'Gadolinium' as an Alternative to Iodinated Contrast Media for X-Ray Angiography in Patients With Severe Allergy

Abstract

-ray coronary angiography (CAG) is an indispensable examination technique for the diagnosis of coronary artery disease and for determination of therapeutic strategies. However, an anaphylactic reaction to the iodinated contrast media can be life-threatening. Gadolinium-based contrast media have been developed to improve the quality of magnetic resonance imaging (MRI) and are considered to be safer and less nephrotoxic than the iodinated agents. It has been recently reported that computed tomography (CT) and digital subtraction angiography (DSA) using gadolinium can provide images of largeand medium-sized vessels of acceptable quality in patients with allergy to iodinated media. 1-5 However, only a few studies of using gadolinium for CAG have been reported and only its safety in patients with renal insufficiency has been discussed. [6][7][8] We report successful CAG using gadodiamide hydrate (Gd DTPA-BMA; Omniscan ® Nycomed, Oslo. Norway) in 3 patients with allergy to iodinated contrast media. Written informed consent for the use of the contrast media was obtained from all patients. Case Reports Case 1A 70-year-old woman (52 kg) with a history of thyroidectomy for thyroid cancer and allergic reaction to iodinated contrast media was admitted to hospital after presenting with chest pain and dyspnea. Electrocardiography showed ST-segment elevation in leads V1-3 leads and T wave inversion in V2-4, and echocardiography showed hypokinesis in the apico-anteroseptal wall of the left ventricle. After sublingual administration of nitroglycerin, her symptoms Circulation Journal Vol. 69, April 2005 and the electrocardiographic findings improved. CAG was performed using 40 ml of undiluted Gd DTPA-BMA in a total of 7 injections because she had a previous, unspecified history of shock as a severe allergic reaction to treatment with an iodinated disinfectant. CAG revealed no significant stenoses in the major coronary arteries (Fig 1) and so we considered her anginal attack might be coronary arterial vasospasm in the left anterior descending artery. Case 2A 71-year-old man (68 kg) with gastric cancer and abdominal aortic aneurysm was admitted to hospital for gastric resection and artificial vessel replacement. He had a history of acute myocardial infarction at 63 years of age and an allergic reaction to an unspecified iodinated contrast media during abdominal CT performed when he was 60 years of age. 99m Tc-tetrofosmin myocardial scintigraphy on admission showed multivessel disease in his coronary arteries, so he underwent preoperative CAG using 40 ml of undiluted Gd DTPA-BMA in a total of 5 injections. Digital subtraction post-processing showed significant stenoses in the mid right coronary artery (segment 2: 75% stenosis), in the circumflex artery (segment 11: 75%, segment 13: 90%), and total occlusions in the distal right coronary artery (segment 4, postero-lateral branch) and the mid left anterior descending artery (segment 7) with contralateral collateral feedings (Fig 2). He underwent coronary artery bypass grafting be...

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“…As such, renal failure is a relative contraindication, as well as pregnancy and breastfeeding. [7][8][9][10] ] Generally, for tumors to grow more than 2 to 3 mm in size, they have to secrete proangiogenic factors. Higher grade tumors are usually associated with increased vascularity.…”

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“…20,21 The use of alternatives to iodinated contrast is another approach to preventing CIN. 8 It has been reported that CAG or PCI can be done with a gadolinium contrast agent; 22,23 this appears to be a feasible alternative method for patients with CRI.…”

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

“…When used in recommended doses, Gd has been shown to be safe, well-tolerated, and not nephro-toxic [31][32][33][34]. However, Gdbased agents have been associated with suboptimal but acceptable quality in angiography [31,32,35,36]. Specifically for cardiac procedures, Gd has rarely been used due to suboptimal image quality.…”

“…Specifically for cardiac procedures, Gd has rarely been used due to suboptimal image quality. Although some operators report low adverse event rates [36][37][38][39], others have reported the occurrence of significant ventricular arrhythmias during coronary angiography [40]. Although lacking the more definitive evidence-based on large-scale randomized controlled trials, current literature shows that Gd can be an alternative agent in selected patients with severe allergic reaction to iodine contrast.…”

“…In another smaller study by Ose et al [36], three patients with allergy to iodinated contrast media underwent coronary angiography using gadolinium as a contrast agent. The indications were recurrent chest pain, evaluation of perioperative risk of gastric cancer and abdominal aortic aneurysm, and evaluation of graft patency after coronary artery bypass surgery.…”