Ahmed Athar, MD, FSCAI; Huu Tam Truong, MD, FSCAI; Jacob A. Doll, MD, FSCAI; Amir Lotfi, MD, FSCAI; Srini Potluri, MD, FSCAI

Introduction

As of May 2022, a significant contrast media shortage has been impacting hospitals across the country. The shutdown of a GE manufacturing facility in Shanghai in April has led to a decreased supply of Omnipaque and Visipaque iodinated contrast media. This shortage is expected to last at least six to eight weeks as additional manufacturing capacity continues to be developed.¹ Other manufacturers have not been impacted. Hospitals fully reliant on GE contrast media will be most impacted by this shortage, and it may not be possible to obtain a supply from alternative manufacturers. Many hospitals have begun canceling elective cardiac procedures and nonurgent imaging. While the full scope, duration, and severity of this shortage remains unclear, this Tip of the Month is intended to support SCAI membership in assessing and responding to this developing issue.

Assessing and Extending Supply

1. Work with hospital leadership and other service lines to anticipate the impact of this shortage on your hospital.
2. Consider deferring nonurgent cardiac and vascular studies until July 2022 or later.
3. Avoid “add-on” angiographic studies such as left ventriculogram, aortic angiography, or peripheral angiography that could be performed with alternative imaging modalities or deferred.
4. Distribute contrast media from larger bottles (100–200 mL) into smaller bottles (50 mL) for single use.² Limit contrast for diagnostic angiography cases to < 50 mL (see tips below).
5. With the ACIST contrast delivery system, use one contrast reservoir for up to five patients, potentially reducing discarded contrast at the end of each case.
6. Reserve a critical supply for the catheterization laboratory to maintain services for an ST-elevation myocardial infarction (STEMI) and other emergent cases.

Reducing Contrast Utilization During Angiography and Percutaneous Coronary Intervention (PCI)*

1. Carefully review the patient’s prior angiograms and catheters used, especially for patients with complex anatomy or a prior coronary artery bypass graft (CABG). This helps to limit angiograms to the projections that best show significant lesions. For example, a priori knowledge of a dilated ascending aorta or an anterior origin of the right coronary artery (RCA) that requires modification from standard diagnostic catheters can save time and contrast.
2. Review prior chest computed tomography (CT) imaging. This can offer significant information regarding the aortic locations and patency of coronaries and grafts as well as the presence and location of coronary calcification.
3. Obtain an echocardiogram prior to cardiac catheterization (with echocardiographic contrast if needed), if feasible. This obviates the need for a routine left ventriculogram.
4. Reduce the volume and frequency of “puffs.” Use of fluoroscopic markers such as calcium and graft clips or markers, along with watching for the subtle motion of the catheter when it engages a coronary, can reduce repeated “puffs” of contrast.
5. Use the fewest number of injections to obtain a diagnostic study. Not every patient requires a full injection of contrast for each coronary or graft in the “standard” six views.
6. Use biplane angiography, if available. Biplane imaging can significantly reduce contrast usage by acquiring two images for each injection.
7. Perform smart angiography. Operators should assess in real time the vessel size and opacification to understand when to stop injecting.
8. Consider using automated injectors. Automated injectors and contrast-saving devices can significantly reduce the volume of contrast delivered to the patient.³ Use RCA settings and educate staff and trainees to inject the minimal necessary contrast.
9. Use smaller catheters for diagnostic angiography. Both 4F or 5F catheters can produce good-quality diagnostic angiograms with a lower volume of contrast, especially when used with an automated injector.
10. Remove contrast prior to catheter removal or intracoronary medication delivery. Diagnostic catheters can hold 1–2 mL of contrast in their lumens, and 6F guide catheters hold nearly 3 mL.
11. Use coronary physiology and intracoronary imaging. The Fractional Flow Versus Angiography for Multivessel Evaluation (FAME) trial demonstrated that the use of fractional flow reserve (FFR) in multivessel disease led to a decrease in the number of stents used, and the volume of contrast delivered in the FFR arm was decreased by 10% relative to the angiography arm.⁴ Intravascular, ultrasound-guided PCI can reduce contrast usage in addition to optimizing stent results by aiding lesion preparation strategy, accurate stent sizing, and post-stent deployment assessment.⁵

Recommendations for Severe Shortage

It is possible that some hospitals may face a crisis in which very little or no contrast media is available. The following are potential strategies for harm reduction:

1. Zero- or very low-contrast PCI is feasible for patients with advanced kidney disease at high risk for contrast-induced nephropathy.⁶ We do not recommend using zero-contrast PCI for the sole purpose of extending the contrast media supply. Instead, elective cases should be deferred, and urgent/emergent cases should be performed with a minimum safe volume of contrast.
2. Gadolinium has been described as an alternative contrast agent for patients with iodinated contrast media allergy, though image quality can be poor, with one study reporting 68% of studies with “reasonably good” images and 32% with “satisfactory” images.⁷ Carbon dioxide may be useful for vascular procedures.
3. Coordination should occur with local hospitals and emergency services to divert or transfer STEMI patients to hospitals with a sufficient supply of contrast media.

References

1. Rowland C. Covid shutdowns in China are delaying medical scans in the U.S. The Washington Post. https://www.washingtonpost.com/business/2022/05/11/medical-scans-dye-shortage. Published May 11, 2022.
2. American Society of Health-System Pharmacists. Considerations for Imaging Contrast Shortage Management and Conservation. https://www.ashp.org/drug-shortages/shortage-resources/considerations-for-imaging-contrast-shortage-management?loginreturnUrl=SSOCheckOnly. Accessed May 16, 2022.
3. Minsinger KD, Kassis HM, Block CA, et al. Meta-analysis of the Effect of Automated Contrast Injection Devices versus Manual Injection and Contrast Volume on Risk of Contrast Induced Nephropathy. Am J Cardiol. 2014 Jan 1;113(1):49–53.
4. Tonino PAL, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009 Jan 15;360(3):213–24.
5. Mariani J Jr, Guedes C, Soares P, et al. Intravascular ultrasound guidance to minimize the use of iodine contrast in percutaneous coronary intervention: the MOZART (Minimizing cOntrast utiliZation With IVUS Guidance in coRonary angioplasTy) randomized controlled trial. JACC Cardiovasc Interv. 2014 Nov;7(11):1287–93.
6. Ali ZA, Galougahi KK, Nazif T, et al. Imaging- and physiology-guided percutaneous coronary intervention without contrast administration in advanced renal failure: a feasibility, safety, and outcome study. Eur Heart J. 2016 Oct 21;37(40):3090–95.
7. Saleh L, Juneman E, Movahed MR. The use of gadolinium in patients with contrast allergy or renal failure requiring contrast angiography, coronary intervention, or vascular procedure. Catheter Cardiovasc Interv. 2011 Nov 1;78(5):747–54.

* Adapted from the December 2020 Tip of the Month.