed an elevated aldosterone/cortisol ratio on the right side, lateralized ratio of 7.4, and contralateral ratio of 0.76; the patient was diagnosed with right unilateral PA. She underwent right adrenalectomy and showed improvements in aldosterone level from 312.4 pg/mL to 83.0 pg/mL, potassium from 3.0 mEq/L to 3.9 mEq/L, and systolic blood pressure from 138 mm Hg to 117 mm Hg. In PA patients with iodine allergy, AVS can be performed safely and precisely using gadolinium contrast combined with CTA.

Adrenal Vein Sampling in a Patient With Primary Hyperaldosteronism and Severe Contrast Allergy

We report on a case of a 50-year-old female patient with primary hyperaldosteronism, in whom adrenal venous sampling was required to differentiate between unilateral and bilateral disease. Because of a history of severe allergy to iodinated contrast media, premedication with glucocorticoids was indicated. Exogenous glucocorticoids, however, can affect measurements of serum cortisol. To avoid this potential confounding effects on the cortisol assay, we decided to use dexamethasone instead of prednisolone or hydrocortisone. A high-dose adrenocorticotropin (ACTH) stimulation test with the simultaneous use of dexamethasone revealed an adequate adrenal cortisol response. ACTH-stimulated adrenal venous sampling showed reliable results, which provided a solid basis for further clinical decision-making.

Gadolinium-based coronary angiography in a patient with prior known anaphylaxis to iodine-based dye

Gadodiamide is a gadolinium-based chemical element that is considered safe and well tolerated in patients without renal dysfunction and is therefore routinely used as a contrast agent in magnetic resonance imaging. Although radio-opaque, it is not frequently used for coronary angiography due to its less than optimal image quality and prohibitive cost. Our center’s previous experience was less than satisfactory but the addition of a power injection system yielded good quality diagnostic images. We report a case of 63 years old male with a known history of severe, life-threatening anaphylactic reaction to previous iodinated dye presenting with persistent angina despite optimal medical therapy. Coronary and bypass graft angiography was performed using 24 cc of undiluted Gadodiamide (OMNISCAN) with a power injector (ACIST®) without any incidents or premedication with an interpretable angiogram.

Zero-iodinated contrast retrograde percutaneous coronary interventions of chronic total occlusions using gadolinium and imaging guidance: a case report of a patient with severe anaphylaxis to iodinated contrast

Background

Gadolinium-based contrast agents have been used as an alternative to iodinated contrast agents for simple percutaneous coronary interventions (PCIs) in patients with obstructive coronary artery disease. Their use has been limited in complex PCI due to poor image quality with gadolinium contrast. Significant dilution of gadolinium is required in an effort to avoid malignant ventricular arrhythmias. Further, the recommended amount of gadolinium contrast that can be used is very limited.

Case summary

We describe a case of patient with severe anaphylaxis to iodinated contrast agents despite pre-exposure prophylaxis with steroids and histamine blockers who underwent intravascular imaging-guided PCI of chronic total occlusions (CTOs) of left anterior descending and dominant left circumflex arteries using gadolinium contrast.

Discussion

In patients with anaphylaxis to iodinated contrast agents (i) complex coronary interventions including CTO PCI can be successfully performed without use of iodinated contrast, and (ii) combination of intravascular ultrasound guidance and gadolinium-based contrast agents can be safely and effectively used to perform complex PCI.

Gadolinium to the rescue for mechanical thrombectomy in acute ischemic stroke

INTRODUCTION

Mechanical thrombectomy in the setting of acute ischemic stroke (AIS) requires cerebral digital subtraction angiography (DSA), typically performed with iodinated contrast medium. We present a case of emergent cerebral DSA and mechanical thrombectomy using gadolinium-based contrast for cerebral DSA in a patient with a history of anaphylaxis to iodinated contrast agents (ICs).

CASE REPORT

A 72-year-old man developed left ventricle assist device thrombus while on anticoagulation. During hospitalization he suffered right middle cerebral artery occlusion with a National Institutes of Health stroke scale score of 10. He had a history of anaphylaxis and the advanced directives revealed do not resuscitate/do not intubate status. We performed an emergent DSA as part of thrombectomy procedure using gadolinium-based contrast mixed in 1:1 proportion with normal saline. The images obtained were of adequate quality and the patient underwent successful thrombectomy with modified thrombolysis in cerebral infarction 2B recanalization.

CONCLUSION

Gadolinium-based contrast agents could be effective alternatives for cerebral DSA in patients undergoing mechanical thrombectomy for AIS who have a history of anaphylactic reaction to ICs.

Mono-Energy Coronary Angiography with a Compact Synchrotron Source

X-ray coronary angiography is an invaluable tool for the diagnosis of coronary artery disease. However, the use of iodine-based contrast media can be contraindicated for patients who present with chronic renal insufficiency or with severe iodine allergy. These patients could benefit from a reduced contrast agent concentration, possibly achieved through application of a mono-energetic x-ray beam. While large-scale synchrotrons are impractical for daily clinical use, the technology of compact synchrotron sources strongly advanced during the last decade. Here we present a quantitative analysis of the benefits a compact synchrotron source can offer in coronary angiography. Simulated projection data from quasi-mono-energetic and conventional x-ray tube spectra is used for a CNR comparison. Results show that compact synchrotron spectra would allow for a significant reduction of contrast media. Experimentally, we demonstrate the feasibility of coronary angiography at the Munich Compact Light Source, the first commercial installation of a compact synchrotron source.

Successful transfemoral aortic Edwards(®) SAPIEN(®) bioprosthesis implantation without using iodinated contrast media in a woman with severe allergy to contrast agent

Severe anaphylactoid reaction after the use of iodinated contrast media are rare but can contraindicate the use of contrast agent. It was the case of a 53-year-old woman suffering from symptomatic severe aortic stenosis, recused for cardiac surgery because of deleterious effects of chest-wall irradiation, with porcelain aorta. We decided to implant a 23-mm Edwards(®) SAPIEN(®) transcatheter aortic valve via a femoral route without using any contrast media. The implantation was successful after surgical approach of the femoral artery, transesophageal echocardiography guiding, and localization of native leaflets and coronary trunk with catheters. Immediate and one month post-interventional follow-up was favorable and echocardiography showed a good functioning of the aortic bioprosthesis. Although conventional angiography is the best way to visualize the good positioning of the valve before deployment, our case suggests that, in special situations, transfemoral implantation of an Edwards(®) SAPIEN(®) aortic bioprosthesis is feasible without any contrast injection.

Clinically useful dilution factors for iodine and gadolinium contrast material: an animal model of pediatric digital subtraction angiography using state-of-the-art flat-panel detectors

BACKGROUND

Iodinated and gadolinium contrast agents pose some risk for certain pediatric patients, including allergic-like reactions, contrast-induced nephropathy (CIN) and nephrogenic systemic fibrosis (NSF). Digital flat-panel detectors enhance image quality during angiography and might allow use of more dilute contrast material to decrease risk of complications that might be dose-dependent, such as CIN and NSF.

OBJECTIVE

To assess the maximum dilution factors for iodine- and gadolinium-based contrast agents suitable for vascular imaging with fluoroscopy and digital subtraction angiography (DSA) on digital flat-panel detectors in an animal model.

MATERIALS AND METHODS

We performed selective catheterization of the abdominal aorta, renal artery and common carotid artery on a rabbit. In each vessel we performed fluoroscopy and DSA during contrast material injection using iodinated and gadolinium contrast material at 100%, 80%, 50%, 33% and 20% dilutions. An image quality score (0 to 3) was assigned by each of eight evaluators. Intracorrelation coefficient, paired t-test, one-way repeated analysis of variance, Spearman correlation and receiver operating characteristic curve analysis were applied to the data.

RESULTS

Overall the image quality scores correlated linearly with dilution levels. For iodinated contrast material, the optimum cut-off level for DSA when a score of at least 2 is acceptable is above 33%; it is above 50% when a score of 3 is necessary. For gadolinium contrast material, the optimum cut-off for DSA images is above 50% when a score of at least 2 is acceptable and above 80% when a score of 3 is necessary.

CONCLUSION

Knowledge of the relationship between image quality and contrast material dilution might allow a decrease in overall contrast load while maintaining appropriate image quality when using digital flat-panel detectors.

Determination of infarct size in ex vivo swine hearts by multidetector computed tomography using gadolinium as contrast medium

OBJECTIVE

To demonstrate the feasibility of using multidetector computed tomography with gadolinium contrast (Gd-MDCT) for the quantification of myocardial infarct (MI).

MATERIALS AND METHODS

MI was induced in male swine (n = 6). One week later, the animals received 0.2-mmol/kg gadopentetate dimeglumine and were sacrificed. On the excised hearts, Gd-MDCT with several tube voltages (80, 120, and 140 kV), late gadolinium enhancement MRI (LGE-MRI), and triphenyl-tetrazolium-chloride staining were then conducted. We used a 2-SD threshold for the CT images and several threshold limits (2, 3, 4, 5, 6 SD, and full width at half-maximum [FWHM]) for the LGE-MRI images to delineate the infarct area. Total infarct volume and infarct fraction of each heart were calculated.

RESULTS

MI size measured by MDCT at 140 kV showed good correlation with the reference triphenyl-tetrazolium-chloride value. Applying an 80-kV tube voltage, however, significantly underestimated MI size. In our study, the LGE-MRI method, using the 6-SD threshold, provided the most accurate determination of MI size. LGE-MRI, using the 2- and 3-SD threshold limits, significantly overestimated infarct size.

CONCLUSIONS

The Gd-MDCT technique has been found suitable for the evaluation of MI in an ex vivo experimental setting. Gd-MDCT has the ability to detect MI even at low kV settings, but accuracy is limited by a high image noise because of reduced photon flux.

Intravascular ultrasound-assisted coronary sinus lead implant in patient with contrast anaphylaxis

Ultrasound imaging has been used in a range of cardiac interventions. We describe the use of intravascular ultrasound to assist in coronary sinus lead implantation in a patient where contrast venography was contraindicated.

Clinical pharmacology, uses, and adverse reactions of iodinated contrast agents: a primer for the non-radiologist

Iodinated contrast agents have been in use since the 1950s to facilitate radiographic imaging modalities. Physicians in almost all specialties will either administer these agents or care for patients who have received these drugs. Different iodinated contrast agents vary greatly in their properties, uses, and toxic effects. Therefore, clinicians should be at least superficially familiar with the clinical pharmacology, administration, risks, and adverse effects associated with iodinated contrast agents. This primer offers the non-radiologist physician the opportunity to gain insight into the use of this class of drugs.

The use of gadolinium in patients with contrast allergy or renal failure requiring coronary angiography, coronary intervention, or vascular procedure

Coronary artery angiography remains an important procedure for the assessment of coronary arteries. It requires injection of iodinated contrast for the opacification of coronary arteries. Severe allergy to iodine contrast and renal insufficiency are two main problems with iodine-based contrast media. Gadolinium (Gd) has different chemical structure with no cross reactivity with iodine-based contrast media in patients with iodine allergy. The use of Gd is commonly used in contrast-enhanced magnetic resonance imaging for image enhancement, making it a potential alternative in patients in whom iodine is contraindicated. The aim of this manuscript is to review the available literature on the use of Gd in patients with contraindication to iodine contrast due to allergy or in patients with severe renal failure requiring coronary or vascular procedures.