Use of indocyanine green dye for sentinel lymph node mapping in patients with endometrial cancer and a history of iodinated contrast allergy.

Objectives: Sentinel lymph node (SLN) mapping is a surgical technique with high accuracy in detecting metastases while limiting morbidity associated with full lymphadenectomy in endometrial cancer. Cervical injection of indocyanine green (ICG) dye is associated with very high SLN detection rates; however, iodinated contrast allergy has traditionally been viewed as a contraindication to ICG use. The objective of this study was to describe the use of ICG in a population of patients with iodinated contrast allergies undergoing surgical staging for endometrial cancer. Methods: IRB approval was obtained. All patients with clinically early-stage endometrial cancer who underwent minimally invasive surgical staging with SLN mapping with ICG at a single academic institution from 1/1/2017 to 12/31/2020 were identified retrospectively. Patients with reported iodinated contrast allergies prior to surgery were identified. Data were collected through electronic medical record review and compared using descriptive statistics. Results: 820 patients who underwent minimally invasive surgical staging with SLN mapping with ICG were identified, and 25 had documented iodinated contrast allergies. Documented reactions included rash/hives (n = 10, 40 %), anaphylaxis (n = 6, 24 %), shortness of breath (n = 5, 20 %), diarrhea (n = 1, 4 %), and not specified (n = 3, 12 %). A majority (24/25, 96 %) received 4 mg intravenous dexamethasone during induction of general anesthesia as per the institutional enhanced recovery after surgery (ERAS) protocol. No patients experienced allergic reactions or other adverse events after ICG injection. Conclusions: No patients in this cohort demonstrated an adverse reaction after ICG injection for SLN mapping. This study supports the reasonable safety of ICG in patients with contrast allergies, particularly when routine ERAS protocols containing dexamethasone are utilized.

Optimizing Outcomes for Acute Mesenteric Ischemia in the Context of Hypogammaglobulinemia: A Detailed Analysis of Surgical and Medical Strategies.

Acute mesenteric ischemia is a critical condition marked by a sudden loss of blood supply to the intestines, often leading to rapid tissue necrosis and severe clinical outcomes if untreated. In the context of hypogammaglobulinemia, an immunodeficiency characterized by decreased levels of immunoglobulins, this vascular emergency becomes even more daunting. Hypogammaglobulinemia can impair the immune system's response to both infection and ischemic injury, intensifying the severity of intestinal damage. This report describes the case of a 52-year-old female with hypogammaglobulinemia who presented with severe abdominal pain. Surgical exploration revealed 100 cm of necrotic small bowel extending from 150 cm distal to the ligament of Treitz to within 10 cm of the ileocecal valve. The necrotic section was surgically removed, and primary anastomosis was performed. This instance highlights the significant impact of immunodeficiency on the progression and management of acute mesenteric ischemia, demonstrating the critical need for early intervention and tailored management strategies, especially in immunocompromised patients, to prevent severe outcomes. The case illuminates the importance of recognizing immunodeficiency as a complicating factor in acute gastrointestinal emergencies, stressing the necessity for prompt and effective medical and surgical interventions to improve prognosis and patient outcomes in complex clinical scenarios.

Novel use of dynamic MR hydrography to rule out esophageal perforation post atrial fibrillation ablation in a patient with anaphylaxis to gadolinium.

Esophageal thermal injury is one of the most devastating complications of atrial radiofrequency ablation, and its diagnosis can be challenging. In this report, we highlight the novel use of free water as a contrast material to better visualize the esophageal lumen in a patient with anaphylaxis to Iodinated contrast media and Gadolinium who recently underwent atrial fibrillation ablation. This becomes particularly handy in patients with contrast allergy, and further emphasizes the role of multimodality imaging.

Fenestrated endovascular aortic repair of a superior mesenteric artery aneurysm using carbon dioxide angiography and intravascular ultrasound.

Superior mesenteric artery aneurysms are rare; however, current guidelines suggest they all require repair due to the high rupture and mortality rates, and endovascular repair is an effective management strategy. Iodinated contrast traditionally used in endovascular repair can cause significant complications, including severe allergic reactions and contrast-induced nephropathy in patients with chronic renal disease. Therefore, other imaging methods should be used during endovascular procedures to reduce these risks. We describe a unique and innovative approach using carbon dioxide angiography and intravascular ultrasound during fenestrated endovascular repair of an uncommon superior mesenteric artery aneurysm in a patient with severe contrast allergies.

Ultrasound-guided carotid angioplasty and stenting in a patient with iodinated contrast allergy: A case report.

BACKGROUND: Ischemic stroke is an entity with high incidence, morbidity, and mortality rates. Carotid artery stenosis is an important and independent risk factor for ischemic stroke. The three current approaches for treating carotid artery stenosis are drug treatment, carotid endarterectomy (CEA), carotid angioplasty and stenting (CAS). The approach is chosen based on the degree of stenosis. CEA or CAS could have been chosen for the current patient, who had severe carotid stenosis and an iodinated contrast allergy. After thoroughly communicating with the patient, the patient chose CAS for treatment. Therefore, we performed ultrasound-guided CAS to avoid the use of iodinated contrast. CASE SUMMARY: The main symptoms of the patient were numbness and weakness of the left limb. Computed tomography angiography of the head and neck at another hospital indicated multiple sites of stenosis in the arteries of the head and neck. The patient requested CAS for treatment but was allergic to iodinated contrast media. Thus, routine digital subtraction angiography (DSA) with iodinated contrast could not be used for the procedure. The diagnosis of this patient was as follows: (1) Right parietal lobe cerebral infarction; (2) multiple sites of stenosis in the arteries of the head and neck (severe stenosis of the right internal carotid artery, severe stenosis of the right subclavian artery); (3) right subclavian steal syndrome; and (4) hypertension (stage 3, high risk). The interventions included routine treatment for cerebral infarction, oral administration of clopidogrel (75 mg qd) and aspirin (100 mg qd), ultrasound-guided CAS, and postoperative follow-up. Postoperative color Doppler ultrasound and cerebrovascular magnetic resonance angiography of the carotid artery showed good vascular recovery, and the postoperative follow-up indicated a good prognosis. CONCLUSION: This case study suggests that ultrasound-guided endovascular treatment is a potential option for patients with contraindications to the iodinated contrast agents used in DSA-guided surgery, although excellent surgical operating skills are needed.

Knowledge assessment of radiologists, radiology residents, and radiographers regarding contrast materials and management of adverse drug reactions occurring due to contrast materials: a cross-sectional study.

The purpose of this study was to assess the knowledge of the radiology personnel regarding contrast media used in radiology and the management of associated adverse drug reactions. Methods: A questionnaire-based cross-sectional study was conducted from 21 February to 31 March 2019 in five major hospitals of Peshawar, Pakistan. A 30-item questionnaire was adopted from the existing literature containing both open and closed-ended questions and the authors conducted a pilot study among 25 participants to assess the face validity of the tool. A universal sampling technique was adopted. Descriptive statistics were used to summarize the findings of the study. Results: Less than half of the participants could correctly classify iodinated contrast media used in radiology on the basis of ionicity and osmolaity. Sixty-three percent chose severe contrast material-induced allergic reaction as type I hypersensitivity reaction while almost half of them correctly identified the features of iodinated contrast media associated with lesser side effects. Very few of them (6.7%) had read the ACR 2018 manual on contrast media. Regarding the risk factors for acute adverse reactions and signs/symptoms of anaphylaxis few could answer satisfactorily. Twenty-eight percent of participants correctly identified epinephrine as the initial medication in an anaphylactic reaction. Regarding the preferred route of administration, concentration and dose of epinephrine, the participants' correct response was quite poor (43.8%, 6.7%, and 8.6%, respectively). More than 65% of participants could name a single intravenous corticosteroid and antihistamine. Conclusion: Radiology personnel's knowledge regarding contrast material and management of severe contrast material-induced allergic reactions is unsatisfactory.

Retrograde carbon dioxide coronary sinus venography.

It is potentially harmful to perform coronary sinus (CS) angiography in patients with severe contrast allergy or severe renal dysfunction due to the risk of contrast-induced nephropathy (CIN). However, angiography is a well-established method to guide LV-lead position during cardiac resynchronization therapy-implantation. These two case reports describe the first successful applications of carbon dioxide CS angiography in patients requiring cardiac resynchronization therapy.

Successful visualization of pulmonary embolism using fluoroscopic video analysis in a patient with iodine contrast allergy: a case report.

Background: Contrast-enhanced computed tomography (CT) is commonly used to diagnose pulmonary embolism (PE). However, a history of iodine contrast allergy presents a dilemma in the management of patients with PE. As an alternative approach, X-ray fluoroscopic video analysis has been recently reported to be useful in diagnosing PE. Case summary: A 78-year-old man with dyspnoea of 1-month duration visited our hospital. His oxygen saturation was 89%, and echocardiography demonstrated right heart strain. We could not perform contrast-enhanced CT because the patient had a history of contrast allergy and refused to undergo premedicated contrast CT with anti-histamine and/or corticosteroid. Therefore, a video analysis of pulmonary circulation using dynamic chest X-ray (DCR) was performed. The reconstructed pseudo-colour video showed defects of pulmonary circulation in both lung areas. We diagnosed PE and started anticoagulant therapy. Multiple segmental defects were also observed in pulmonary perfusion scintigraphy on Day 3, which confirmed the diagnosis of PE. He was discharged on Day 9, and an improvement of the pulmonary circulation as assessed with DCR was observed. He had no symptoms at the last follow-up visit at 1 year after discharge. Discussion: We describe the successful visualization of PE using DCR in a patient with iodine contrast allergy.

Successful Adrenal Vein Sampling Using Dexamethasone Premedication in Patients With Iodine Contrast Media Allergy.

Context: Preparation of patients with iodine contrast media (ICM) allergy who require adrenal vein sampling (AVS) to establish source of aldosterone excess of their confirmed primary aldosteronism (PA) is controversial. Usual premedication with high-dose prednisone can interfere with cortisol determinations, possibly altering the aldosterone to cortisol ratios for the identification of lateralized aldosterone excess. Objective: We aimed to evaluate the efficacy and safety of premedication with high-dose dexamethasone to perform AVS in patients with ICM. Methods: One hundred and seventy-seven consecutive patients with confirmed PA who underwent bilateral simultaneous basal and post-ACTH bolus AVS at our center between January 2010 and December 2020 were retrospectively analyzed for history of ICM allergy. A total of 7 patients (4%) with previous allergic reactions to ICM were prepared with 3 doses of 7.5 mg dexamethasone premedication rather than the usual 50 mg of prednisone. Results: No breakthrough allergic reactions were reported in the 7 patients. Despite adequate serum cortisol suppression following dexamethasone, the basal and post-ACTH selectivity index were respectively > 2 and > 5 bilaterally in all patients, confirming adequate cannulation of both adrenal veins. Four patients had lateralized ratios (A/C ratio > 2 basally and > 4 post-ACTH), while 3 had bilateral source during AVS study. In the 3 patients undergoing unilateral adrenalectomy for lateralized source and contralateral suppression and adequate follow-up data, cure of PA was achieved at mean 58 months postoperatively. Conclusion: AVS using dexamethasone premedication is safe and accurate for diagnosing the source of aldosterone excess in patients with PA and ICM allergy.

First Transcatheter Aortic Valve Replacement With Gadobutrol in a Patient With Severe Contrast Allergy.

Iodinated contrast media (ICM) is an integral part of interventional cardiology procedures however, a proportion of patients have contrast allergy. We report the first TAVR performed with a gadolinium-based contrast agent, gadobutrol (GBCA) in a patient with severe recurrent ICM allergic reactions despite prophylactic treatment.

Adrenal Vein Sampling in a Patient With Primary Hyperaldosteronism and Severe Contrast Allergy.

We report on a case of a 50-year-old female patient with primary hyperaldosteronism, in whom adrenal venous sampling was required to differentiate between unilateral and bilateral disease. Because of a history of severe allergy to iodinated contrast media, premedication with glucocorticoids was indicated. Exogenous glucocorticoids, however, can affect measurements of serum cortisol. To avoid this potential confounding effects on the cortisol assay, we decided to use dexamethasone instead of prednisolone or hydrocortisone. A high-dose adrenocorticotropin (ACTH) stimulation test with the simultaneous use of dexamethasone revealed an adequate adrenal cortisol response. ACTH-stimulated adrenal venous sampling showed reliable results, which provided a solid basis for further clinical decision-making.

Outcomes in Patients with Known Contrast Allergy Undergoing Contrast-Enhanced Endourologic Procedures: A Retrospective Cohort Study.

Background: Intravenous (IV) administration of iodinated contrast agents carries the risk of allergic reaction, yet this risk is unclear with administration into the urinary tract. We sought to evaluate patients with known contrast, iodine, or shellfish allergies for allergic response when undergoing urologic imaging requiring intraluminal urinary tract contrast administration. Materials and Methods: We retrospectively reviewed consecutive patients undergoing endourologic procedures from 2010 to 2015 at our institution. Clinical records were reviewed for demographics, medical history, allergies, procedure details, fluids administered, anesthetic and pharmacologic agents administered, and continuous monitoring parameters. Patients with known allergies to iodine, shellfish, and/or contrast were identified and evaluated for clinical or hemodynamic signs of allergy. A convenience sample of 50 patients without allergy history was used as a comparison group. Results: We identified 1405 procedures involving 1000 consecutive patients. Procedures included retrograde pyelograms and antegrade nephrostograms. Eighty-six cases involving 58 patients with contrast, iodine, or shellfish allergies were identified. Of those with contrast allergy history, 18 (20.1%) cases involved patients with a history of anaphylactic reaction. Of these, 11 (61%) received steroid prophylaxis. No patients in either group (Allergy, No Allergy) were identified as having an allergic reaction during the procedure. There were no statistically significant differences in intraoperative IV fluids (p = 0.931), procedure duration (p = 0.747), or vasopressor use (p = 0.973) between groups. Owing to the zero event rate of contrast allergy, we used the Hanley and Lippman-Hand method, which places true population risk (95% confidence interval) of a significant event at <3.5%. Conclusions: In 86 cases involving patients with a history of contrast allergy, we found no evidence of clinically significant allergic reaction to intraluminal endourologic contrast administration under continuous anesthesia monitoring. The risk of significant reactions to contrast administered within the urinary tract appears to be low in these patients, regardless of prophylaxis.

Sentinel lymph node biopsy in patients with endometrial cancer and an indocyanine green or iodinated contrast reaction - A proposed management algorithm.

OBJECTIVE: To describe the incidence of adverse reactions to indocyanine green (ICG) administered during sentinel lymph node (SLN) biopsy for endometrial cancer, and to propose an ICG management algorithm for these patients. METHODS: All patients who underwent surgery for endometrial cancer with SLN biopsy using ICG from 1/2017 to 8/2020 were identified using a single-institution prospective database. Surgical adverse events (SAEs) related to the procedure were identified. A review of the literature was performed. RESULTS: In all, 1414 patients met inclusion criteria and were evaluated. Sixty-seven (4.7%) patients had a history of either an iodine or contrast allergy. No patients had a history of documented ICG allergy. Among patients with an iodine or contrast allergy, 65 (97%) received a corticosteroid with or without diphenhydramine prior to ICG administration. One hundred five patients (7.4%) experienced 116 SAEs. Among these patients, 3 experienced potentially allergic SAEs possibly related to ICG administration. After thorough chart review, however, the likelihood these SAEs were due to ICG appeared low. No patients experienced an anaphylactic response after ICG admission. CONCLUSION: There were no anaphylactic reactions to ICG intracervical administration during 1414 consecutive SLN biopsies, including in patients with a documented iodine or contrast allergy. Intracervical injection of ICG is safe, and premedication using corticosteroids with or without diphenhydramine prior to SLN biopsy is a reasonable strategy in patients with iodinated contrast allergy.

Gadolinium-based coronary angiography in a patient with prior known anaphylaxis to iodine-based dye.

Gadodiamide is a gadolinium-based chemical element that is considered safe and well tolerated in patients without renal dysfunction and is therefore routinely used as a contrast agent in magnetic resonance imaging. Although radio-opaque, it is not frequently used for coronary angiography due to its less than optimal image quality and prohibitive cost. Our center's previous experience was less than satisfactory but the addition of a power injection system yielded good quality diagnostic images. We report a case of 63 years old male with a known history of severe, life-threatening anaphylactic reaction to previous iodinated dye presenting with persistent angina despite optimal medical therapy. Coronary and bypass graft angiography was performed using 24 cc of undiluted Gadodiamide (OMNISCAN) with a power injector (ACIST®) without any incidents or premedication with an interpretable angiogram.

Fidelity of Electronic Documentation for Reactions Prompting Premedication to Iodinated Contrast Media.

PURPOSE: The aims of this study were to assess the fidelity of electronic health record documentation prompting premedication to iodinated contrast media and to determine the appropriateness of administered premedication on the basis of that documentation. METHODS: In this retrospective quality assurance cohort study, medication adverse events recorded in electronic health records between January 1, 2018, and August 31, 2019, to "iodine," "iodine-containing products," and "iodinated contrast media" were identified (N = 4,309); entries missing documentation (n = 1,651) and breakthrough reactions (n = 22) were excluded. Reaction description, severity, and free-text comments were used to categorize each entry as concordant (documentation matches recorded severity per the ACR Manual on Contrast Media version 10.3), discordant (description-severity mismatch, agent unrelated to iodinated contrast media, not a hypersensitivity reaction), or unclear. A subset of patients undergoing premedication was identified, and premedication was categorized as appropriate, inappropriate, or unsure on the basis of the index reaction using the aforementioned framework. Descriptive statistics were calculated. RESULTS: There were 2,636 adverse event entries in 2,441 patients: 59.9% (1,578 of 2,636) were classified as concordant, 30.2% (797 of 2,636) as discordant (n = 377 not a hypersensitivity reaction, n = 317 description-severity mismatch, and n = 103 unrelated agent), and 9.9% (n = 261) as unclear documentation. For the premedicated subset, concordance classification was feasible for 202 unique patients premedicated 335 times. Premedication was appropriate in 72% (240 of 335) and inappropriate in 22% (73 of 335); 17% of premedication events (56 of 335) were inappropriately administered for a prior physiologic reaction. CONCLUSIONS: Premedication prompts in the electronic health record are often erroneous because of inaccurate coding, incomplete data, and reaction misclassification. These errors result in inappropriate premedication for a substantial minority of patients.

Prognostic implications of prior contrast reaction in patients with emergency premedication before undergoing percutaneous coronary intervention.

BACKGROUND: Patients with iodinated contrast material (ICM) adverse reactions are at increased risk for breakthrough reactions. Previous studies suggest that the severity of a prior ICM adverse reaction corresponds to the severity of a repeat reaction. OBJECTIVE: We investigated whether the severity of prior ICM adverse reactions in patients receiving emergency premedication therapy prior to PCI predicts outcomes. METHODS: A retrospective observational study of percutaneous coronary intervention (PCI) encounters between January 1, 2005, and May 30, 2018, was conducted at Geisinger Medical Center. Patients with ICM adverse reactions premedicated with an emergency premedication regimen prior to PCI were included in the study. PCIs were stratified based on the severity of the index ICM adverse reactions; PCIs with a prior severe reaction were compared to PCIs with a prior mild-moderate reaction. RESULTS: We evaluated 604 PCI, of these, 144 (23.8%) had prior severe reactions and 460 (76.2%) had mild-to-moderate reactions. Nine patients had breakthrough reactions, of which seven were of the same or decreased severity in comparison to the index reactions. The overall breakthrough reactions occurred in 1 of 144 patients (0.7%) with an initial severe reaction and in 8 of 460 (1.7%) with an initial mild/moderate reaction (p = 0.69). Outcomes including length of hospital stay and 30-day mortality were similar for PCI with or without severe index ICM reactions. CONCLUSION: Frequency and severity of breakthrough reaction and clinical outcomes in patients treated with emergency premedication regimen prior to PCI were independent of the severity of index ICM reactions.

Approach to Perioperative Anaphylaxis in 2020: Updates in Diagnosis and Management.

PURPOSE OF REVIEW: The goal of the paper is to review the epidemiology, pathogenesis, diagnosis, and manifestations of perioperative anaphylaxis (POA). We seek to review the most common culprits of POA and different diagnostic modalities for evaluation. RECENT FINDINGS: Specific IgE testing has a limited role in POA evaluation due to lack of widespread availability and low sensitivity. Basophil activation testing is complementary to skin tests and can assist NMBA sensitivity diagnosis in complex cases. In the past years, there has been an exponential increase in suspected teicoplanin allergic reactions in the European Union. Chlorhexidine is also being increasingly implicated as a culprit in POA. Multiple classes of perioperative medications cause POA. Diagnostic modalities available include skin testing with nonirritating concentrations, basophil activation tests, specific IgE, and drug provocation testing. An accurate record and critical analysis of perioperative events is more important than isolated test results. Future studies evaluating the pathophysiology of these reactions and other therapeutic strategies, such as targeting the MRGPRX2 receptor, are needed.

Absence of Iodinated Contrast Hypersensitivity and Characterization of Gadolinium Utilization in an Interventional Pain Population.

BACKGROUND: Iodinated contrast media (ICM) allergy labels pose a unique clinical problem for the interventional pain physician due to the drawbacks of gadolinium for enhancement during pain procedures, as well as the reluctance to add to the cumulative steroid burden with steroid premedication. However, the risks of ICM hypersensitivity specific to this setting have not been previously described. METHODS: We aimed to describe the incidence of ICM-induced hypersensitivity during the performance of epidural injections in a large healthcare system. We also sought to characterize preexisting ICM allergy labels and how these affected consequent gadolinium utilizations in this population. RESULTS: 6,471 epidural pain procedures requiring contrast enhancement were performed during the 18-month study period. There were no reported contrast-induced hypersensitivity reactions in this time. 108 patients (1.6%) had a preexisting ICM allergy; a shellfish/seafood allergy was recorded in 118 patients (1.82%), and 51 charts (0.78%) were labeled with "iodine" allergy. 183 individuals received gadolinium for enhancement during epidural steroid injections. 96.7% of gadolinium utilization occurred in the context of preexisting allergy labels in the electronic medical record. Of note, 20 patients (18.5%) with ICM allergy labels also received iodinated contrast, and this was uneventful in all cases. CONCLUSION: Our results suggest that ICM-associated hypersensitivity is very rare during epidural procedures and the incidence is significantly lower than expected based on reaction rates during intravascular administration. This may be related to both dose as well as route of administration. The establishment of a protocol for safe workup of ICM allergy labels would be useful in optimizing pain procedures.

Zero-iodinated contrast retrograde percutaneous coronary interventions of chronic total occlusions using gadolinium and imaging guidance: a case report of a patient with severe anaphylaxis to iodinated contrast.

BACKGROUND: Gadolinium-based contrast agents have been used as an alternative to iodinated contrast agents for simple percutaneous coronary interventions (PCIs) in patients with obstructive coronary artery disease. Their use has been limited in complex PCI due to poor image quality with gadolinium contrast. Significant dilution of gadolinium is required in an effort to avoid malignant ventricular arrhythmias. Further, the recommended amount of gadolinium contrast that can be used is very limited. CASE SUMMARY: We describe a case of patient with severe anaphylaxis to iodinated contrast agents despite pre-exposure prophylaxis with steroids and histamine blockers who underwent intravascular imaging-guided PCI of chronic total occlusions (CTOs) of left anterior descending and dominant left circumflex arteries using gadolinium contrast. DISCUSSION: In patients with anaphylaxis to iodinated contrast agents (i) complex coronary interventions including CTO PCI can be successfully performed without use of iodinated contrast, and (ii) combination of intravascular ultrasound guidance and gadolinium-based contrast agents can be safely and effectively used to perform complex PCI.

MultiHance as a contrast alternative for Gadovist allergic patients.

The dramatic rise in the use of contrast agents for diagnostic imaging within the last decade has largely contributed to the effectiveness of MR imaging, however even with the use of prophylaxis, adverse reactions to contrast, including anaphylaxis, still occur. We describe the case of a 46-year-old female patient with a hemangiopericytoma requiring ongoing contrast MR surveillance, and a documented anaphylactic reaction to Gadovist (gadobutrol injection) despite premedication. Allergy testing was positive to intradermal undiluted Gadovist, confirming an IgE-mediated Gadovist allergy, with subsequent skin testing by prick and intradermal negative to undiluted MultiHance. She went on to receive MultiHance prior to her subsequent MRI scans without clinical reaction and without premedication, demonstrating that there may be superior alternatives to traditionally used gadolinium dyes in patients with moderate to severe reactions, and warrants further investigation into the anaphylactoid characteristics between the different gadolinium-based contrast agents.