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.

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.

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.

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.

Zero-contrast percutaneous coronary intervention for chronic total occlusions guided by intravascular ultrasound with ChromaFlo mode: a case report

Background

Contrast agent allergy may result in severe adverse events that prevent the use of percutaneous coronary intervention (PCI) in some patients, especially for those with complex lesions.

Case summary

We describe a 59-year-old man who presented with the multi-vessel disease and suffered from contrast allergy. The patient refused to have coronary artery bypass grafting surgery, thus two-stage PCI procedures without iodinated contrast media were performed after a detailed discussion with the heart team, including a chronic total occlusion (CTO) lesion in the proximal left anterior descending artery. The intravascular ultrasound (IVUS) was used for finding the entry point of the proximal fibre cap, and assessing the lesion, thereby marking the positions of the proximal and distal edges of the stent. After PCI, stent expansion and subtle edge dissection or incomplete apposition were confirmed by IVUS and ChromaFlo imaging. Zero-contrast PCI was done successfully without any complication.

Discussion

This case report illustrates the feasibility and safety of performing CTO-PCI without contrast agent in carefully and well prepared selected patients.

Practical advantages of contrast-enhanced ultrasound in abdominopelvic radiology

Computed tomography (CT) and magnetic resonance imaging (MRI) are two of the workhorse modalities of abdominopelvic radiology. However, these modalities are not without patient- and technique-specific limitations that may prevent a timely and accurate diagnosis. Contrast-enhanced ultrasound (CEUS) is an effective, rapid, and cost-effective imaging modality with expanding clinical utility in the United States. In this pictorial essay, we provide a case-based discussion demonstrating the practical advantages of CEUS in evaluating a variety of pathologies in which CT or MRI was precluded or insufficient. Through these advantages, CEUS can serve a complementary role with CT and MRI in comprehensive abdominopelvic radiology.

Delayed severe anaphylactoid reaction following retrograde pyelogram: A case report

Retrograde pyelography is used to evaluate upper collecting system in patients with hematuria who have contrast allergy. Reported here is a patient who developed severe, late-onset anaphylactoid reaction after retrograde pyelography. Premedication is commonly used to reduce risk of allergic reaction but has limited evidence to support its efficacy. Caution should be used when evaluating microhematuria with retrograde pyelography in patients with prior anaphylactoid reaction to intravenous contrast.

Shellfish allergy and relation to iodinated contrast media: United Kingdom survey

AIM

To assess current practice of United Kingdom cardiologists with respect to patients with reported shellfish/iodine allergy, and in particular the use of iodinated contrast for elective coronary angiography. Moreover we have reviewed the current evidence-base and guidelines available in this area.

METHODS

A questionnaire survey was send to 500 senior United Kingdom cardiologists (almost 50% cardiologists registered with British Cardiovascular Society) using email and first 100 responses used to analyze practise. We involved cardiologists performing coronary angiograms routinely both at secondary and tertiary centres. Three specific questions relating to allergy were asked: (1) History of shellfish/iodine allergy in pre-angiography assessment; (2) Treatments offered for shellfish/iodine allergy individuals; and (3) Any specific treatment protocol for shellfish/iodine allergy cases. We aimed to establish routine practice in United Kingdom for patients undergoing elective coronary angiography. We also performed comprehensive PubMed search for the available evidence of relationship between shellfish/iodine allergy and contrast media.

RESULTS

A total of 100 responses were received, representing 20% of all United Kingdom cardiologists. Ninety-three replies were received from consultant cardiologists, 4 from non-consultant grades and 3 from cardiology specialist nurses. Amongst the respondents, 66% routinely asked about a previous history of shellfish/iodine allergy. Fifty-six percent would pre-treat these patients with steroids and anti-histamines. The other 44% do nothing, or do nonspecific testing based on their personal experience as following: (1) Skin test with 1 mL of subcutaneous contrast before intravenous contrast; (2) Test dose 2 mL contrast before coronary injection; (3) Close observation for shellfish allergy patients; and (4) Minimal evidence that the steroid and anti-histamine regime is effective but it makes us feel better.

CONCLUSION

There is no evidence that allergy to shellfish alters the risk of reaction to intravenous contrast more than any other allergy and asking about such allergies in pre-angiogram assessment will not provide any additional information except propagating the myth.