The Controversy of Contrast-Induced Nephropathy With Intravenous Contrast: What Is the Risk?

Contrast-induced nephropathy (CIN) has long been observed in both experimental and clinical studies. However, recent observational studies have questioned the prevalence and severity of CIN following intravenous contrast exposure. Initial studies of acute kidney injury following intravenous contrast were limited by the absence of control groups or contained control groups that did not adjust for additional acute kidney injury risk factors, including prevalent chronic kidney disease, as well as accepted prophylactic strategies. More contemporary use of propensity score-adjusted models have attempted to minimize the risk for selection bias, although bias cannot be completely eliminated without a prospective randomized trial. Based on existing data, we recommend the following CIN risk classification: patients with estimated glomerular filtration rates (eGFRs) ≥ 45mL/min/1.73m2 are at negligible risk for CIN, while patients with eGFRs<30mL/min/1.73m2 are at high risk for CIN. Patients with eGFRs between 30 and 44mL/min/1.73m2 are at an intermediate risk for CIN unless diabetes mellitus is present, which would further increase the risk. In all patients at any increased risk for CIN, the risk for CIN needs to be balanced by the risk of not performing an intravenous contrast-enhanced study.

Patient discomfort associated with the use of intra-arterial iodinated contrast media: a meta-analysis of comparative randomized controlled trials.

BACKGROUND: Discomfort characterized by pain and warmth are common adverse effects associated with the use of intra-arterial iodinated contrast media (CM). The objective of this review was to pool patient-reported outcomes available from head-to-head randomized controlled trials (RCTs) and to compare the discomfort rates associated with iso-osmolar contrast media (IOCM; i.e., iodixanol) to those reported with various low-osmolar contrast media (LOCM). METHODS: A review of the literature published between 1990 and 2009 available through Medline, Medline Preprints, Embase, Biological Abstracts, BioBase, Cab Abstracts, International Pharmaceutical Abstracts, Life Sciences Collection, Inside Conferences, Energy Database, Engineering Index and Technology Collection was performed to compare rates of discomfort associated with the use of the IOCM (iodixanol) vs. various LOCM agents in head-to-head RCTs. All trials with a Jadad score ≥2 that reported patient discomfort data following intra-arterial administration of CM were reviewed, coded, and extracted. RESULTS: A total of 22 RCTs (n = 8087) were included. Overall discomfort (regardless of severity) was significantly different between patients receiving IOCM and various LOCMs (risk difference [RD] -0.049; 95% confidence interval [CI]: -0.076, -0.021; p = 0.001). IOCM was favored over all LOCMs combined with a summary RD value of -0.188 (95% CI: -0.265, -0.112; p < 0.001) for incidence of pain, regardless of severity. A greater reduction in the magnitude of pain was observed with IOCM (iodixanol), particularly with selective limb and carotid/intracerebral procedures. Similarly, the meta-analysis of warmth sensation, regardless of severity, favored IOCM over LOCMs with an RD of -0.043 (95% CI: -0.074, -0.011; p = 0.008). A positive linear relationship was observed between the discomfort effect size and age and a negative relationship with increasing proportion of women. The opposite trends were observed with warmth sensation. CONCLUSIONS: IOCM was associated with less frequent and severe patient discomfort during intra-arterial administration. These data support differences in osmolality as a possible determinant of CM discomfort.

Comparison of intravenous alteplase with a combined intravenous-endovascular approach in patients with stroke and confirmed arterial occlusion (RECANALISE study): a prospective cohort study.

BACKGROUND: The efficacy of intravenous (IV) alteplase is restricted by the speed of recanalisation and the site of the occlusion. The aim of this study was to ascertain the effect of a combined IV-endovascular approach (intra-arterial alteplase and, if required, additional thrombectomy) in patients with stroke due to arterial occlusion. METHODS: We compared recanalisation rates, neurological improvement at 24 h, and functional outcome at 3 months between two periods (February, 2002, to March, 2007, vs April, 2007, to October, 2008) in patients in a prospective registry who were treated with different regimens of alteplase within 3 h of symptom onset. Patients with confirmed occlusion who were treated before April, 2007, were treated with IV alteplase; after April, 2007, patients were treated with a systematic IV-endovascular approach. Analysis was by intention to treat. FINDINGS: 46 (87%) of 53 patients treated with the IV-endovascular approach achieved recanalisation versus 56 (52%) of 107 patients in the IV group (adjusted relative risk [RR] 1.49, 95% CI 1.21-1.84; p=0.0002). Early neurological improvement (NIHSS score of 0 or 1 or an improvement of 4 points or more at 24 h) occurred in 32 (60%) patients in the IV-endovascular group and 42 (39%) patients in the IV group (adjusted RR 1.36, 0.97-1.91; p=0.07). Favourable outcome (mRS of 0-2 at 90 days) occurred in 30 (57%) patients in the IV-endovascular group and 47 (44%) patients in the IV group (adjusted RR 1.16, 0.85-1.58; p=0.35). The mortality rate at 90 days was 17% in both groups, and symptomatic intracranial haemorrhage was reported in five (9%) patients in the IV-endovascular group and in 12 (11%) patients in the IV group. Better clinical outcome was associated with recanalisation in both groups and with time to recanalisation in the IV-endovascular group. INTERPRETATION: An IV-endovascular approach is associated with higher recanalisation rates than is IV alteplase in patients with stroke and confirmed arterial occlusion. In patients treated with an IV-endovascular approach, a shorter time from symptom onset to recanalisation is associated with better clinical outcomes.

Sonographic follow-up of the access site after arterial angiography: Impact on the detected complication rate.

OBJECTIVE: This study prospectively evaluated the impact of sonographic follow-up on the detection rate of access site complications in arterial angiography and determined parameters associated with major complications of the access site after arterial angiography. METHODS: Sonographic follow-up (mean +/- SD, 1.46 +/- 1.11 days after) of the access site (transfemoral, n = 896; and transbrachial, n = 44) was obtained prospectively in 940 arterial angiographies and included evaluations for hematoma, pseudoaneurysm, arteriovenous fistula, arterial dissection, and venous/arterial thrombosis. Clotting parameters, anticoagulation therapy, and several patient and procedure characteristics were recorded. Univariate and multivariate logistic regression analyses were performed. RESULTS: Sonography depicted major access site complications in 39 of 940 angiographies (4.2%). Major access site complications (major local hematoma, n = 13; retroperitoneal hematoma, n = 1; pseudoaneurysm, n = 18; arterial dissection, n = 1; arteriovenous fistula, n = 1; arterial thrombosis, n = 2; and venous thrombosis, n = 3) required conservative (n = 32 [3.4%]) or surgical (n = 7 [0.7%]) treatment. Independent factors significantly associated with major access site complications were age older than 60.33 years and sheath size greater than 5F (P < .05). CONCLUSIONS: Major access site complications were detected in 4.2% of cases and were significantly associated with age and sheath size.

Adjuvant intraarterial injection of 131I-labeled lipiodol after resection of hepatocellular carcinoma: progress report of a case-control study with a 5-year minimal follow-up.

UNLABELLED: Recurrences after resection of hepatocellular carcinoma are frequent. A single postoperative injection of (131)I-labeled lipiodol in the hepatic artery was shown in 1999 by Lau and colleagues to be an effective adjuvant treatment, and those results were strengthened by our experience with a case-control study, reported in 2003. The goal of this paper is to update the 2003 results for a minimal follow-up of 5 y. METHODS: Between January 1999 and September 2001, 38 patients were given an adjuvant postoperative intraarterial injection of (131)I-lipiodol and were matched (for Okuda group and tumor size) with 38 patients who had undergone resection between January 1997 and January 1999 without postoperative treatment. The 2 groups were similar. RESULTS: There were 28 recurrences in the control group and 22 in the (131)I-lipiodol group (not statistically significant), and the mean time of recurrence was 21 and 26.5 mo, respectively, after surgery (statistically significant). The number of recurrences was lower in the first 2 y in the (131)I-lipiodol group (statistically significant). Disease-free survival was better (P < 0.03) in the (131)I-lipiodol group than in the control group (2-, 3-, and 5-y rates [+/-95% confidence interval] of 77% +/- 7%, 63% +/- 8%, and 42% +/- 8.5%, respectively, for the (131)I-lipiodol group vs. 47% +/- 8%, 34% +/- 8%, and 27% +/- 8%, respectively, for the control group). Overall survival did not differ between the 2 groups (P = 0.09), even though there was a trend toward better survival in the (131)I-lipiodol group (2-, 3-, and 5-y rates of 76% +/- 7%, 68% +/- 7.5%, and 51% +/- 9%, respectively, vs. 68% +/- 7.5%, 53% +/- 8%, and 39% +/- 8%, respectively, in the control group). CONCLUSION: With a longer follow-up, the results of this retrospective case-control study still favor a single postoperative injection of (131)I-lipiodol. These retrospective findings point out the need for a large-scale, prospective, randomized study.

Transbrachial angiography: an effective and safe approach.

BACKGROUND: Description of the technique of the transbrachial catheter diagnostics, retrospective evaluation of the technical success rate and the complications. PATIENTS AND METHODS: In a period of 8 years the transbrachial approach was used in 2555 patients, 1734 men and 821 women with an average age of 62.9 years. The investigation was done with outpatients in approximately 90% of the cases. Usually, the preferred arm was not punctured. For the diagnostics F4 and F5-catheter sheaths and selective catheter and/or plain catheters were used. RESULTS: 12 times (0.47%) the investigation did not succeed technically. The image quality of the vascular representations was diagnostically sufficient. The total complication rate amounted to 0.47%. The following complications appeared: four dissections in the site of puncture, one embolism into arteries at the forearm, three transitory ischemic attacks, four haematoma at the site of puncture. CONCLUSIONS: The transbrachial catheter diagnostics is a little invasive, efficient and low-risk method, which is practicable in out-patients.

[Conventional local intra-arterial fibrinolysis, spray lysis and mechanically accelerated fibrinolysis. An assessment of their position in the spectrum of angioplasty technics]. / Konventionelle lokale intraarterielle Fibrinolyse, Spraylyse und mechanisch akzelerierte Fibrinolyse. Standortbestimmung im Spektrum der Angioplastietechniken.

Intra-arterial local fibrinolysis was performed in 72 patients (51 men, 21 women, mean age 66.8 years) during the course of 78 angioplasties. 11.1% were stage IIa (Fontaine), 38.9% were stage II b, 27.8% were stage III and 22.2% were stage IV. The methods used were conventional fibrinolysis (15.4%), spray lysis (47.4%) and mechanically accelerated fibrinolysis (37.2%). In 66.7% the urokinase dose was < 600,000 I.U., in 17.9% it was > 1,000,000 I.U. Additional balloon dilatation was performed in 72 cases, percutaneous aspiration of thrombo-embolic material in 41 cases and stent implantation in 7 cases. Angiographically the procedure was successful in 90.7%; the Doppler index rose from 0.47 +/- 0.27 to 0.85 +/- 0.3 (p < 0.001). At discharge, staging was: I = 38.9%, IIa = 38.9%, IIb = 5.6%, III = 1.4%, IV = 15.3%. There were no systemic bleeding complications. In 5.1%, complications had to be treated surgically.