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Gadolinium Chelates in Angiography and Interventional Radiology: A Useful Alternative to Iodinated Contrast Media for Angiography¹

¹ From the Department of Radiology, University of Virginia Health System, 1215 Lee St, Charlottesville, VA 22908 (D.J.S., G.D.H.), and Department of Radiology, Dotter Interventional Institute, Oregon Health Sciences University, Portland (J.A.K.). Received April 6, 2001; revision requested May 18; revision received June 28; accepted July 16. Address correspondence to D.J.S. (e-mail: djs4m@virginia.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION GADOLINIUM-BASED CONTRAST MEDIA:... SPECIFIC ADVERSE EFFECTS IMAGING CONSIDERATIONS GADOLINIUM-ENHANCED ANGIOGRAPHY:... HOW TO USE GADOLINIUM... CONCLUSION REFERENCES

 
Gadolinium has physical properties that are well suited for radiographic imaging. Digital subtraction angiography with a gadolinium chelate as contrast medium can provide images of suitable quality for diagnosis and intervention. The overall safety profile of gadolinium-based contrast media is excellent. In particular, these contrast media are well tolerated in patients with renal insufficiency when administered intraarterially in doses of less than 0.3–0.4 mmol per kilogram body weight, with a decreased incidence of contrast medium–induced nephropathy, as compared with similar volumes of iodinated contrast material. The currently available formulations of gadolinium chelates can be injected safely into every arterial and venous structure. However, substantial data are lacking on the intraarterial use of gadolinium in patients with renal insufficiency, particularly at doses that exceed those routinely used in magnetic resonance angiography. Gadolinium chelates in appropriate volumes are useful alternative contrast media in selected high-risk patients undergoing angiographic studies.

© RSNA, 2002

Index terms: Angiography, contrast media, 9*.1211² • Contrast media, complications • Contrast media, effects • Contrast media, toxicity • Gadolinium • Iodine and iodine compounds • Uremia

	INTRODUCTION

TOP ABSTRACT INTRODUCTION GADOLINIUM-BASED CONTRAST MEDIA:... SPECIFIC ADVERSE EFFECTS IMAGING CONSIDERATIONS GADOLINIUM-ENHANCED ANGIOGRAPHY:... HOW TO USE GADOLINIUM... CONCLUSION REFERENCES

 
Patients with a history of renal insufficiency or a history of severe allergic reaction to iodinated contrast media present a serious dilemma to the interventional radiologist when diagnostic angiographic or interventional procedures are contemplated. Contrast medium–induced nephropathy has been reported (1–4) to occur in approximately 10%–30% of patients with preexisting renal insufficiency when iodinated contrast media are used intravascularly.

Despite the recovery of renal function in most of these patients, contrast medium–induced nephropathy can still be a serious problem in a substantial percentage of these patients. Permanent deterioration in renal function can occur. Some investigators (5,6) cite a 10%–25% incidence of dialysis, at least transiently, in patients developing contrast medium–induced nephropathy, especially when oliguria develops. In addition, in up to 30% of the patients, renal function fails to return to baseline (5). Equally disturbing are reports of a 34% mortality rate in patients who develop contrast medium–induced nephropathy while hospitalized, compared with a 7% mortality rate in patients who do not develop contrast medium–induced nephropathy during hospitalization (7). Although others (6) have failed to demonstrate a similar increase in mortality rate and important coexistent medical problems such as sepsis and transient hypotension may have contributed to the deterioration in renal function in some patients, it is clear that contrast medium–induced nephropathy results in prolongation of the hospital stay and occasional need for dialysis and predisposes at least some patients to permanent worsening of renal function and death.

Occasionally, patients with a history of a severe life-threatening allergic reaction to iodinated contrast media will require a study with iodinated contrast medium. More frequently, patients have been told "never" to receive iodinated contrast media because of a previous "reaction" that they may not be able to recall. In these patients, the radiologist is left in a difficult situation regarding whether to administer iodinated contrast medium.

Noninvasive studies such as duplex sonography or magnetic resonance (MR) angiography or venography represent alternative diagnostic options in patients at risk for an adverse reaction to iodinated contrast media or contrast medium–induced nephropathy. However, when these studies are inconclusive or if a percutaneous invasive procedure is contemplated, another strategy is needed.

Recently, fenoldopam and acetylcysteine have been proposed as possible options to reduce nephropathy induced by iodinated contrast medium (8,9). Both strategies require administration of the drug for some period of time prior to the procedure. Although there is limited clinical experience with these two agents at this time, renal failure may still occur (9). Use of carbon dioxide (CO₂)-enhanced angiography has been advocated in selected patients (10). Unfortunately, CO₂-enhanced angiography has limited applications and does not always result in a complete examination (11,12). Use of small amounts of iodinated contrast medium can be used to supplement a CO₂-enhanced study; however, it is unclear if the amount of iodinated contrast medium used is an important risk factor for contrast medium–induced nephropathy (13,14).

Another strategy is to use a gadolinium-based contrast medium in place of iodinated contrast media, either alone or in conjunction with CO₂-enhanced angiography. Because of the ability of gadolinium to attenuate x rays, its use with digital subtraction angiography (DSA) can produce diagnostic-quality images for angiographic and interventional radiologic procedures (15–18). With doses recommended for MR imaging, use of a gadolinium chelate during angiography has been reported to result in a reduced incidence of contrast medium–induced nephropathy, when compared with the use of iodinated contrast media. The authors of several reports (19–21) support the safety of gadolinium chelates in patients with preexisting renal insufficiency, when used intravenously for MR studies.

	GADOLINIUM-BASED CONTRAST MEDIA: PROPERTIES

TOP ABSTRACT INTRODUCTION GADOLINIUM-BASED CONTRAST MEDIA:... SPECIFIC ADVERSE EFFECTS IMAGING CONSIDERATIONS GADOLINIUM-ENHANCED ANGIOGRAPHY:... HOW TO USE GADOLINIUM... CONCLUSION REFERENCES

 
Free gadolinium, which is a rare-earth element, is toxic and is excreted by the body slowly, with a biologic half-life of several weeks (22). To reduce its toxicity, therefore, free gadolinium must be chelated to another chemical that prevents the biologic availability of free gadolinium. Four gadolinium-based contrast agents are available for use in the United States: gadopentetate dimeglumine (Magnevist; Berlex, Wayne, NJ, and Schering, Berlin, Germany), gadodiamide (Omniscan; Nycomed, Princeton, NJ), gadoteridol (ProHance; Bracco Diagnostic, Princeton, NJ), and gadoversetamide (OptiMARK; Mallinckrodt, St Louis, Mo) (Table). These four agents have similar biodistributions, pharmacokinetics, and half-lives (23–26). The biologic elimination half-life of these agents is approximately 1 hours, and these agents demonstrate a 500-fold increase in renal excretion when compared with the excretion of free gadolinium (27,28).

	SPECIFIC ADVERSE EFFECTS

TOP ABSTRACT INTRODUCTION GADOLINIUM-BASED CONTRAST MEDIA:... SPECIFIC ADVERSE EFFECTS IMAGING CONSIDERATIONS GADOLINIUM-ENHANCED ANGIOGRAPHY:... HOW TO USE GADOLINIUM... CONCLUSION REFERENCES

 
Although there is substantial evidence in the literature documenting the clinical safety of gadopentetate dimeglumine, gadodiamide, and gadoteridol, adverse reactions have been reported in association with their administration. The total incidence of adverse events appears to be less than 5%, and the incidence of any single adverse event is approximately 1% or less in all patients (38). The most common events are nausea, headache, and emesis.

Anaphylactoid reactions have also been reported with each of these agents. The incidence of such reactions is probably in the range of one in 100,000 to one in 500,000 administrations (22). Not surprisingly, the risk of adverse reactions is higher in patients with a history of reaction to iodinated contrast media (33,39).

It is important to note that the intraarterial use of gadolinium chelates represents an "off-label" use of these U.S. Food and Drug Administration–approved contrast agents. The Food and Drug Administration–approved doses for intravenous use are shown in the Table. Although higher doses of gadolinium agents have been administered safely in some patients (40), because the clinical use of higher doses has not been studied to any great extent it seems prudent to limit the total dose of gadolinium administered for angiographic studies to 0.3–0.4 mmol per kilogram (mmol/kg) body weight. A more detailed discussion regarding gadolinium doses is presented later.

	IMAGING CONSIDERATIONS

TOP ABSTRACT INTRODUCTION GADOLINIUM-BASED CONTRAST MEDIA:... SPECIFIC ADVERSE EFFECTS IMAGING CONSIDERATIONS GADOLINIUM-ENHANCED ANGIOGRAPHY:... HOW TO USE GADOLINIUM... CONCLUSION REFERENCES

 
The density, atomic number, and thickness of an object, as well as the x-ray beam characteristics, determine the absorption of x-rays by an object. Differential absorption of x rays by the object determines image contrast. The differences in atomic number of the elements constituting the tissue and contrast medium are the primary sources of contrast in medical imaging.

Gadolinium has a higher atomic number (Z = 64) and a higher k edge (50 keV) than iodine (Z = 53; k edge, 33 keV). These properties allow gadolinium and iodine to absorb x rays in the diagnostic energy spectrum. In theory, the higher k edge of gadolinium allows the use of imaging at a higher kilovolt peak level (in the range of 96 kVp) without the loss of contrast, as compared with a lower kilovolt peak level used for imaging with iodinated media (in the range of 73 kVp). Results of in vitro experiments have substantiated these findings (41).

Diagnostic and interventional radiology procedures with gadolinium-based media have been performed at 70–110 kVp (16,42). We have found that imaging with gadolinium chelates at 96 kVp results in better image quality at a lower radiation dose, relative to the lower 70–80 kVp traditionally used with iodinated contrast media (43). However, gadolinium chelates are limited as an angiographic contrast media because of the relatively low concentration of gadolinium chelate molecules in the preparations available in the United States.

In general, for an average-sized adult patient, an increase to 96 kVp results in a reduction in the radiation dose by about one-half, but because of the reduced concentration of the gadolinium chelates, we typically increase the dose by a factor of about 1.8 to reduce the "mottle" effect. Overall there is about a 10% reduction in radiation dose when comparing imaging with gadolinium-based media to imaging with iodinated media. This small benefit is lost as patient size increases, and the benefit increases as patient size decreases.

The results of laboratory phantom experiments have demonstrated that radiographic images of similar volumes of gadolinium exhibit image contrast equal to that obtained with an iodine preparation containing 37.5–75.0 milligrams of iodine per milliliter (ie, one-eighth to one-fourth strength iodine preparation containing 300 mg of iodine per milliliter) (Fig 1). As "soft-tissue" attenuation increases (body parts increase in thickness), image contrast is relatively unchanged at these higher kilovolt peak levels for gadolinium-enhanced images but deteriorate more rapidly for iodinated contrast medium–enhanced images. When imaged with 20 cm of water attenuation, image contrast with a full-strength gadolinium chelate is equal to approximately 75–150 mg of iodine per milliliter (ie, one-fourth to one-half strength iodine preparation containing 300 mg of iodine per milliliter) (Fig 1). Tissue attenuation results in "hardening" of the x-ray beam (shifting of the energy spectrum toward higher energy values). Beam hardening results in increased image contrast for a given concentration of gadolinium relative to that of iodine and accounts for some of the differences noted between theoretical models and calculations and in vivo observations of image contrast.

View larger version (65K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. (a, b) From left to right, phantoms demonstrate contrast with 300 mg iodine per milliliter, 150 mg iodine per milliliter, 75 mg iodine per milliliter, 0.5 mmol gadolinium per milliliter (full-strength gadolinium chelate) (arrow), 37.5 mg iodine per milliliter, and 18.75 mg iodine per milliliter. (a) Phantom with 0 cm of water attenuation at 96 kVp. (b) Phantom with 20 cm of water attenuation at 96 kVp. The full-strength gadolinium chelate (arrow) demonstrates image contrast in a range between the contrast levels at 75 and 150 mg iodine per milliliter.

View larger version (101K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. (a, b) From left to right, phantoms demonstrate contrast with 300 mg iodine per milliliter, 150 mg iodine per milliliter, 75 mg iodine per milliliter, 0.5 mmol gadolinium per milliliter (full-strength gadolinium chelate) (arrow), 37.5 mg iodine per milliliter, and 18.75 mg iodine per milliliter. (a) Phantom with 0 cm of water attenuation at 96 kVp. (b) Phantom with 20 cm of water attenuation at 96 kVp. The full-strength gadolinium chelate (arrow) demonstrates image contrast in a range between the contrast levels at 75 and 150 mg iodine per milliliter.

	GADOLINIUM-ENHANCED ANGIOGRAPHY: BACKGROUND AND SAFETY

TOP ABSTRACT INTRODUCTION GADOLINIUM-BASED CONTRAST MEDIA:... SPECIFIC ADVERSE EFFECTS IMAGING CONSIDERATIONS GADOLINIUM-ENHANCED ANGIOGRAPHY:... HOW TO USE GADOLINIUM... CONCLUSION REFERENCES

The initial reports of gadolinium chelates as contrast media for conventional angiography in patients with renal insufficiency were uniformly favorable in terms of their effect on renal function, with no cases of contrast medium–induced renal failure. The volumes of gadolinium chelate were in keeping with those used for MR angiography (0.3–0.4 mmol/kg). However, the majority of these publications were either case reports or small retrospective series.

In 1998, Gemery at al (51) published a case report of a 61-year-old woman with peripheral vascular disease, diabetes, and renal insufficiency (serum creatinine level, 4.6 mg/dL [407 µmol/L]) who developed transient acute worsening of her renal function after lower extremity angiography with 80 mL (0.44 mmol/kg) of gadoteridol. Although the authors attributed the increase in creatinine level to the gadoteridol, the patient was receiving increasing oral doses of furosemide prior to the procedure and received 80 mg of furosemide intravenously after the angiographic examination. This may have contributed to the renal failure, because furosemide after angiography with iodinated contrast medium in patients with renal insufficiency increases the incidence of contrast medium–induced nephropathy to 40% when compared with hydration alone (11%) or mannitol administration (28%) (52). Recently, a case of acute pancreatitis and worsening renal failure in a patient with diabetes, hyperlipidemia, hypertension, and a baseline serum creatinine level of 3.8 mg/dL (336 µmol/L) has been described in a letter (53). The patient underwent diagnostic angiography, angioplasty, and stent placement with the use of gadodiamide. However, the volume of contrast medium used was not reported. The patient developed acute pancreatitis within 12 hours of angiography, followed by worsening of her renal function. As illustrated by these two reports, patients with renal insufficiency who are undergoing contrast-enhanced angiography are frequently medically complex and in flux. In most instances, there is more than one potential explanation for the deterioration in renal function.

The reported cases of renal failure attributed to gadolinium chelates emphasize another point: that the renal "safety" of gadolinium may be relative, in comparison with iodinated contrast media, rather than absolute. In 2000, Spinosa et al (54) reported the results of a prospective study of 42 procedures in 40 patients with baseline renal insufficiency in which CO₂ with either small quantities of iodinated contrast medium (iohexol) or gadodiamide were used for lower extremity angiography and interventions in patients with baseline renal insufficiency. Contrast medium–induced renal failure (>0.5 mg/dL [44 µmol/L] increase in serum creatinine level within 24 hours of the procedure) occurred in 40% of patients who received iohexol and in 5% of patients who received gadodiamide (P < .05). The average volumes of contrast medium used in each group were similar (53 mL of iohexol, 55 mL of gadodiamide). These results provide strong evidence of the comparative safety of gadodiamide as an angiographic contrast medium in patients with renal insufficiency.

	HOW TO USE GADOLINIUM CHELATES IN ANGIOGRAPHY AND VENOGRAPHY

TOP ABSTRACT INTRODUCTION GADOLINIUM-BASED CONTRAST MEDIA:... SPECIFIC ADVERSE EFFECTS IMAGING CONSIDERATIONS GADOLINIUM-ENHANCED ANGIOGRAPHY:... HOW TO USE GADOLINIUM... CONCLUSION REFERENCES

 
The three features of gadolinium chelates that are most attractive for DSA are the apparent low nephrotoxicity, the liquid nature of the medium, and the angiographic appearance as positive contrast. Although CO₂ has no known nephrotoxicity, it is invisible (and therefore indistinguishable from room air) and displaces blood in a vessel rather than mixes with it. Great care must be exercised when handling the gas to prevent contamination by room air. Furthermore, the lack of an available power injector for CO₂ in the United States requires hand injection of contrast medium by the angiographer during all examinations. CO₂ is also a negative contrast medium that can sometimes "break up" into bubbles, causing image deterioration (55). Gadolinium chelates require no special handling and can be used in conventional angiographic power injectors. These agents mix with blood in a manner completely analogous to iodinated contrast media, increasing the overall radiographic opacity of the blood. Less image manipulation is required with gadolinium-enhanced DSA than with CO₂-enhanced DSA.

The major limitations of gadolinium chelates for DSA are the low radiopacity of the currently available preparations and the limited volumes that should be used. As noted earlier, gadolinium-based contrast media have a radiopacity that is equivalent to solutions with approximately 70–150 mg of iodine per milliliter in vivo. Visualization of larger, high-flow vessels can be limited. Gadobutrol (Gadovist; Schering) contains 1 mmol gadolinium per milliliter and should result in improved radiopacity. It is available in Europe and is undergoing testing in the United States.

Indications for the use of gadolinium chelates are any contraindication to iodinated contrast media and, in some cases, contraindications to CO₂-enhanced angiography. As mentioned earlier, a history of a life-threatening anaphylactic reaction to iodinated contrast media or baseline renal insufficiency are the usual clinical features of patients considered for gadolinium-enhanced DSA. The use of gadolinium chelates in patients with rapidly deteriorating renal function is of questionable value, unless a treatable vascular cause is suspected. When iodinated contrast media are contraindicated for cerebral or upper extremity DSA, we believe gadolinium chelates, rather then CO₂, should be used (46,56,57).

The only contraindication to gadolinium-based contrast media known is hypersensitivity (39). Caution should be exercised when administering gadolinium chelates to nursing women, because the extent to which these agents are excreted in human milk is not known, according to manufacturers’ information. Data on the intravascular use of gadolinium chelates in children and pregnant patients is limited, and these contrast media should be used only if the potential benefit justifies the potential risk to the fetus, according to manufacturers’ information. Gadolinium-enhanced DSA in these patients should be considered only if the potential benefits justify the potential risk. Gadolinium can be used safely in patients undergoing hemodialysis, although clearance by peritoneal dialysis is slow (37,58,59).

The appropriate volume of gadolinium that can be used safely in patients with renal insufficiency remains to be determined. There is ample clinical evidence that intravenous doses of up to 0.3 mmol/kg are well tolerated, with no reported cases of contrast medium–induced nephropathy (21,60–62). To our knowledge, there is no documented experience with higher doses in peer-reviewed scientific publications. For this reason, a 0.3 mmol/kg limit should be adhered to during DSA whenever feasible. This is readily accomplished when gadolinium-enhanced angiography is supplemented with CO₂-enhanced angiography during diagnostic and interventional procedures (54).

There does not appear to be any anatomic vascular bed in which gadolinium enhancement cannot be used for DSA. Patients will report mild discomfort when undiluted gadopentetate dimeglumine is injected into small body parts or the extremities. This is presumably due to the high osmolality of this particular medium (Table). Both gadodiamide and gadoteridol have osmolalities that are less than half that of gadopentetate dimeglumine. Patients rarely report subjective complaints when these contrast media are used.

The small total dose of a gadolinium (0.3–0.4 mmol/kg) that is customarily used for DSA places a restriction on the volume available for the examination. The total dose for a 70-kg individual is 42–56 mL. Examinations must therefore be carefully tailored when performed with gadolinium enhancement alone. Owing to the low molar concentration of gadolinium in currently available solutions, these contrast media usually cannot be visualized at fluoroscopy when injected into arteries and veins. The low concentration also prohibits dilution of these agents for use in large and/or high-flow vessels. A 1:1 dilution of the contrast medium with saline or 5% dextrose solution increases the available volume for injection but lowers the radiopacity of the medium. Dilution is less of problem in the extremities when injecting directly into a run-off vessel, the neck, or nonvascular spaces such as the renal collecting system or biliary tree, but dilution can severely degrade the quality of images of deep abdominal arteries and veins. When using a gadolinium chelate as the sole contrast medium, test injections should be recorded as DSA runs or performed by using road-map imaging algorithms. The number of test injections should be minimized, and the volume restricted to 2–5 mL rather than the usual 5–10 mL.

Gadolinium chelates can be power injected by using standard injectors, with the same flow rates and pressures as are used with iodinated contrast media. Contrast medium delivery with power injectors is more controlled and uniform than hand injection. However, substantial amounts of contrast medium can be wasted while loading the injector syringe or during connection to the catheter. For this reason, we believe an additional 10–20 mL of gadolinium chelate should be loaded into the injector syringe. The volume of each injection should be carefully recorded to ensure that the desired maximal dose is not exceeded. Any contrast medium that is not loaded into the injector can be used as table contrast medium.

A wide range of focused examinations can be easily performed with doses of gadolinium that remain within the 0.3–0.4 mmol/kg threshold. Renal, iliac, and carotid DSA can frequently be completed with 40–50 mL of contrast medium. Placement of inferior vena cava filters and upper extremity venography for central venous access are typical venous studies that require limited volumes of contrast medium. Studies of larger volumes, such as aortograms with bilateral lower extremity runoff, can be accomplished by supplementing the study with CO₂-enhanced angiography (18,46,47,53). In these studies, the gadolinium chelate is used to help clarify areas poorly defined with the CO₂ injections (Fig 2) or when a gaseous contrast medium is contraindicated. When the gadolinium injections constitute only a limited portion of the study, the volume of each injection can be increased because fewer injections are needed overall.

View larger version (177K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. (a) CO2-enhanced abdominal aortogram (left anterior oblique projection) demonstrates right renal artery stenosis (straight arrow). Overlying bowel gas (curved arrow) deteriorates the CO2-enhanced image. (b) Selective gadolinium-enhanced right renal artery angiogram (left anterior oblique projection) obtained with 6 mL of full-strength gadodiamide clearly defines the right renal artery stenosis (arrow). (c) Gadolinium-enhanced angiogram (left anterior oblique projection) obtained after injection of 6 mL of gadodiamide through a vascular sheath (curved arrow) in the abdominal aorta demonstrates a widely patent right main renal artery (straight arrow) after balloon angioplasty and stent placement. POST = postangioplasty.

View larger version (181K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. (a) CO2-enhanced abdominal aortogram (left anterior oblique projection) demonstrates right renal artery stenosis (straight arrow). Overlying bowel gas (curved arrow) deteriorates the CO2-enhanced image. (b) Selective gadolinium-enhanced right renal artery angiogram (left anterior oblique projection) obtained with 6 mL of full-strength gadodiamide clearly defines the right renal artery stenosis (arrow). (c) Gadolinium-enhanced angiogram (left anterior oblique projection) obtained after injection of 6 mL of gadodiamide through a vascular sheath (curved arrow) in the abdominal aorta demonstrates a widely patent right main renal artery (straight arrow) after balloon angioplasty and stent placement. POST = postangioplasty.

View larger version (165K): [in this window] [in a new window] [Download PPT slide]   Figure 2c. (a) CO2-enhanced abdominal aortogram (left anterior oblique projection) demonstrates right renal artery stenosis (straight arrow). Overlying bowel gas (curved arrow) deteriorates the CO2-enhanced image. (b) Selective gadolinium-enhanced right renal artery angiogram (left anterior oblique projection) obtained with 6 mL of full-strength gadodiamide clearly defines the right renal artery stenosis (arrow). (c) Gadolinium-enhanced angiogram (left anterior oblique projection) obtained after injection of 6 mL of gadodiamide through a vascular sheath (curved arrow) in the abdominal aorta demonstrates a widely patent right main renal artery (straight arrow) after balloon angioplasty and stent placement. POST = postangioplasty.

	CONCLUSION

TOP ABSTRACT INTRODUCTION GADOLINIUM-BASED CONTRAST MEDIA:... SPECIFIC ADVERSE EFFECTS IMAGING CONSIDERATIONS GADOLINIUM-ENHANCED ANGIOGRAPHY:... HOW TO USE GADOLINIUM... CONCLUSION REFERENCES

	FOOTNOTES

 
9*: Vascular system, location unspecified.

See also the Viewpoint and Commentary by Nyman et al in this issue.

Abbreviation: DSA = digital subtraction angiography

	REFERENCES

TOP ABSTRACT INTRODUCTION GADOLINIUM-BASED CONTRAST MEDIA:... SPECIFIC ADVERSE EFFECTS IMAGING CONSIDERATIONS GADOLINIUM-ENHANCED ANGIOGRAPHY:... HOW TO USE GADOLINIUM... CONCLUSION REFERENCES

 

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