This document discusses contrast agents used in angiography and factors related to contrast-induced nephropathy (CIN). It notes that the route of contrast administration, volume administered, and properties of the specific contrast agent can influence CIN risk. Low-osmolar contrast agents are associated with less adverse effects than ionic agents. Hydration before and after the procedure can help reduce CIN incidence. Gadolinium may be considered as an alternative to iodinated contrast for patients at high risk of CIN.

1. Contrast Agent in Angiography M. Fathi ;Bs Medical Imaging- TUMS October 2011- Kerman

2. Selection of contrast media

3. Aspects of importance with regard to CIN include: Route of administration Volume of CM Specific of the CM R. Solomon- International Society of Nephrology

4. Route of administration Intra-arterial: DSA Intravenous: Radiography, CT, MRI

5. Intra-arterial administration delivers a higher concentration of CM to the kidney is true only for studies performed above the renal arteries.

6. coronary angiography peripheral DSA

7. Greater volume of CM often administered in intra-arterial studies, particularly when diagnostic studies are combined with interventions.

8. VOLUME OF CM Maximum volume of contrast agent to be administered in each patient: (5 x body weight in kg) divided by serum creatinine (mg/dl) Maximum volume is: 300 ml. Cigarroa et al- Am J Med

9. Specific of the CM HOCM 1500–2000 mOsm/kg IOCM 280–290 mOsm/kg LOCM 600–1000 mOsm/kg

10. Specific of the CM Patient 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. Chemical Structure (Brand) % Salt Concentration % Iodine Concentration Viscosity Osmolality Age years Gender Baseline SCr mg/dL Volume of CM

11. Witch one? Iodinated LOCM, most of which are nonionic agents, are associated with less discomfort and have a lower incidence of adverse effects. 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. ACR PRACTICE GUIDELINE FOR THE USE OF INTRAVASCULAR CONTRAST MEDIA

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. 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

15. Ideal CM in Angiography Water soluble Chemical and heat stable Biologically inert (no antigenic) Low viscosity Low or Iso-osmolar, excreted Selectively through the kidney Safe Inexpensive

16. CM in Diagnostic Angiography

17. Organ Base Choice Cerebral Angiography Renal Angiography Extremity Angiography Interventional Angiography Cardiac (Coronary) Angiography Pulmonary Angiography

18. Cerebral Angiography Indications: Atherosclerotic Dissection Tumor Aneurysm AVM Stroke

19. Contrast Agent Injection Technique Viscosity Osmolality Concentration Volume Overall PSI: 180 Injection Rate: 6 ml/s for Vertebral Artery 8 ml/s for Carotid Artery Injection Volume: 10 ml for Vertebral Artery 12 ml for Carotid Artery

20. Renal Angiography Indications: Arterial Stenosis Transplant (Donor) Fibro muscular Dysplasia

21. Contrast Agent Injection Technique Viscosity Osmolality Concentration Volume PSI: 300 Injection Rate: 15 ml/s Injection Volume: 20 ml

22. Upper Extremity Angiography Indications: Trauma Ischemia AVM Subclavian Steal Phenomenon…

23. Contrast Agent Injection Technique Viscosity Osmolality Concentration Volume PSI: 350 for Aortogram PSI: 180 for Subclavian … Injection Rate: 18 – 25 ml/s for Aortogram 7 ml/s for all Injection Volume: 40 ml for Aortogram 15 ml for Arm 20 – 25 for Hand

24. Lower Extremity Angiography Indications: Trauma Ischemia AVM

25. Contrast Agent Injection Technique Viscosity Osmolality Concentration Volume Overall PSI: 180- 300 Injection Rate: 10 ml/s for Aortogram 12 ml/s for femur 15 ml/s for leg 20 - 25 ml/s for foot Injection Volume: 15 ml for Aortogram 10 - 40 ml for selective

26. Catheter

27. Major Adverse Effects in CM: Systemic Effects Renal Effects Cardiac Effects Vascular Effects Michael a. Bettmann – AJR

28. CIN 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. In more severe cases, the serum creatinine may continue to rise for 5 to 10 days and, in rare cases, dialysis may be needed. 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).

29. Serum Creatinine Measurement History of “kidney disease” as an adult, including tumor and transplant. Diabetes treated with insulin Prior renal surgery Metformin or metformin-containing drug combinations. Regular use of nephrotoxic medications, such as aminoglycosides. Chronic or high dose use of non-steroidal anti-inflammatory drugs.

30. Gadolinium as an Alternative Agent In patients with renal insufficiency or severe allergy to iodinated contrast media, gadolinium can be considered as a substitute for use in angiography. 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). 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.

31. Hydration 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

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