Percutaneous carotid angioplasty and stenting with the use of gadolinium in lieu of iodinated contrast medium: technical case report and review of the literature

Usefulness of the fusion imaging of 3D-CT and MRA for carotid artery stenting with minimum use of contrast medium in patient with renal dysfunction

Patients with severe internal carotid artery (ICA) stenosis with multiple medical problems generally undergo carotid artery stenting (CAS). However, it is difficult to perform CAS in some patients because iodinated contrast medium is hard to use. We report a patient with asymptomatic ICA stenosis and chronic renal failure, in whom successful treatment was achieved using CAS with minimal use of iodinated contrast medium. A 68-year-old man with severely chronic renal failure was consulted for treatment of left ICA stenosis. Magnetic resonance angiography (MRA) and carotid echography revealed left ICA severe stenosis, and systemic non-contrast MRA showed left femoral artery constriction, but right femoral artery to be intact. CAS was therefore performed through the right femoral artery, using non-contrast three-dimensional computed tomography (3D-CT) with MRA fusion imaging, intravascular ultrasonography, and a small amount of iodinated low-osmolar contrast medium. Postoperative course was uneventful with no aggravation of renal dysfunction, and he was discharged 7 days postoperatively. These techniques are very useful for patients with chronic renal failure, and this present case represents the first report of CAS treated by using non-contrast 3D-CT with MRA fusion image technique.

Gadolinium-based coronary angiography in patients with contraindication for iodinated x-ray contrast medium: a word of caution

BACKGROUND

In coronary angiography, the use of contrast agents containing iodine still defines the gold standard. In patients with contraindications for iodine exposition, gadolinium has been considered to be a safe alternative to standard iodinated contrast medium for coronary angiography. The aim of the present study was to assess the safety and technical quality of gadolinium-based coronary angiography.

METHODS

Nineteen consecutive patients with contraindication to iodinated contrast medium underwent gadolinium-based coronary angiography. Contraindications included previous anaphylactic shock or severe allergic reaction to iodinated contrast medium (n = 13) or thyrotoxicosis (n = 6). Gadolinium was diluted 1:1 with sodium chloride before application. Patients were clinically observed for potential side effects, and renal function was assessed by determination of creatinine values and calculation of creatinine clearance in pre- and postprocedural blood samples. Image quality was evaluated by two independent observers, and classified into three different categories (grade 1, high diagnostic quality; grade 2, moderate diagnostic quality; and grade 3, poor quality).

RESULTS

During angiography, a mean of 32.6 +/- 10.9 mL (range 10-45 mL) gadolinium was used. No patient developed a significant impairment of renal function within 24 hours after the examination (mean creatinine value preprocedural: 1.12 +/- 0.15 mg/dL, postprocedural: 6 hours 1.15 +/- 0.18 mg/dL, 24 hours 1.13 +/- 0.16 mg/dL) (baseline vs. 6 hours P = 0.23, baseline vs. 24 hours P = 0.66, 6 hours vs. 24 hours P = 0.12) (mean creatinine clearance preprocedural: 73.8 +/- 18 mg/dL, postprocedural: 6 hours 71.7 +/- 16.8 mg/dL, 24 hours 73.2 +/- 17.8 mg/dL) (baseline vs. 6 hours P = 0.2, baseline vs. 24 hours P = 0.71, 6 hours vs. 24 hours P = 0.21). Four patients (21%) suffered severe complications due to gadolinium application, such as malignant cardiac arrhythmias (n = 3) and hemodynamic decompensation (n = 1). Image quality was generally reduced in comparison to iodine contrast coronary angiography, but was adequate for diagnostic purposes (13 patients [68.4%] had reasonably good picture contrast [grade 2.1 +/- 0.3]; in 6 patients [31.6%], image quality was satisfactory [grade 2.6 +/- 0.13]). Opacification of distal vessels as compared to proximal segments was remarkably reduced.

CONCLUSIONS

Gadolinium-based coronary angiography is a potential alternative technique in patients with allergy to iodinated contrast medium or thyrotoxicosis with reduced, but acceptable, image quality for diagnostic purposes. Nevertheless, possible life-threatening side effects and complications have to be considered.

Carotid intervention 2: technical considerations

Carotid angioplasty and stenting (CAS) is an evolving technique for treating patients with carotid occlusive disease. However, technical and clinical outcomes are closely related to the knowledge and experience of the interventionalist, and procedural mistakes often lead to serious neurological complications. This article discusses the preinterventional workup of a patient selected for CAS, the different steps of a CAS procedure, the potential complications, how to avoid them, and once they occur how to intervene. Finally, a short overview of the follow-up is given.