Choice and Use of Contrast Agent

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The choice of contrast agent is an important intra-procedural consideration and has evolved considerably over the last several years with the development of low- and iso-osmolar contrast agents. Traditional iodine-based contrast agents were hypertonic and included ionic compounds such as diatrizoate (Hypaque, Renografin) that frequently caused mild hemodynamic changes in addition to contrast-related nephropathy. Given substantially lower costs in recent years, most laboratories have switched to the routine use of low-osmolar, non-ionic contrast agents for improved hemodynamic effects and patient comfort. An important effect of low-osmolar agents is believed to be reductions in contrast-related nephropathy. In a meta-analysis that included data from 25 trials, the risk of contrast-related nephropa-thy was 39% lower in patients who received low-osmolar contrast agents, compared with hypertonic contrast agents.69 This benefit appeared to be even more pronounced in patients with preexisting renal disease, with a 50% risk reduction in that population.

More recently, the introduction of iodixanol (Visi-paque), an iso-osmolar contrast agent, has raised the question of whether the incidence of contrast-related nephropathy can be further reduced. In a widely cited study of patients with CKD and diabetes melli-tus, the use of iso-osmolar contrast agents reduced the incidence of contrast-related nephropathy by more than 90%, compared with low-osmolar contrast agents.70 An additional study comparing these two types of contrast agents also suggested a reduction in major adverse cardiovascular events with the use of iso-osmolar contrast in patients undergoing high-risk PCI.71

Finally, some investigators have begun to use alternative, non-iodine-based contrast agents such as gadolinium, particularly for peripheral angiography. Although case reports of its use in the coronary circulation do exist, many questions remain regarding the overall safety and feasibility of this approach, particularly given the high serum osmolality of these agents.72,73

Regardless of the selection of a contrast agent, it is imperative that the least amount of volume required for adequate visualization of the coronary artery and technical success of the procedure be used. For patients who are at particularly high risk, the maximum allowable contrast dose should be calculated before the procedure, so that the interventional cardiologist and team can be aware of its use during the procedure. Staging of nonurgent procedures is also a possibility in many settings and will minimize the risk of developing contrast-related nephropathy. Unfortunately, there are few data on how long one should wait before staging procedures.

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