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Contrast Agent in Angiography M. Fathi ;Bs Medical Imaging- TUMS October 2011- Kerman
Selection of contrast media
Aspects of importance with regard to CIN include:  <ul><li>Route of administration  </li></ul><ul><li>Volume of CM </li></...
Route of administration  <ul><li>Intra-arterial:  DSA </li></ul><ul><li>Intravenous:  Radiography, CT, MRI   </li></ul>
Intra-arterial  administration delivers a higher concentration of CM to the kidney is true only for studies performed abov...
<ul><li>coronary angiography </li></ul><ul><li>peripheral DSA </li></ul>
Greater volume of CM often administered in  intra-arterial  studies, particularly when diagnostic studies are combined wit...
VOLUME OF CM <ul><li>Maximum volume of contrast agent to be administered in each patient:  </li></ul><ul><li>(5 x body wei...
Specific of the CM <ul><li>HOCM  1500–2000 mOsm/kg </li></ul><ul><li>IOCM  280–290 mOsm/kg </li></ul><ul><li>LOCM  600–100...
<ul><li>Specific of the CM </li></ul><ul><li>Patient  </li></ul>Meta-regression analysis of the available data on the inci...
Witch one? <ul><li>Iodinated LOCM, most of which are nonionic agents, are associated with less discomfort and have a lower...
Contrast Media Specifications ACR Manual on Contrast Media Product Chemical structure % Salt Concentration % Iodine Concen...
Contrast Media Specifications ACR Manual on Contrast Media Brand Names: Iopromide = Ultravist Iohexol = Ominipaque Iodixan...
 
Ideal CM in Angiography <ul><li>Water soluble </li></ul><ul><li>Chemical and heat stable  </li></ul><ul><li>Biologically i...
CM in Diagnostic Angiography
Organ Base Choice  <ul><li>Cerebral Angiography </li></ul><ul><li>Renal Angiography </li></ul><ul><li>Extremity Angiograph...
Cerebral Angiography <ul><li>Indications:  </li></ul><ul><li>Atherosclerotic  </li></ul><ul><li>Dissection </li></ul><ul><...
<ul><li>Contrast Agent  </li></ul><ul><li>Injection Technique  </li></ul><ul><li>Viscosity  </li></ul><ul><li>Osmolality <...
Renal Angiography <ul><li>Indications: </li></ul><ul><li>Arterial Stenosis  </li></ul><ul><li>Transplant (Donor)  </li></u...
<ul><li>Contrast Agent  </li></ul><ul><li>Injection Technique  </li></ul><ul><li>Viscosity  </li></ul><ul><li>Osmolality <...
Upper Extremity Angiography <ul><li>Indications:  </li></ul><ul><li>Trauma </li></ul><ul><li>Ischemia </li></ul><ul><li>AV...
<ul><li>Contrast Agent  </li></ul><ul><li>Injection Technique  </li></ul><ul><li>Viscosity  </li></ul><ul><li>Osmolality <...
Lower Extremity Angiography <ul><li>Indications:  </li></ul><ul><li>Trauma </li></ul><ul><li>Ischemia </li></ul><ul><li>AV...
<ul><li>Contrast Agent  </li></ul><ul><li>Injection Technique  </li></ul><ul><li>Viscosity  </li></ul><ul><li>Osmolality <...
Catheter
Major Adverse Effects in CM: <ul><li>Systemic Effects </li></ul><ul><li>Renal Effects </li></ul><ul><li>Cardiac Effects </...
CIN <ul><li>In most studies, an increase in serum creatinine of at least 0.5 mg/dL or 25% above baseline during the 48- to...
Serum Creatinine Measurement <ul><li>History of “kidney disease” as an adult, including tumor and transplant. </li></ul><u...
Gadolinium as an Alternative Agent <ul><li>In patients with renal insufficiency or severe allergy to iodinated contrast me...
Hydration <ul><li>The incidence of CIN was decreased by hydration with 0.45% saline or 0.9% saline administered at a rate ...
 
www.newirsa.org <ul><li>سایت انجمن علوم پرتونگاری ایران </li></ul>
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Contrast Agents in Angiography

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  • I thought Gadolinium was a contraindicated to CKD because it causes Nephrogenic Systemic Fibrosis. Please comment.
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  • its highly superb
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  • Hi Mr Fathi.
    Your presentation is excellent
    If possible، send me.
    my email address: fatemeshabani88@yahoo.com
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  • Hi Dear Fathi, Im so interested with your perfect presentation.
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Contrast Agents in Angiography

  1. 1. Contrast Agent in Angiography M. Fathi ;Bs Medical Imaging- TUMS October 2011- Kerman
  2. 2. Selection of contrast media
  3. 3. Aspects of importance with regard to CIN include: <ul><li>Route of administration </li></ul><ul><li>Volume of CM </li></ul><ul><li>Specific of the CM </li></ul><ul><ul><ul><ul><li>R. Solomon- International Society of Nephrology </li></ul></ul></ul></ul>
  4. 4. Route of administration <ul><li>Intra-arterial: DSA </li></ul><ul><li>Intravenous: Radiography, CT, MRI </li></ul>
  5. 5. Intra-arterial administration delivers a higher concentration of CM to the kidney is true only for studies performed above the renal arteries.
  6. 6. <ul><li>coronary angiography </li></ul><ul><li>peripheral DSA </li></ul>
  7. 7. Greater volume of CM often administered in intra-arterial studies, particularly when diagnostic studies are combined with interventions.
  8. 8. VOLUME OF CM <ul><li>Maximum volume of contrast agent to be administered in each patient: </li></ul><ul><li>(5 x body weight in kg) divided by serum creatinine (mg/dl) </li></ul><ul><li>Maximum volume is: 300 ml. </li></ul><ul><li>Cigarroa et al- Am J Med </li></ul>
  9. 9. Specific of the CM <ul><li>HOCM 1500–2000 mOsm/kg </li></ul><ul><li>IOCM 280–290 mOsm/kg </li></ul><ul><li>LOCM 600–1000 mOsm/kg </li></ul>
  10. 10. <ul><li>Specific of the CM </li></ul><ul><li>Patient </li></ul>Meta-regression analysis of the available data on the incidence of CIN following intra-arterial administration of low- or iso-osmolality CM suggests that the osmolality of the contrast agent alone does not account for the differences in the adverse reactions. <ul><li>Chemical Structure (Brand) </li></ul><ul><li>% Salt Concentration </li></ul><ul><li>% Iodine Concentration </li></ul><ul><li>Viscosity </li></ul><ul><li>Osmolality </li></ul><ul><li>Age years </li></ul><ul><li>Gender </li></ul><ul><li>Baseline SCr mg/dL </li></ul><ul><li>Volume of CM </li></ul>
  11. 11. Witch one? <ul><li>Iodinated LOCM, most of which are nonionic agents, are associated with less discomfort and have a lower incidence of adverse effects. </li></ul><ul><li>Iso-osmolar iodinated contrast media (IOCM) are also currently available. At this time there are only preliminary data on this agent, so indications for its use (instead of LOCM) have not been clearly defined. </li></ul><ul><ul><ul><ul><ul><li>ACR PRACTICE GUIDELINE FOR THE USE OF INTRAVASCULAR CONTRAST MEDIA </li></ul></ul></ul></ul></ul>
  12. 12. Contrast Media Specifications ACR Manual on Contrast Media Product Chemical structure % Salt Concentration % Iodine Concentration Iodine + (mg/ml) Viscosity 37 (cps) Osmolality (mOsm/kg) Iohexol 240 Nonionic None 24 240 3.4 520 Iopromide 240 Nonionic <0.1 24 240 2.8 483 Iohexol 300 Nonionic None 30 300 6.3 672 Iopromide 300 Nonionic <0.1 30 300 4.9 607 Iohexol 350 Nonionic None 35 350 10.4 844 Iopromide 370 Nonionic None 37 370 10.0 774
  13. 13. Contrast Media Specifications ACR Manual on Contrast Media Brand Names: Iopromide = Ultravist Iohexol = Ominipaque Iodixanol = Visiopaque Product Chemical structure % Salt Concentration % Iodine Concentration Iodine + (mg/ml) Viscosity 37 (cps) Osmolality (mOsm/kg) Iodixanol 270 Nonionic None 27 270 6.3 290 Iopromide 320 Nonionic None 32 320 11.8 290
  14. 15. Ideal CM in Angiography <ul><li>Water soluble </li></ul><ul><li>Chemical and heat stable </li></ul><ul><li>Biologically inert (no antigenic) </li></ul><ul><li>Low viscosity </li></ul><ul><li>Low or Iso-osmolar, excreted </li></ul><ul><li>Selectively through the kidney </li></ul><ul><li>Safe </li></ul><ul><li>Inexpensive </li></ul>
  15. 16. CM in Diagnostic Angiography
  16. 17. Organ Base Choice <ul><li>Cerebral Angiography </li></ul><ul><li>Renal Angiography </li></ul><ul><li>Extremity Angiography </li></ul><ul><li>Interventional Angiography </li></ul><ul><li>Cardiac (Coronary) Angiography </li></ul><ul><li>Pulmonary Angiography </li></ul>
  17. 18. Cerebral Angiography <ul><li>Indications: </li></ul><ul><li>Atherosclerotic </li></ul><ul><li>Dissection </li></ul><ul><li>Tumor </li></ul><ul><li>Aneurysm </li></ul><ul><li>AVM </li></ul><ul><li>Stroke </li></ul>
  18. 19. <ul><li>Contrast Agent </li></ul><ul><li>Injection Technique </li></ul><ul><li>Viscosity </li></ul><ul><li>Osmolality </li></ul><ul><li>Concentration </li></ul><ul><li>Volume </li></ul><ul><li>Overall PSI: 180 </li></ul><ul><li>Injection Rate: </li></ul><ul><li>6 ml/s for Vertebral Artery </li></ul><ul><li>8 ml/s for Carotid Artery </li></ul><ul><li>Injection Volume: </li></ul><ul><li>10 ml for Vertebral Artery </li></ul><ul><li>12 ml for Carotid Artery </li></ul>
  19. 20. Renal Angiography <ul><li>Indications: </li></ul><ul><li>Arterial Stenosis </li></ul><ul><li>Transplant (Donor) </li></ul><ul><li>Fibro muscular Dysplasia </li></ul>
  20. 21. <ul><li>Contrast Agent </li></ul><ul><li>Injection Technique </li></ul><ul><li>Viscosity </li></ul><ul><li>Osmolality </li></ul><ul><li>Concentration </li></ul><ul><li>Volume </li></ul><ul><li>PSI: 300 </li></ul><ul><li>Injection Rate: </li></ul><ul><li>15 ml/s </li></ul><ul><li>Injection Volume: </li></ul><ul><li>20 ml </li></ul>
  21. 22. Upper Extremity Angiography <ul><li>Indications: </li></ul><ul><li>Trauma </li></ul><ul><li>Ischemia </li></ul><ul><li>AVM </li></ul><ul><li>Subclavian Steal Phenomenon… </li></ul>
  22. 23. <ul><li>Contrast Agent </li></ul><ul><li>Injection Technique </li></ul><ul><li>Viscosity </li></ul><ul><li>Osmolality </li></ul><ul><li>Concentration </li></ul><ul><li>Volume </li></ul><ul><li>PSI: 350 for Aortogram </li></ul><ul><li>PSI: 180 for Subclavian … </li></ul><ul><li>Injection Rate: </li></ul><ul><li>18 – 25 ml/s for Aortogram </li></ul><ul><li>7 ml/s for all </li></ul><ul><li>Injection Volume: </li></ul><ul><li>40 ml for Aortogram </li></ul><ul><li>15 ml for Arm </li></ul><ul><li>20 – 25 for Hand </li></ul>
  23. 24. Lower Extremity Angiography <ul><li>Indications: </li></ul><ul><li>Trauma </li></ul><ul><li>Ischemia </li></ul><ul><li>AVM </li></ul>
  24. 25. <ul><li>Contrast Agent </li></ul><ul><li>Injection Technique </li></ul><ul><li>Viscosity </li></ul><ul><li>Osmolality </li></ul><ul><li>Concentration </li></ul><ul><li>Volume </li></ul><ul><li>Overall PSI: 180- 300 </li></ul><ul><li>Injection Rate: </li></ul><ul><li>10 ml/s for Aortogram </li></ul><ul><li>12 ml/s for femur </li></ul><ul><li>15 ml/s for leg </li></ul><ul><li>20 - 25 ml/s for foot </li></ul><ul><li>Injection Volume: </li></ul><ul><li>15 ml for Aortogram </li></ul><ul><li>10 - 40 ml for selective </li></ul>
  25. 26. Catheter
  26. 27. Major Adverse Effects in CM: <ul><li>Systemic Effects </li></ul><ul><li>Renal Effects </li></ul><ul><li>Cardiac Effects </li></ul><ul><li>Vascular Effects </li></ul><ul><ul><ul><ul><ul><li>Michael a. Bettmann – AJR </li></ul></ul></ul></ul></ul>
  27. 28. CIN <ul><li>In most studies, an increase in serum creatinine of at least 0.5 mg/dL or 25% above baseline during the 48- to 72-hour period following contrast media exposure is considered clinically significant,5 although not all clinicians are in agreement. </li></ul><ul><li>In more severe cases, the serum creatinine may continue to rise for 5 to 10 days and, in rare cases, dialysis may be needed. </li></ul><ul><li>Incidence of CIN increases as serum creatinine levels increase: 0% at <1.5 mg/dL (normal); 50% to 75% at 1.6 to 4.5 mg/dL (moderate CIN); 90% to 100% at >4.5 mg/dL (severe CIN). </li></ul>
  28. 29. Serum Creatinine Measurement <ul><li>History of “kidney disease” as an adult, including tumor and transplant. </li></ul><ul><li>Diabetes treated with insulin </li></ul><ul><li>Prior renal surgery </li></ul><ul><li>Metformin or metformin-containing drug combinations. </li></ul><ul><li>Regular use of nephrotoxic medications, such as aminoglycosides. </li></ul><ul><li>Chronic or high dose use of non-steroidal anti-inflammatory drugs. </li></ul>
  29. 30. Gadolinium as an Alternative Agent <ul><li>In patients with renal insufficiency or severe allergy to iodinated contrast media, gadolinium can be considered as a substitute for use in angiography. </li></ul><ul><li>Gadolinium-DTPA at a concentration of 0.5 mmol/mL is equivalent to a 12.5% to 25% dilution of standard iodinated contrast material (eg, iohexol). </li></ul><ul><li>investigators who advocate the use of gadolinium during angiography in patients with renal insufficiency recommend that the total dose of gadolinium not exceed 0.3 to 0.4 mmol/kg body weight (about 40 to 50 mL for a 70-kg patient),50 which is adequate for manytypes of angiographic examinations. </li></ul>
  30. 31. Hydration <ul><li>The incidence of CIN was decreased by hydration with 0.45% saline or 0.9% saline administered at a rate of 100 ml/hr beginning 12 hours before and continuing 12 hours after angiography </li></ul>
  31. 33. www.newirsa.org <ul><li>سایت انجمن علوم پرتونگاری ایران </li></ul>

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