Radiology
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kaufman, J. A.
Right arrow Articles by Waltman, A. C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kaufman, J. A.
Right arrow Articles by Waltman, A. C.
(Radiology. 1999;212:280-284.)
© RSNA, 1999

Technical Developments

Gadolinium-based Contrast Agents as an Alternative at Vena Cavography in Patients with Renal Insufficiency—Early Experience1

John A. Kaufman, MD, Stuart C. Geller, MD, Hasan Bazari, MD and Arthur C. Waltman, MD

1 From the Division of Vascular Radiology (J.A.K., S.C.G., A.C.W.) and the Department of Medicine, Division of Nephrology (H.B.), Harvard Medical School, Massachusetts General Hospital, GRB 290, 55 Fruit St, Boston, MA 02114. Received April 30, 1998; revision requested July 6; revision received August 18; accepted December 15. Address reprint requests to J.A.K. (e-mail: kaufmanfamily@sprintmail.com).


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
The authors reviewed results of digital subtraction vena cavography with a gadolinium-based contrast agent in 14 patients with serum creatinine levels greater than or equal to 1.5 mg/dL (133 µmol/L). All cavograms were diagnostic. In 11 patients, there was no impairment of renal function. In three patients, a rise in serum creatinine level of greater than or equal to 0.5 mg/dL (44 µmol/L) was attributable to concurrent medical problems. Gadolinium-based contrast agents may be suitable for digital subtraction vena cavography in patients with renal insufficiency.

Index terms: Angiography, contrast media, 566.1245, 80.1248, 982.1245 • Venae cavae, angiography, 566.1245, 80.1248, 982.1245 • Venography, 566.1245, 80.1248, 982.1245


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Invasive imaging of the vena cava is usually performed with iodinated contrast agents. In patients with renal insufficiency (serum creatinine level, >=1.5 mg/dL [133 µmol/L]), an alternative contrast agent with a low risk of contrast agent–induced acute renal failure would be desirable. Gaseous CO2, which has no nephrotoxicity, has been used as a contrast agent for inferior vena cavography (1,2). Care must be exercised when preparing CO2 for injection, as it indistinguishable from room air. Injection rates are difficult to control because CO2 must be injected by hand unless a power injector is available. Invasive imaging of the vena cava without any contrast agent is possible with intravascular ultrasonography, but this requires use of specialized equipment (3). A simple to use, readily available alternative contrast agent for procedures in the vena cava would be useful.

In several case reports, the application of gadolinium-based magnetic resonance (MR) imaging contrast agents for digital subtraction angiography (DSA) has been described (4–6). These contrast agents appear to have little clinical nephrotoxicity (4–8). In this study, we used gadolinium-based contrast agents for diagnostic and interventional procedures in the vena cava. To our knowledge, this application of gadolinium-based contrast agents has not been reported previously.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
From July 1996 through March 1998, 14 patients (six men, eight women; age range, 37–86 years; mean age, 66 years ± 17 [SD]) with serum creatinine levels greater than or equal to 1.5 mg/dL (133 µmol/L) underwent invasive catheter-based procedures in the vena cava (inferior vena cava [IVC] in 13 patients and superior vena cava [SVC] in one) performed with gadolinium-based contrast agents (gadodiamide, Omniscan, Nycomed, Princeton, NJ, or gadopentetate dimeglumine, Magnevist, Berlex Laboratories, Wayne, NJ) alone (n = 12) or in conjunction with CO2 (n = 2). The procedures were IVC filter placement in 10 patients, thrombolysis of the IVC in one, and diagnostic studies in three (Table). All filter placements were in patients with documented thromboembolic disease and either contraindications to or failed anticoagulation therapy. During the same time, no patients with elevated serum creatinine levels underwent cavography with CO2 alone. The gadolinium-based contrast agent used was based on availability in the angiography suite.


View this table:
[in this window]
[in a new window]
  		Patient Data
 
In our institution, gadolinium-based contrast agents are routinely used alone or in conjunction with CO2 as alternative contrast agents for DSA in nonpregnant, nonlactating adult (older than 18 years) patients with a serum creatinine level greater than or equal to 1.5 mg/dL (133 µmol/L) when it is anticipated that only a limited volume of contrast agent will be necessary. The maximum dose of gadolinium-based contrast agent never exceeds 0.4 mmol per kilogram of body weight (0.8 mL/kg), or 60 mL. These are the same guidelines observed in our clinical practice of MR angiography, during which a gadolinium-based contrast agent is injected into a peripheral vein. This dose of gadolinium-based contrast agent for venous injection is not considered investigational in our institution, and thus institutional review board approval was not required.

Written informed consent was obtained prior to all procedures. In 13 patients, a common femoral vein approach was used to place a 5.0–7.1-F pigtail catheter (Cook, Bloomington, Ind) in the infrarenal IVC. The SVC study was performed by injecting the contrast agent through an existing chest port. In 12 cases, gadodiamide (0.3–0.4 mmol/kg) was diluted 2:1 with normal saline solution, usually resulting in 60–80-mL total volume (Fig 1). In two cases, undiluted contrast agent (gadodiamide or gadopentetate dimeglumine) was used (Fig 2). In all cases, the majority of the contrast agent was loaded into a power injector, with approximately 10 mL reserved for test injections by hand. After the operator was satisfied with the position of the catheter, digital subtraction cavography (large focal spot, 70–80 kV) was performed with power injection of 15–20 mL of contrast agent for 1–2 seconds, with acquisition at a rate of 2–6 frames per second. When IVC filters were placed, a completion cavogram was obtained through the filter introducer sheath with use of a similar rate and volume of contrast agent and the same digital subtraction technique.



View larger version (158K):
[in this window]
[in a new window]
  		Figure 1a. Patient 5. IVC filter placement in an 86-year-old woman with deep venous thrombosis and a closed head injury, with use of diluted gadodiamide (GADO INJ) as a contrast agent. LT = left. (a) Digital subtraction inferior vena cavogram was obtained prior to (PRE FILTER) filter placement after injection of gadodiamide diluted 2:1 with normal saline solution at a rate of 15 mL/sec for 2 seconds through a 5-F pigtail catheter positioned at the confluence of the iliac veins. Contrast agent density is adequate. The renal veins (arrows) are readily identified. (b) Digital subtraction inferior vena cavogram was obtained through the filter delivery sheath with the same contrast agent and injection rates after placement (S/P FILTER) of the filter (arrow).

 


View larger version (160K):
[in this window]
[in a new window]
  		Figure 1b. Patient 5. IVC filter placement in an 86-year-old woman with deep venous thrombosis and a closed head injury, with use of diluted gadodiamide (GADO INJ) as a contrast agent. LT = left. (a) Digital subtraction inferior vena cavogram was obtained prior to (PRE FILTER) filter placement after injection of gadodiamide diluted 2:1 with normal saline solution at a rate of 15 mL/sec for 2 seconds through a 5-F pigtail catheter positioned at the confluence of the iliac veins. Contrast agent density is adequate. The renal veins (arrows) are readily identified. (b) Digital subtraction inferior vena cavogram was obtained through the filter delivery sheath with the same contrast agent and injection rates after placement (S/P FILTER) of the filter (arrow).

 


View larger version (82K):
[in this window]
[in a new window]
  		Figure 2a. Patient 13. IVC thrombolysis in a 49-year-old man with IVC thrombosis. (a) Digital subtraction inferior vena cavogram was obtained at 48 hours after thrombolysis by means of hand injection of 40 mL of CO2 through a 5-F pigtail catheter. A poorly defined mural filling defect (arrow) is depicted in the region of the right renal vein orifice. (b) Repeat digital subtraction inferior vena cavogram through the same catheter was obtained with undiluted gadodiamide at 20 mL/sec for 2 seconds. The residual thrombus (arrow) in the region of the right renal vein (a posterior structure) is better defined with the gadodiamide, which mixes with blood rather than displacing it. Note the apparent difference in caliber of the suprarenal IVC when compared with a as a result of anterior layering of CO2.

 


View larger version (77K):
[in this window]
[in a new window]
  		Figure 2b. Patient 13. IVC thrombolysis in a 49-year-old man with IVC thrombosis. (a) Digital subtraction inferior vena cavogram was obtained at 48 hours after thrombolysis by means of hand injection of 40 mL of CO2 through a 5-F pigtail catheter. A poorly defined mural filling defect (arrow) is depicted in the region of the right renal vein orifice. (b) Repeat digital subtraction inferior vena cavogram through the same catheter was obtained with undiluted gadodiamide at 20 mL/sec for 2 seconds. The residual thrombus (arrow) in the region of the right renal vein (a posterior structure) is better defined with the gadodiamide, which mixes with blood rather than displacing it. Note the apparent difference in caliber of the suprarenal IVC when compared with a as a result of anterior layering of CO2.

 
When CO2 was used, aliquots of 20–40 mL were injected by hand with use of techniques described previously (1,2). In patient 13, CO2 was used in conjunction with gadolinium-based contrast agent because multiple injections were performed during catheter positioning. CO2 was also used in patient 7 because the serum creatinine level was rising acutely, and there seemed to be little advantage to use of a gadolinium-based contrast agent. However, the CO2 inferior vena cavogram was considered inadequate for planning filter placement, and gadolinium-based contrast agent was then used to obtain a satisfactory study.

During the procedures, all patients underwent monitoring of vital signs, cardiac rhythm, and oxygen saturation, according to routine departmental protocols. The serum creatinine level was measured at 24 and 48 hours after the procedure in all patients, also according to routine protocol for angiography in patients with an abnormal serum creatinine level. Acute renal failure was defined as a rise in serum creatinine level of greater than or equal to 0.5 mg/dL (44 µmol/L) within 48 hours before or after the procedure (9).

Patient charts were reviewed for clinical evidence of acute renal failure (decreased or absent urine output, elevation of serum creatinine level, need for dialysis) within 48 hours before or after the procedure. Concurrent medical and surgical conditions were also recorded.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The mean serum creatinine level the day of the procedure was 2.8 mg/dL ± 1.1 (248 µmol/L ± 97). Patient 13 underwent vena cavography on three successive days during a thrombolysis procedure (total volume of gadodiamide, 130 mL). His data were excluded from the calculation of averages. For the remaining 13 patients, the average serum creatinine level at 48 hours after the procedure was 2.8 mg/dL ± 1.3 (248 µmol/L ± 115). The average volume of gadolinium-based contrast agent was 45 mL ± 11. There were no anaphylactic or other adverse reactions to the gadolinium-based contrast agent.

In eight patients, the serum creatinine level decreased an average of 0.3 mg/dL ± 0.3 (26 µmol/L ± 26) after the procedure. The serum creatinine level increased in six patients at 48 hours, including patient 13. In patients 5, 6, and 11, the rise in creatinine level was less than or equal to 0.3 mg/dL (26 µmol/L). This was not considered evidence of contrast agent–induced renal failure.

A rise in serum creatinine level greater than or equal to 0.5 mg/dL (44 µmol/L) occurred in three patients but was attributed to causes other than the contrast agent in all cases. In patient 2, the rise in creatinine level was 0.5 mg/dL (44 µmol/L). This patient had a history of congestive heart failure, coronary artery disease, a single kidney with a severe proximal renal artery stenosis, and past episodes of azotemia with aggressive diuresis. She was in congestive heart failure with a urinary tract infection and was undergoing aggressive diuresis at the time of the IVC filter placement. In the 24 hours prior to the filter placement, her serum creatinine level had risen slightly. The aggressive diuresis continued following filter placement. The nephrology service evaluated the patient on multiple occasions during her admission and attributed her rise in creatinine level to intravascular volume depletion due to diuresis.

Patient 7 had a rise in creatinine level of 1.3 mg/dL (115 µmol/L) at 48 hours. This immunocompromised patient previously had a normal serum creatinine level. On the day of IVC filter placement, he presented with hypotension, sepsis, phlegmasia cerulea dolens that required emergent surgical intervention, myoglobinuria, and elevated serum creatinine level of 1.9 mg/dL (168 µmol/L). The IVC filter was placed with use of both CO2 and gadodiamide. The patient remained vasopressor dependent, developed progressive multiple organ system failure, and died after 7 days. His renal failure was considered to be related to hypotension and myoglobinuria.

Patient 13 presented with anuria and IVC thrombosis. The patient had an underlying chronic right renal vein thrombosis that had occurred after liver transplantation. In the 48 hours preceding thrombolysis, his creatinine level had risen from 1.9 to 4.5 mg/dL (from 168 to 398 µmol/L). At the time of initiation of thrombolysis, he was found to have thrombosis of the IVC to the level of the hepatic veins with obstruction of both renal veins. He was studied on three successive days during catheter-directed thrombolysis, each time with CO2 and 40–50 mL of gadodiamide. At 48 hours after initiation of thrombolysis, he began to urinate, but his creatinine level had risen to 5.5 mg/dL (486 µmol/L). On the third day (at the time his last gadodiamide-enhanced cavogram was obtained), his serum creatinine level decreased to 5.0 mg/dL (442 µmol/L). At 48 hours after acquisition of his last cavogram, his creatinine level further decreased to 4.1 mg/dL (362 µmol/L). His creatinine level returned to baseline over the following week. The nephrology service attributed his rise in creatinine level to mechanical obstruction of the renal veins by thrombus, which was not relieved until the second day of thrombolysis.

In patients 7 and 13, the two patients in whom both CO2 and gadodiamide were used, the CO2 was injected first. Gadodiamide was then used because the angiographer performing the study determined that the CO2 images were unsatisfactory (Fig 2). All gadolinium-enhanced cavograms were considered diagnostic and of satisfactory quality to allow planning of interventions at the time of the procedure. Specifically, the IVC could be evaluated from the level of the confluence of the iliac veins to the diaphragmatic hiatus, allowing identification of the renal veins and, in one case, intraluminal thrombus. There were no instances in which the operator decided to switch to iodinated contrast agents in order to obtain a satisfactory study.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Catheter-based imaging and interventions in the vena cava are an important part of radiologic practice. Iodinated contrast agents are suitable for the majority of patients with normal renal function who require invasive procedures in the vena cava. Patients with renal insufficiency, however, are at increased risk of contrast agent–induced acute renal failure following angiography with iodinated contrast agents (9,10). The risk of contrast agent–induced acute renal failure is difficult to predict, as it varies on the basis of patient profile, type of iodinated contrast agent, and definition of renal failure. With use of the definitions and guidelines proposed by Solomon et al (9), the incidence of contrast agent–induced acute renal failure is 11% in patients with a baseline creatinine level greater than or equal to 1.5 mg/dL (133 µmol/L) who undergo cardiac catheterization. To our knowledge, there are no studies of contrast agent–induced renal failure following cavography with iodinated contrast agents. An alternative contrast agent that permits invasive imaging of the vena cava without the risk of nephrotoxicity would be useful for this subset of patients.

Gadolinium-based contrast agents were developed for and are primarily used in MR imaging (11). These contrast agents have an excellent safety profile in patients with renal insufficiency (7,8,12). Although decreased creatinine clearance has been observed in isolated ischemic rat nephrons after perfusion with gadolinium tetraazacyclododecanetetraacetic acid (DOTA) (13), other studies have shown no change or slight increase in glomerular filtration rate with high doses (0.5–0.6 mmol/kg) of Gd-DOTA in isolated rat kidneys and in vivo in dogs (14,15). To our knowledge, the explanation for the lack of nephrotoxicity of gadolinium-based contrast agents is not known. In this series, 11 of 14 patients experienced either a decrease in serum creatinine level or an elevation that was less than 0.5 mg/dL (44 µmol/L) at 48 hours after their procedure.

The three patients in this series who experienced an elevation in serum creatinine level of greater than or equal to 0.5 mg/dL (44 µmol/L) at 48 hours after cavography with gadodiamide had other explanations for their renal failure. These cases underscore the important point that the use of a gadolinium-based contrast agent will not halt or reverse ongoing acute renal failure or overcome other causes of renal dysfunction. Furthermore, these cases reflect the observational nature of this series. The presence of ongoing acute decompensation of renal function did not preclude the use of gadolinium-based contrast agent in these patients, although we currently avoid use of gadolinium-based contrast agent in such cases because there seems to be little benefit in terms of renal function.

Use of gadolinium-based contrast agents is not entirely without risk. Adverse reactions, including true anaphylaxis, are rare but do occur (16). Fortunately, cross sensitivity in patients with prior anaphylaxis to iodinated contrast agents does not appear to be a problem (16). In one study of patients with a baseline serum creatinine level greater than or equal to 2.0 mg/dL (177 µmol/L) who received 0.1 mmol/kg of gadopentetate dimeglumine intravenously for brain MR imaging, the overall adverse reaction rate was 3.6% within 72 hours of injection (8). None of the events was considered serious or life threatening. The patients in the current series tolerated the injections of gadolinium-based contrast agent without incident.

Theoretically, gadolinium-based contrast agents should work well as a radiologic contrast agent. The k edge of gadolinium-based contrast agents is 52 and exceeds that of iodine, which is 33. In vitro experimental findings have shown that above a mean 72 kVp ± 6, image contrast is better with gadolinium-based contrast agents than with iodinated agents (17). Below this kilovolt peak setting, iodine provides image contrast superior to that with gadolinium-based contrast agents (17). Quinn and co-workers (18) determined in a tissue phantom that at equimolar concentrations, gadopentetate dimeglumine caused 250% greater attenuation than did iopromide (Ultravist 370; Berlex Laboratories) in a CT scanner at 120 kV, 250 mA, with 5-mm section thickness, and a 2.5-second exposure. They found that 90 mL of gadopentetate dimeglumine (47 mmol, equal to 10 times the U. S. Food and Drug Administration approved dose) injected intravenously provided satisfactory enhancement of the circle of Willis.

Despite the theoretically favorable x-ray imaging properties of gadolinium-based contrast agent, the actual vascular enhancement observed during DSA is weaker than that observed with iodinated contrast agents. This is due to the relatively low concentration of gadolinium in currently available MR imaging contrast agents. In one study, the density of gadopentetate dimeglumine diluted 50% with normal saline solution was found to be equivalent to that of a solution of 40 mg of iodine per milliliter at 80 kVp (5). The typical iodine content of contrast agents used for DSA is 200–300 mg of iodine per milliliter (19).

The low density of current gadolinium-based contrast agents presents a dilemma when used for DSA. Ideally, the contrast agent should not be diluted, to maximize its density during imaging (6). However, the maximum dose of gadodiamide approved by the U. S. Food and Drug Administration is 0.3 mmol/kg, or 0.6 mL/kg (manufacturer's recommendation, Nycomed, Princeton, NJ). The maximum approved dose of gadopentetate dimeglumine is only 0.1 mmol/kg, or 0.2 mL/kg (manufacturer's recommendation, Berlex Laboratories, Wayne, NJ). Therefore, dilution is usually necessary in most cases in order to achieve a contrast agent volume that is sufficient for cavography without vastly exceeding the approved dosages. We were unwilling to exceed a dose of 0.4 mmol/kg (0.8 mL/kg) because of a lack of published safety data.

The choice of definition of contrast agent–induced renal failure has a major effect on any study in which this entity is examined (10,20). Some authors have advocated use of a percentage change instead of or in addition to an absolute rise in serum creatinine level, as well as extension of the period of observation to 72 hours (10,20). We chose the definition of a rise in serum creatinine level greater than or equal to 0.5 mg/dL (44 µmol/L) at 48 hours as this is among the criteria for contrast agent–induced acute renal failure used by the nephrology service in our hospital.

In most situations, CO2 gas is an inexpensive, safe alternative contrast agent for DSA studies. The actual cost of the volume of CO2 used for most angiographic applications is pennies (1,21). The limitations associated with CO2-enhanced venography include the need to temporarily displace all of the blood in the IVC with a large volume of gas for accurate imaging (Fig 2) and lack of readily available CO2 power injectors for controlled administration of the contrast agent (21). Venous administration of large volumes of CO2 to a patient in the supine position can, rarely, result in trapping of the gas in the anterior pulmonary artery outflow tract, with obstruction of blood flow ("vapor lock") and cardiovascular compromise (22). Furthermore, cavography with CO2 may be contraindicated in patients with intracardiac or intrapulmonary right-to-left shunts. Ehrman et al (22) noted seizures in two patients and loss of consciousness in a third patient in whom reflux of CO2 occurred into the arterial circulation during imaging of upper extremity hemodialysis fistulas.

Gadolinium-based contrast agents can be used in any patient (with the exception of patients who are pregnant or lactating or experienced anaphylaxis after exposure to gadolinium) for diagnostic and interventional procedures in the vena cava without the need for specialized equipment. Owing to the expense of the gadolinium-based contrast agents (purchase price of $70–$100 per 20-mL vial) and the limited volumes that can be used, they are most suitable for patients with contraindications to conventional contrast agents such as renal insufficiency. Gadolinium-based contrast agents may be of special utility for venographic studies in patients with renal insufficiency and known or suspected right-to-left shunts.

The risk factors for contrast agent–induced acute renal failure in patients with renal insufficiency include contrast agent type, patient hydration, diabetes, site of injection, prior episodes of contrast agent–induced renal failure, and the volume of contrast agent used (23). A safe threshold volume of iodinated contrast agent that can be used without risk of contrast agent–induced renal failure in these patients has not been determined. Similarly, the minimal volume of iodinated contrast agent required for cavography has not been established. In our institution, we regularly inject 30–40 mL of contrast agent per cavogram and obtain both a pre- and postplacement cavogram when placing an IVC filter. The typical total volume of contrast agent, including test injections by hand to confirm catheter placement, ranges from 70 to 100 mL for an IVC filter placement. The purchase price of 100 mL of nonionic contrast agent varies greatly by region and manufacturer, but it is currently approximately $45 at our institution.

This article is a description of our initial limited experience with gadolinium-based contrast agents in vena cavography. A multiinstitutional, prospective, randomized comparative study with either CO2 or a conventional iodinated contrast agent is required to fully evaluate this application of gadolinium-based contrast agents. Inclusion of only those patients with stable renal insufficiency would simplify data analysis and interpretation.

Gadolinium-based contrast agents have been described as alternative contrast agents at DSA in case reports by several authors (4–6). Findings in this small series suggest that gadolinium-based contrast agents are suitable as an alternative at digital subtraction vena cavography in patients with renal insufficiency, particularly when a limited volume of contrast agent is needed.


   Footnotes
 
Abbreviations: IVC = inferior vena cava DOTA = tetraazacyclododecane-tetraacetic acid DSA = digital subtraction angiography SVC = superior vena cava

Author contributions: Guarantor of integrity of entire study, J.A.K.; study concepts and design, J.A.K.; definition of intellectual content, all authors; literature research, J.A.K.; clinical studies, all authors; data acquisition, J.A.K.; data analysis, all authors; statistical analysis, J.A.K.; manuscript preparation and editing, J.A.K.; manuscript review, all authors.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Kerns SR, Hawkins IF, Jr. Carbon dioxide digital subtraction angiography: expanding applications and technical evolution. AJR 1995; 164:735-741.[Abstract/Free Full Text]
  2. Sullivan KL, Bonn J, Shapiro MJ, Gardiner GA. Venography with carbon dioxide as a contrast agent. Cardiovasc Intervent Radiol 1995; 18:141-145.[Medline]
  3. McCowan TC, Ferris EJ, Carver DK. Inferior vena caval filter thrombi: evaluation with intravascular US. Radiology 1990; 177:783-788.[Abstract/Free Full Text]
  4. Kinno Y, Odagiri K, Andoh K, Itoh Y, Tarao K. Gadopentetate dimeglumine as an alternative contrast material for use in angiography. AJR 1993; 160:1293-1294.[Free Full Text]
  5. Kaufman JA, Geller SC, Waltman AC. Renal insufficiency: gadopentetate dimeglumine as a radiographic contrast agent during peripheral vascular interventional procedures. Radiology 1996; 198:579-581.[Abstract/Free Full Text]
  6. Matchett WJ, McFarland DR, Russell DK, Sailors DM, Moursi MM. Azotemia: gadopentetate dimeglumine as a contrast agent at digital subtraction angiography. Radiology 1996; 201:569-571.[Abstract/Free Full Text]
  7. Prince MR, Arnoldus C, Frisoli JK. Nephrotoxicity of high-dose gadolinium compared with iodinated contrast. JMRI 1996; 5:162-166.
  8. Aresenault TM, King BF, Marsh JW, Jr, et al. Systemic gadolinium toxicity in patients with renal insufficiency and renal failure: retrospective analysis of an initial experience. Mayo Clin Proc 1996; 71:1150-1154.[Medline]
  9. Solomon R, Werner C, Mann D, D'Elia J, Silva P. Effects of saline, mannitol, and furosemide on acute decreases in renal function induced by radiocontrast agents. N Engl J Med 1994; 331:1416-1420.[Abstract/Free Full Text]
  10. Lautin EM, Freeman NJ, Schoenfeld AH, et al. Radiocontrast-associated renal dysfunction: incidence and risk factors. AJR 1991; 157:49-58.[Abstract/Free Full Text]
  11. Brasch RC. Introduction to the gadolinium class. J Comput Assist Tomogr 1993; 17(suppl):19-23.
  12. Haustein J, Niendorf HP, Krestin G, et al. Renal tolerance of gadolinium-DTPA/dimeglumine in patients with chronic renal failure. Invest Radiol 1992; 27:352-354.[Medline]
  13. Brillet G, Dubois M, Beaufils H, Bourbouze R, Deray G. Renal tolerance of gadolinium-DOTA and gadolinium-DTPA in rats. Invest Radiol 1994; 29:352-354.[Medline]
  14. Katzberg RW, Sahler LG, Duda SW, et al. Renal handling and physiologic effects of the paramagnetic contrast medium Gd-DOTA. Invest Radiol 1990; 25:714-719.[Medline]
  15. Brown PWG, Haylor JL, Morcos SK, El Nahas AM. The functional effects of gadolinium-DTPA on the isolated perfused rat kidney. Eur J Radiol 1993; 16:85-89.[Medline]
  16. Murphy KJ, Brunberg JA, Cohan RH. Adverse reactions to gadolinium contrast media: a review of 36 cases. AJR 1996; 167:847-849.[Abstract/Free Full Text]
  17. Cardinal HN, Holdsworth DW, Drangova M, Hobbs BB, Fenster A. Experimental and theoretical x-ray imaging performance: comparison of iodine and lanthanide contrast agents. Med Phys 1993; 20:15-31.[Medline]
  18. Quinn AD, O'Hare NJ, Wallis FJ, Wilson GF. Gd-DTPA: an alternative contrast medium for CT. J Comput Assist Tomogr 1994; 18:634-636.[Medline]
  19. Bettman MA. Angiographic contrast media. In: Kandarpa K, Aruny JE, eds. Handbook of interventional radiologic procedures. 2nd ed. Boston, Mass: Little Brown, 1996; 313-317.
  20. Rudnick MR, Berns JS, Cohen RM, Goldfarb S. Nephrotoxic risks of renal angiography: contrast media-associated nephrotoxicity and atheroembolism—a critical review. Am J Kidney Dis 1994; 24:713-727.[Medline]
  21. Caridi JG, Hawkins IF. CO2 digital subtraction angiography: potential complications and their prevention. JVIR 1997; 8:383-391.[Medline]
  22. Ehrman KO, Taber TE, Gaylord GM, Brown PB, Hage JP. Comparison of diagnostic accuracy with carbon dioxide versus iodinated contrast material in the imaging of hemodialysis access fistulas. JVIR 1994; 5:771-775.[Medline]
  23. Bettmann MA. Physiologic effects and systemic reactions. In: Baum S, eds. Abram's angiography. Boston, Mass: Little Brown, 1997; 22-37.



This article has been cited by other articles:


Home page
 Nephrol Dial TransplantHome page
C. M. Erley, B. D. Bader, E. D. Berger, N. Tuncel, S. Winkler, G. Tepe, T. Risler, and S. Duda
Gadolinium-based contrast media compared with iodinated media for digital subtraction angiography in azotaemic patients
Nephrol. Dial. Transplant., October 1, 2004; 19(10): 2526 - 2531.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Neuroradiol.Home page
J. W. Henson, R. G. Nogueira, D. J. Covarrubias, R. G. Gonzalez, and M. H. Lev
Gadolinium-Enhanced CT Angiography of the Circle of Willis and Neck
AJNR Am. J. Neuroradiol., June 1, 2004; 25(6): 969 - 972.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
R. T. Andrews
Contrast Peripheral Phlebography and Pulmonary Angiography for Diagnosis of Thromboembolism
Circulation, March 30, 2004; 109(12_suppl_1): I-22 - I-27.
[Abstract] [Full Text]

Home page
 Am. J. Roentgenol.Home page
H. S. Thomsen
Guidelines for Contrast Media from the European Society of Urogenital Radiology
Am. J. Roentgenol., December 1, 2003; 181(6): 1463 - 1471.
[Full Text] [PDF]

Home page
 RadiologyHome page
U. Nyman, B. Elmstahl, P. Leander, M. Nilsson, K. Golman, and T. Almen
Are Gadolinium-based Contrast Media Really Safer than Iodinated Media for Digital Subtraction Angiography in Patients with Azotemia?
Radiology, May 1, 2002; 223(2): 311 - 318.
[Abstract] [Full Text] [PDF]

Home page
 RadiologyHome page
D. J. Spinosa, J. A. Kaufmann, and G. D. Hartwell
Gadolinium Chelates in Angiography and Interventional Radiology: A Useful Alternative to Iodinated Contrast Media for Angiography
Radiology, May 1, 2002; 223(2): 319 - 325.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kaufman, J. A.
Right arrow Articles by Waltman, A. C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kaufman, J. A.
Right arrow Articles by Waltman, A. C.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
RADIOLOGY RADIOGRAPHICS RSNA JOURNALS ONLINE