Immediate and late adverse reactions in coronary angiography. A comparison between iodixanol and ioxaglate

Trends in contrast media research the last 100 years

This review focuses on the trends in contrast media (CM) research published in Acta Radiologica during the last 100 years, since the first edition in 1921. The main topics covered are the developments of iodine- and gadolinium-based CM. Other topics include manganese-based CM for magnetic resonance imaging (MRI) and barium for the investigation of the alimentary tract. From a historic point of view, special CM for use in cholegraphy and myelography are addressed in the review. Today, these imaging procedures are obsolete due to the development of computed tomography, MRI, and ultrasound. The historical use of radioactive thorium-based CM for angiography is also addressed. Furthermore, publications on adverse reactions to CM are reviewed.

Fixed drug eruption induced by an iodinated non-ionic X-ray contrast medium: a practical approach to identify the causative agent and to prevent its recurrence

We describe the case of a 61-year-old physician who developed a fixed drug eruption (FDE) after i.v. administration of a non-ionic monomeric iodinated X-ray contrast medium (CM) (iopromide). During CM injection, a sensation of heat occurred, which was most intense in the right inguinal region. Four hours later, the FDE arose with a red macule of approximately 2 cm in diameter covering a dermal infiltration in the right inguinal region, and enlarged up to a final size of 15 x 8 cm, accompanied by a burning sensation. The patient's history revealed a similar reaction in the same localization and of the same clinical appearance after CM injection 1 year before. Patch testing 4 months later revealed positive reactions to iomeprol and iohexol. Iopamidol injection for another CT examination 23 months later was well tolerated. Based on these results, we suggest patch testing after CM-induced FDE, which could help to select a CM for future CT examinations. Late onset of adverse CM reactions may manifest as FDE. Patch testing within the previous skin reaction area is the diagnostic tool that should be used to confirm the suspected agent, possible cross-reacting agents and well-tolerated agents.

A practical guide to diagnose lesser-known immediate and delayed contrast media-induced adverse cutaneous reactions

The terms "immediate" and "delayed" adverse reactions induced by contrast media (CM) refer to the reactions' onset but do not provide substantial information concerning the clinical manifestation, the potential risk factors, the treatment modalities, or prevention. Because a variety of different reactions caused by different pathophysiological mechanisms may arise immediately or be delayed after CM injection, and because these need different management, the aim of the present paper is to present the clinical features and to exactly characterize lesser-known cutaneous reactions. A thorough knowledge of the clinical features, their adequate treatment, and, possibly, the subsequent diagnostic procedure for preventing recurrence after reexposure to CM would improve patient management.

Delayed adverse reactions to iodinated radiographic contrast media after coronary angiography: a search for possible risk factors

OBJECTIVE

The incidence of and risk factors for delayed adverse events (DAEs) that appear from 1 h to 7 days after injection of radiographic contrast media were investigated in patients who had undergone coronary angiography (CAG).

METHODS

DAEs were monitored by questionnaire in 155 patients who received iomeprol. Isosorbide dinitrate was injected in every case. Risk factors for DAEs were analysed by a logistic regression model.

RESULTS

Of 118 patients who returned questionnaires, 54 complained of DAEs, although no severe or fatal reactions occurred. Erythema, rash and nausea were frequent events. Female gender, total dose of isosorbide dinitrate <2 mg, and execution of acetylcholine provocation test were found to be the major risk factors, and the incidence of DAEs increased as the number of risk factors increased.

CONCLUSION

Care should be taken when CAG is performed on female patients who undergo acetylcholine provocation tests and receive low-dose nitric oxide donor injections.

Comparative tolerability of contrast media used for coronary interventions

Radiographic contrast media (CM) are necessary to provide x-ray absorption of the bloodstream; all other observed effects need to be regarded as adverse. Four types of CM are currently used in diagnostic and interventional cardiology: ionic high-osmolar CM (HOCM), either ionic or non-ionic low-osmolar CM (LOCM), and non-ionic iso-osmolar CM (IOCM). Focusing on the potential cardiovascular effects caused by the CM, there is a clear difference between HOCM and the LOCM or IOCM. HOCM have a poorer profile due to a higher incidence of hypotension and electrophysiological effects. To prevent contrast-induced nephropathy, HOCM should be avoided and patients should receive the minimal dose of LOCM or IOCM with intravenous hydration before and after the procedure. Clinical hyperthyroidism has been detected after CM use, but the condition appears, ultimately, to be self-limited and to occur mainly in elderly patients. When assessing the need for a CM in terms of improved patient safety, preventing serious complications should be the major factor determining the choice. CM should not be selected on the basis of minor adverse effects since these are, ultimately, of low clinical relevance. Thrombotic events, in contrast, carry a high clinical relevance and we consider that these should be the main issue governing current choice. Ionic LOCM appear to have better profile than other CM with respect to interaction with platelet function and coagulation. In relation to thrombotic events in randomised clinical studies, ionic CM have been associated, mainly, with favourable and some neutral results compared with non-ionic agents. Only one trial indicated a more pronounced antithrombotic effect of the non-ionic IOCM relative to the ionic LOCM. The antithrombotic advantages of ionic over non-ionic LOCM are, in part, balanced by a greater frequency of minor adverse effects such as nausea, vomiting or cutaneous rashes. A matter of concern is the delayed adverse effects observed with non-ionic IOCM. However, severe and life-threatening reactions are exceptional and there are probably no significant differences between IOCM and LOCM whether ionic or non-ionic. However, in patients with known allergies, non-ionic CM are to be recommended. On the basis of the available pre-clinical and clinical data, the ionic LOCM or the non-ionic IOCM are the agents to be recommended in percutaneous coronary interventions because of their antithrombotic advantages over non-ionic LOCM.

Early and late reactions after the use of iopamidol 340, ioxaglate 320, and iodixanol 320 in cardiac catheterization

BACKGROUND

Although modern contrast agents have tolerability superior to older agents, significant differences remain between the agents currently in use.

METHODS

To investigate the incidence of early (<24 hours) and late (>24 hours to 7 days) reactions to 3 contrast agents commonly used in cardiac catheterization, we performed a randomized, prospective, double-blind trial in which 2001 patients received one of the following agents: iopamidol 340, a nonionic monomer; ioxaglate 320, an ionic dimer; and iodixanol 320, a nonionic dimer. Possible reactions to contrast were recorded during the hospital admission and after discharge by means of a questionnaire, telephone follow-up, or both.

RESULTS

Early reactions occurred in 22.2% of those receiving ioxaglate, 7.6% of those receiving iodixanol, and 8.8% of those receiving iopamidol (P <.0001). Late skin reactions occurred in 12.2% of those receiving iodixanol, 4.3% of those receiving ioxaglate, and 4.2% of those receiving iopamidol (P <.0001).

CONCLUSIONS

The early side effect profile of certain ionic contrast agents suggests that these agents should no longer be used routinely in cardiac catheterization. The use of nonionic agents, however, is associated with late skin reactions, but there are notable differences between the monomeric and dimeric compounds. Although the skin reactions are generally benign, this is not always the case. Patients should be advised accordingly.

A comparison of the efficacy and safety of ioxaglate and iobitridol in renal angioplasty

PURPOSE

To compare ioxaglate and iobitridol for percutaneous transluminal renal angioplasty (PTRA) as regards thromboembolic complications, the quality of diagnosis, and renal and general safety.

METHODS

One hundred and eighty-nine patients were prospectively studied, 98 of whom received ioxaglate, and 91, iobitridol. Twenty-two were secondarily excluded from the evaluation of thromboembolic complications as they did not undergo PTRA.

RESULTS

Two hundred and two PTRAs were performed. The total volumes of contrast medium administered and the procedure durations were the same for each patient. In the ioxaglate group, four dissections (3 stents), one occlusive dissection, and two spasms occurred; in the iobitridol group, there were three dissections (all stented), one occlusive dissection (stented), and two spasms. The final angiograms showed four renal infarctions with ioxaglate (2 of which were in patients who were not anticoagulated), two with iobitridol. No significant difference was seen in the incidence of thromboembolic complications when the PTRA was performed after anticoagulation (n = 150; 3.9% vs 4%, p = 0.78); in the whole population, thromboembolic complications were more frequent in the ioxaglate group but the difference was not significant (5.7% vs 3.7%, p = 0.74). The quality of the diagnosis and the general and renal safety were the same in the two groups.

CONCLUSION

Regarding the clotting phenomenon, we recorded as many thromboembolic complications with ioxaglate as with iobitridol.