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Background: Left atrial appendage closure (LAAC) is an alternative to reduce thrombotic risk in patients with nonvalvular atrial fibrillation. This procedure conventionally requires the use of a contrast agent. A significant proportion of patients who undergo this procedure have chronic kidney disease, with a high risk of contrast-induced nephropathy., Objective: We aimed to systematically review existing literature regarding the feasibility and safety of a zero-contrast LAAC technique., Methods: We searched the MEDLINE/PubMed, Embase, and Cochrane Central Register of Controlled Trials databases for studies comparing a zero-contrast LAAC technique with conventional LAAC up to April 2024. From each study, we extracted baseline characteristics, feasibility, and safety outcomes. A random model meta-analysis was used to compare outcomes between groups., Results: Five studies reporting data from 367 patients were included. A 100% successful implantation rate was reported in all the zero-contrast groups. The mean number of recaptures reached no significant difference between the groups (mean difference, -0.15; CI, -0.67 to 0.37; I 2 = 0%; P = .58). The zero-contrast group had a significantly shorter fluoroscopy time (mean difference, -4.03; CI, -7.72 to -0.34; I 2 = 67%; P = .03). Complications related to the procedure, peridevice leak, and device-associated thrombus rates were not significantly different between the groups., Conclusion: Zero-contrast LAAC is a feasible alternative. The success and complication rates are consistent with those of conventional LAAC. Aside from the inherent benefit of zero-contrast exposure, this technique allows a reduction in fluoroscopy time., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Among patients undergoing percutaneous vascular intervention, contrast-induced nephropathy (CIN) is associated with increased morbidity and mortality. Serum uric acid/albumin ratio (UAR) has emerged as a new marker associated with poor cardiovascular outcomes. We aimed to evaluate the relationship between UAR and CIN occurrence in patients treated for peripheral artery disease., Methods: Patients underwent percutaneous intervention due to peripheral artery disease were enrolled. The primary endpoint was development of contrast related nephropathy. Patients were divided into 2 groups according to the CIN occurrence., Results: A total of 663 patients were enrolled and mean age was 62 ± 10 years. After the intervention, 45 patients had CIN and 618 patients did not have CIN. Logistic regression analysis was performed to define the parameters of CIN. Male gender, diabetes, UAR, contrast volume, presence of coronary artery disease, and C-reactive protein levels were found significant in univariate analysis. However, only UAR was found significant in multivariate analysis (odds ratio 95% confidence interval: 3.426 (1.059-11.079), (P = 0.040)).Therefore, it is the only independent predictor for occurrence of CIN., Conclusions: UAR is a reliable scoring system, which predicts CIN in such patient group. This score is not only cost-effective also simple, which can be easily applied into the clinical practice., (Copyright © 2024 Elsevier Inc. All rights reserved.)

International consensus supports the development of standardized protocols for measured glomerular filtration rate (mGFR) to facilitate the integration of mGFR testing in both clinical and research settings. To this end, the European Kidney Function Consortium convened an international group of experts with relevant experience in mGFR. The working group performed an extensive literature search to inform the development of recommendations for mGFR determination using 1-compartment plasma clearance models and iohexol as the exogenous filtration marker. Iohexol was selected as it is non-radio labeled, inexpensive, and safe, can be assayed at a central laboratory, and the other commonly used non-radio-labeled tracers have been (inulin) or are soon to be (iothalamate) discontinued. A plasma clearance model was selected over urine clearance as it requires no urine collection. A 1 compartment was preferred to 2 compartments as it requires fewer samples. The recommendations are based on published evidence complemented by expert opinion. The consensus paper covers practical advice for patients and health professionals, preparation, administration, and safety aspects of iohexol, laboratory analysis, blood sample collection and sampling times using both multiple and single-sample protocols, description of the mGFR mathematical calculations, as well as implementation strategies. Supplementary materials include patient and provider information sheets, standard operating procedures, a study protocol template, and support for mGFR calculation., (Copyright © 2024 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

The fluorescent compound relmapirazin has been rationally designed for use in point-of-care measurement of glomerular filtration rate (GFR), with attributes including negligible protein binding, negligible metabolites in vivo, negligible tubular secretion, and excellent chemical and photo stability. Twenty-four nonclinical assays were performed in accordance with FDA requirements yielding negligible toxicology concerns. Here, a clinical study was performed to validate relmapirazin as a GFR tracer in patients by comparison to iohexol. This was evaluated in 120 adults at three clinical sites with eGFR values ranging from normal to Stage 4 chronic kidney disease. Relmapirazin and iohexol were administered intravenously in consecutive boluses to each subject and serial blood samples obtained over the subsequent 12 hours. Plasma concentrations were measured and the corresponding plasma GFR for each agent was determined using a standard two-compartment pharmacokinetic assessment. Urine from each subject was collected for the entire 12-hour study period to measure the amount of administered dose appearing in the urine. A near perfect linear regression correlation was observed between the GFRs measured by these two tracers (r 2 =0.99). Bland-Altman analysis confirmed agreement between these two measures of GFR (limits of agreement -7.0 to +5.6 mL/min; mean of -0.7 mL/min). The GFR determined by relmapirazin was independent of GFR stratification by chronic kidney disease stage, and importantly by race. The percent of the administered relmapirazin dose recovered in the urine was greater than or equal to that of iohexol with no reported severe adverse events. Thus, relmapirazin may be used as a GFR tracer agent in humans., (Copyright © 2024 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

In the diagnosis of migraine, which is a neurovascular disease, gadolinium-based contrast agents (GBCAs) are used to rule out more serious conditions. On the other hand, it remains unclear as a scientific gap whether GBCAs may trigger migraine-related pain. The aim of this study was to investigate the effect of GBCAs on mechanical and thermal pain behaviour in a nitroglycerin (NTG)-induced migraine model in mice. NTG (10 mg/kg) was administered intraperitoneally to adult (6-8weeks old) BALB/c mice 2 h before behavioral tests 5 times every other day on days 1st, 3rd, 5th and 9th to induce migraine model (N = 50). As GBCAs, gadobenate dimeglumine (linear-ionic), Gadodiamide (linear-nonionic), and gadobutrol (macrocyclic-nonionic) were delivered intravenously through the tail vein of mice for 5 days on test days. Mechanical pain threshold (plantar and facial withdrawal threshold) was evaluated by plantar von Frey and periorbital von Frey tests on days 1st, 5th, and 9th, and thermal pain threshold (latency) was evaluated by hot plate and cold plate tests on days 3rd and 7th. There was a statistically significant increase in mechanical and thermal hyperalgesia in NTG administered groups compared to the control group. Gadodiamide, gadobutrol and gadobenate dimeglumine administration significantly decreased latency, paw and facial withdrawal threshold (0.18 ± 0.05, 0.17 ± 0.07, 0.16 ± 0.09; 9th day values respectively) compared to NTG group (0.27 ± 0.05). The results of this in vivo study show that GBCAs produce effects that may trigger migraine attacks in migraine. It is recommended that these effects be further investigated and supported by further clinical studies., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Gadolinium Leakage into Ocular Structures (GLOS) is common following acute cerebrovascular events. The objective of this study was to investigate the occurrence of GLOS in an acute traumatic brain injury (TBI) cohort without acute cerebrovascular injury and to explore associated factors., Methods: Enrolled acute TBI patients had a baseline MRI ≤48 h of injury (TP1) and follow-up MRI ≤72 h after baseline (TP2). Vitreous chamber enhancement and signal intensity ratios (SIRs) were calculated using pre- and post-contrast Fluid Attenuated Inversion Recovery (FLAIR). White matter hyperintensities (WMHs) were assessed using the Fazekas scale., Results: Of the 128 TBI patients included, median age was 47 years, 70% male, and 66% presented with Glasgow Coma Scale of 15. No GLOS was detected at TP1 but was present in 23% of patients at TP2. GLOS+ patients were older (68 years [56-76] vs 39 years [27-53], p < 0.001), more likely to report falls as injury mechanism (62% vs 36%, p = 0.006), report history of hypertension (41% vs 19%, p = 0.025), and had a higher burden of WMHs (59% vs 14% with a total Fazekas ≥2, p < 0.001). Quantitative SIRs confirmed qualitative assessments: GLOS+ patients had higher SIRs at TP2 (0.43 vs 0.22, p < 0.001). Age (OR 3.28, 95%CI [1.88-5.71], p < 0.001) and prior TBI history (OR 4.99, 95%CI [1.46-17.06], p = 0.010) were independent predictors of GLOS. When age was removed, total Fazekas score (OR 2.53, 95%CI [1.60-4.00], p < 0.001) was an independent predictor of GLOS., Conclusions: GLOS is primarily associated with age and may serve as another imaging marker of chronic vascular disease., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier B.V.)

Background: In April of 2022, the COVID-19 pandemic resulted in a global shortage of intravenous contrast media (ICM), which led our health care system to implement rationing measures., Study Objectives: We set out to determine if the reduction in ICM use was associated with a change in the incidence of acute kidney injury (AKI)., Methods: We conducted a multicenter retrospective cohort analysis to compare the incidence of AKI in patients who presented before and after ICM rationing. Adult patients who had a CT of the abdomen performed who had at least 2 creatinine measurements, at least 24 h apart, were included. The maximum increase in creatinine was determined by subtracting the maximal creatinine obtained within 7 days with the initial creatinine. The primary outcome was the development of AKI., Results: A total of 2168 patients met inclusion criteria (1082 before; 1086 after). There was no significant difference in age, gender, comorbid conditions, disposition, or initial estimated glomerular filtration rate between groups. In the prerationing group, 87.7% of patients received ICM compared to 42.7% after. There was no significant difference in the development of AKI between groups (11.1% vs. 11.0%), including when stratified by baseline renal function and adjusted for age, sex, race, comorbid conditions, and emergency severity index., Conclusions: The dramatic reduction in ICM use that resulted from the global shortage was not associated with a change in the incidence of AKI. This reinforces the results of previous studies which have failed to find evidence of a relationship between ICM administration and AKI., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The risk of acute renal failure (ARF) following iodinated contrast media injection has long been overestimated because of the previous use of more toxic ICPs and uncontrolled studies. Nowadays, this concept is being questioned. Patients with severe renal failure and/or ARF are the only group still considered at risk. In these patients, it is necessary to discuss an alternative without an iodinated contrast agent. Contrast-enhanced ultrasound, MRI, spectral CT or PET-CT scan can be used instead of contrast-enhanced CT. Preventive measures should be applied when appropriate substitute to CT is not available or not diagnosed (minimum necessary dose of ICP, interruption of some treatments and prior hydration). These recommendations formalized by the European Society of Urogenital Radiology (ESUR) in 2018 address most situations faced by clinicians. In complex situations, an opinion from a nephrologist remains necessary after asking the radiologist about the availability of acceptable substitutes., (Copyright © 2022 Société Française du Cancer. Published by Elsevier Masson SAS. All rights reserved.)

Purpose: Contrast media (CM)-associated adverse effects including mainly acute kidney injury and hypersensitivity reactions still remain a significant treatment burden to vulnerable patients requiring percutaneous coronary intervention (PCI). The complete omission of CM administration accompanied by intravascular ultrasound (IVUS) guidance may offer an appropriate revascularization treatment., Methods: We hereby present a case series of four patients with challenging coronary lesions and relative/absolute contraindications to CM use [(hypersensitivity reaction owning to CM, history of contrast-induced acute kidney injury, solitary kidney, or advanced chronic kidney disease (CKD)] who underwent absolute zero-contrast IVUS-guided PCI following a predetermined protocol., Results: The initial diagnostic angiography was reviewed for landmark identification, and multiple guidewires created a metallic road map providing additional landmarks and protected side branches. IVUS imaging was performed to determine lesion length, reference segments and landing zones, assess stent expansion/apposition and identify major complications. All procedures were successfully completed without any CM administration, renal function deterioration, pericardial effusion, or stent edge dissection., Conclusions: We demonstrated the feasibility of absolute zero-contrast IVUS-guided PCI in patients with complex coronary lesions susceptible to CM-associated adverse effects. Since the safety of this strategy is well-documented in patients with CKD and challenging lesions morphology even in acute settings, evidence-based validation of this approach is capable of changing the otherwise conservative treatment of vulnerable patients where even minimum doses of CM may have detrimental effects., Summary for the Annotated Table of Contents: Patients with vulnerable renal function as well as former hypersensitivity reaction to contrast media encounter a significant treatment burden regarding coronary artery disease. Zero-contrast IVUS-guided strategy based on a predetermined protocol provides a feasible alternative approach in patients susceptible to contrast media-associated adverse effects even in the presence of complex coronary lesions., Competing Interests: Declaration of competing interest Dimitri Karmpaliotis reports honoraria support provided by Boston Scientific and Abbott Vascular and equity in Saranas, Traverse Vascular, Soundbite and Nanowear. No potential competing interest was reported by Xenofon M Sakellariou, Michail I Papafaklis, Christos Floros, Lampros K Michalis and Christos S Katsouras., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Computed tomography cardiac angiography (CTCA) is recommended for the evaluation of patients with prior coronary artery bypass graft (CABG) surgery. The BYPASS-CTCA study demonstrated that CTCA prior to invasive coronary angiography (ICA) in CABG patients leads to significant reductions in procedure time and contrast-induced nephropathy (CIN), alongside improved patient satisfaction. However, whether CTCA information was used to facilitate selective graft cannulation at ICA was not protocol mandated. In this post-hoc analysis we investigated the influence of CTCA facilitated selective graft assessment on angiographic parameters and study endpoints., Methods: BYPASS-CTCA was a randomized controlled trial in which patients with previous CABG referred for ICA were randomized to undergo CTCA prior to ICA, or ICA alone. In this post-hoc analysis we assessed the impact of selective ICA (grafts not invasively cannulated based on the CTCA result) following CTCA versus non-selective ICA (imaging all grafts irrespective of CTCA findings). The primary endpoints were ICA procedural duration, incidence of CIN, and patient satisfaction post-ICA. Secondary endpoints included the incidence of procedural complications and 1-year major adverse cardiac events., Results: In the CTCA cohort (n ​= ​343), 214 (62.4%) patients had selective coronary angiography performed, whereas 129 (37.6%) patients had non-selective ICA. Procedure times were significantly reduced in the selective CTCA ​+ ​ICA group compared to the non-selective CTCA ​+ ​ICA group (-5.82min, 95% CI -7.99 to -3.65, p ​< ​0.001) along with reduction of CIN (1.5% vs 5.8%, OR 0.26, 95% CI 0.10 to 0.98). No difference was seen in patient satisfaction with the ICA, however procedural complications (0.9% vs 4.7%, OR 0.21, 95% CI 0.09-0.87) and 1-year major adverse cardiac events (13.1% vs 20.9%, HR 0.55, 95% CI 0.32-0.96) were significantly lower in the selective group., Conclusions: In patients with prior CABG, CTCA guided selective angiographic assessment of bypass grafts is associated with improved procedural parameters, lower complication rates and better 12-month outcomes. Taken in addition to the main findings of the BYPASS-CTCA trial, these results suggest a synergistic approach between CTCA and ICA should be considered in this patient group., Registration: ClinicalTrials.gov, NCT03736018., Competing Interests: Declaration of competing interest FP receives institutional research support from Siemens Healthineers. All other authors have reported no conflicts of interest., (Copyright © 2024 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

The use of conventional gadolinium(Gd)-based contrast agents in magnetic resonance imaging (MRI) poses a significant risk of Nephrogenic Systemic Fibrosis (NSF) syndrome in patients with impaired renal function (grades 4 and 5). To address this issue, a new study has introduced a novel metabolic Gadolinium oxide nanoparticle (Gd2O3 NPs) coated with β-cyclodextrin (βCD). The study aims to investigate NSF syndrome by quantifying tissue Gd deposition biodistribution in renal impairment rats using MR molecular imaging. This is the first study of its kind to use this approach. A group of 20 rats were divided into four groups, each containing five rats that underwent 5/6 nephrectomy. The rats received 12 intravenous injections of a novel homemade synthesized gadolinium oxide polycyclodextrin (Gd2O3@PCD) at a dose of 0.1 mmol/kg, conventional contrast agents (CAs) drugs of Omniscan (Gd-DTPA-BMA) and Dotarem (Gd-DOTA), at a dose of 2.5 mmol/kg, and 250 μl saline for two injections per week during six weeks. T1-weighted MR imaging was performed before the injections and once a week for six weeks to quantify Gd deposition in four different organs (skin, liver, heart, and lung) in rats using inductively coupled plasma mass spectrometry (ICP-MS). The relationship between Signal-to-Noise Ratio (SNR) and biodistribution of Gd deposition due to NSF-induced syndrome was also calculated. The results of the study showed that the Gd concentrations in tissues were significantly higher in the Gd2O3@PCD group compared to the other groups, without any significant histopathological changes (P < 0.05). In the Gd2O3@PCD group, Gd was mainly deposited in the skin, followed by the liver, lung, and heart, without any symptoms of thickening or hardening of the skin. The Gd concentrations in the skin, liver, lung, and heart were significantly lower in the Dotarem group than in the Omniscan group (P < 0.05). In the histopathological examinations, the Omniscan group showed increased cellularity in the dermis. A significant hyperintensity was observed in the Gd2O3@PCD-treated rats compared to the Dotarem and Omniscan groups in the liver, heart, and lung. Compared to conventional Gd-based CAs, the novel metabolically Gd2O3@PCD with increased SNR, biosafety, and a considerably lower probability of developing NSF, has potential applicability for diagnosing patients with renal diseases in clinical MR Molecular Imaging (MRMI)., (Copyright © 2024. Published by Elsevier Inc.)

Background: Despite the evidence of good performance, carbon dioxide (CO 2 ) routine employment as a contrast agent for endovascular procedures is far from being adopted with its use currently limited to patients with renal impairment and known allergy to iodinated contrast medium (ICM). The purpose of our study is to evaluate the safety and effectiveness of CO 2 guided endovascular abdominal aortic aneurysm repair (EVAR) in a standard population and to assess the rationale for a future widespread use., Methods: We retrospectively collected data of every patient who underwent CO 2 guided standard EVAR from September 2020 to May 2021 and compared them with the data of every patient who underwent EVAR using ICM from December 2019 to August 2020 in our unit. The selection of the contrast medium was not based on any preoperative factor as the contrast medium was routinely used in every patient in both periods. The primary end point of the study was the technical success rate. Secondary end points were the early and late complication rates, radiation exposure and renal function impairment., Results: 49 patients underwent ICM guided EVAR and 52 patients underwent CO 2 guided EVAR in our unit in the time frames specified above. The technical success rate was 100% in both groups with no accidental coverage of any target vessel. Intraoperative endoleaks were observed in 14% of ICM patients and 25% of CO 2 patients. The radiation exposure was higher in the CO 2 group if compared to the ICM group (311.48 vs. 159.86 median mGy/cm 2 - P < 0.001). The incidence of postoperative acute kidney injury was low and similar in the 2 groups. No significant worsening over time of the renal function has been reported in both groups., Conclusions: EVAR can be safely performed under CO 2 guidance without the integration of any quantity of ICM but with an increase in radiation exposure. The nephroprotective role of CO 2 guided EVAR in a standard population is unclear and the same role in renal impaired patients should be validated with further studies on selected populations., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background & Aims: Nephrotoxicity of intravenous iodinated contrast media (ICM) in cirrhosis is still a debated issue, due to scarce, low-quality and conflicting evidence. This study aims to evaluate the incidence and predisposing factors of acute kidney injury (AKI) in patients with cirrhosis undergoing contrast-enhanced computed tomography (CECT)., Methods: We performed a prospective, multicenter, cohort study including 444 inpatients, 148 with cirrhosis (cohort 1) and 163 without cirrhosis (cohort 3) undergoing CECT and 133 with cirrhosis (cohort 2) unexposed to ICM. Kidney function parameters were assessed at T0, 48-72 h (T1), 5 and 7 days after CECT/enrollment. Urinary neutrophil gelatinase-associated lipocalin (U-NGAL) was measured in 50 consecutive patients from cohort 1 and 50 from cohort 2 as an early biomarker of tubular damage., Results: AKI incidence was not significantly increased in patients with cirrhosis undergoing CECT (4.8%, 1.5%, 2.5% in cohorts 1, 2, 3 respectively, p = n.s.). Most AKI cases were mild and transient. The presence of concomitant infections was the only independent predictive factor of contrast-induced AKI (odds ratio 22.18; 95% CI 2.87-171.22; p = 0.003). No significant modifications of U-NGAL between T0 and T1 were detected, neither in cohort 1 nor in cohort 2 (median ΔU-NGAL: +0.2 [-7.6 to +5.5] ng/ml, +0.0 [-6.8 to +9.5] ng/ml, respectively [p = 0.682])., Conclusions: AKI risk after CECT in cirrhosis is low and not significantly different from that of the general population or of the cirrhotic population unexposed to ICM. It mostly consists of mild and rapidly resolving episodes of renal dysfunction and it is not associated with tubular kidney injury. Patients with ongoing infections appear to be the only ones at higher risk of AKI., Impact and Implications: Nephrotoxicity due to intravenous iodinated contrast media (ICM) in patients with cirrhosis is still a debated issue, as the available evidence is limited and based on very heterogeneous studies, often conducted on small and retrospective cohorts. In this prospective three-cohort study we found that intravenous administration of ICM was associated with a low risk of AKI, similar to that of the general population and to that of patients with cirrhosis unexposed to ICM. Patients with ongoing infections were the only ones to have a significantly increased risk of contrast-induced AKI. Therefore, the actual recommendations of performing contrast imaging studies cautiously in cirrhosis do not seem to be reasonable anymore, with the exception of infected patients, who have a significantly higher risk of contrast-induced AKI., (Copyright © 2023 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Objective: To assess the safety and utility of deferring estimated glomerular filtration rate (eGFR) testing before contrast-enhanced CT (CECT) in low-risk emergency department (ED) patients., Methods: A new question was added to CECT order screens, allowing ordering ED providers to defer eGFR testing in patients deemed low risk for contrast-induced acute kidney injury (AKI). Low risk was defined as no known chronic kidney disease (CKD) or risk factors for AKI or CKD. Patients on chronic dialysis were deemed low risk. The project included three phases: baseline, pilot (optional order question), and full implementation (required order question). Outcomes were operational throughput metrics of CECT order to protocol (O to P) and order to begin (O to B) times. As a balancing safety measure, the proportion of patients deemed to be "low risk" and subsequently found to have eGFR value less than 30 mL/min/1.73 m 2 was reported., Results: A total of 16,446 CECT studies were included from four EDs. In the pilot phase, provider engagement rates with the question were low (5%-14%). After full implementation, median O to P time improved from 23.93 min at baseline to 13.02 (P < .0001) and median O to B time improved from 80.34 min to 76.48 (P = .0002). In 0.3% (2 of 646) studies, CECT was completed in patients categorized as low risk by the ED provider with subsequently resulted eGFR <30 mL/min/1.73 m 2 ., Discussion: Upfront clinical risk assessment for AKI and CKD by ED providers can be used to safely defer eGFR testing and improve operational performance for patients requiring CECT., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Aortic stenosis (AS) and chronic kidney disease (CKD) can coexist. Repeat exposure to contrast media in patients undergoing transcatheter aortic valve implantation (TAVI) has latent mortality risks and increased risk for acute kidney injury. We aimed to assess our "zero-contrast TAVI" protocol for patients with advanced CKD., Methods: Consecutive patients with severe AS who underwent TAVI at a single center registry were enrolled. Zero-contrast TAVI group included patients who underwent TAVI without contrast and who had an estimated glomerular filtration rate <30 mL/min/1.73 m 2 . Conventional TAVI group included patients who underwent the regular TAVI procedure. Patients using balloon-expandable valves via transfemoral approach were analyzed. Baseline clinical and procedural characteristics and clinical outcomes were compared between two groups. The primary outcome was early safety as defined by Valve Academic Research Consortium Criteria. Secondary outcomes included the presence of severe prosthesis-patient mismatch, moderate or greater perivalvular leakage, and requirement for new dialysis (within 3 months)., Results: A total of 520 patients were analyzed. Among these, 32 (6 %) underwent zero-contrast TAVI and 488 (94 %) conventional TAVI. In the zero-contrast TAVI group, 12 patients (37.5 %) had to use 20.7 (11.0-31.2) mL of contrast media. There were no significant differences in the primary and secondary outcomes between zero-contrast TAVI and conventional TAVI groups (78.1 % vs. 86.8 %, P = 0.184 and 9.4 % vs. 8.1 %, P = 0.738 for the primary and secondary outcomes, respectively)., Conclusions: Zero-contrast TAVI is feasible, safe, and effective in patients with AS and stage 4 CKD., Competing Interests: Declaration of competing interest Dr. Izumo is a screening proctor at Edwards Lifesciences., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Simulation-based training has become increasingly prominent within medical education, but its utility within radiology remains underexplored., Objective: To appraise the evidence for the effectiveness of simulation on the management of adverse reactions to contrast media., Methods: A systematic search of the literature was conducted. Eligible studies recruited radiology residents, provided simulation-based training focused on contrast reaction management, and measured any effectiveness outcome compared with any nonsimulation training or no training. The quality of studies was appraised and outcomes were classified according to Kirkpatrick's hierarchy and the strength of evidence., Results: Out of 146 screened results, 15 articles were included that described 17 studies-3 randomized trials and 14 pretest-posttest studies of hands-on or, less commonly, computer-based simulation. In all 16 studies that assessed knowledge before and after intervention, written test scores improved after simulation. Most studies noted improvements in comfort or confidence managing contrast reactions as well. In all three studies that assessed knowledge after simulation and after didactic lecture as a control, posttest scores were not statistically significantly better in the simulation groups than the lecture groups. Common study limitations included single-group designs, measuring only learning outcomes using unvalidated instruments, modest sample sizes, and limited assessment of long-term retention., Conclusion: Simulation produces subjective improvements and knowledge gain relevant to contrast reaction management. Further research is required to demonstrate superiority of simulation-based contrast reaction management training over traditional didactic lecture-based instruction., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Chronic kidney disease is an independent risk factor for the development of coronary artery disease and overlaps with other risk factors such as hypertension and diabetes. Percutaneous coronary intervention is a cornerstone of therapy for coronary artery disease and requires contrast media, which can lead to renal injury. Identifying patients at risk for contrast-associated acute kidney injury (CA-AKI) is critical for preventing kidney damage, which is associated with both short- and long-term mortality. Determination of the potential risk for CA-AKI and a new need for dialysis using validated risk prediction tools identifies patients at high risk for this complication. Identification of patients at risk for renal injury after contrast exposure is the first critical step in prevention. Contrast media volume, age and sex of the patient, a history of chronic kidney disease and/or diabetes, clinical presentation, and hemodynamic and volume status are factors known to predict incident contrast-induced nephropathy. Recognition of at-risk patient subpopulations allows for targeted, efficient, and cost-effective strategies to reduce the risk of renal complications resulting from contrast media exposure., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Acute kidney injury (AKI) is the most common complication after percutaneous coronary intervention (PCI). Accurately estimating patients' risks not only creates a means of benchmarking performance but can also be used prospectively to inform practice., Objectives: The authors sought to update the 2014 National Cardiovascular Data Registry (NCDR) AKI risk model to provide contemporary estimates of AKI risk after PCI to further improve care., Methods: Using the NCDR CathPCI Registry, we identified all 2020 PCIs, excluding those on dialysis or lacking postprocedural creatinine. The cohort was randomly split into a 70% derivation cohort and a 30% validation cohort, and logistic regression models were built to predict AKI (an absolute increase of 0.3 mg/dL in creatinine or a 50% increase from preprocedure baseline) and AKI requiring dialysis. Bedside risk scores were created to facilitate prospective use in clinical care, along with threshold contrast doses to reduce AKI. We tested model calibration and discrimination in the validation cohort., Results: Among 455,806 PCI procedures, the median age was 67 years (IQR: 58.0-75.0 years), 68.8% were men, and 86.8% were White. The incidence of AKI and new dialysis was 7.2% and 0.7%, respectively. Baseline renal function and variables associated with clinical instability were the strongest predictors of AKI. The final AKI model included 13 variables, with a C-statistic of 0.798 and excellent calibration (intercept = -0.03 and slope = 0.97) in the validation cohort., Conclusions: The updated NCDR AKI risk model further refines AKI prediction after PCI, facilitating enhanced clinical care, benchmarking, and quality improvement., Competing Interests: Funding Support and Author Disclosures Dr Anezi Uzendu is supported by the National Heart, Lung and Blood Institutes of Health under Award Number 5T32H110837. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr Chertow serves on the Board of Directors of Satellite Healthcare, a nonprofit dialysis provider; has served as a steering committee member or chair for clinical trials sponsored by Akebia, AstraZeneca, CSL Behring, Gilead, Sanifit, and Vertex; has served as an advisor to Ardelyx, Durect, Eliaz Therapeutics, Miromatrix, Outset, Reata, Renibus, and Unicycive; and has served as a Data Safety and Monitoring Board member or chair for trials sponsored by Bayer, Gilead, Mineralys, Palladio, and ReCor. Dr Giri has received research funds to his institution; and has served on advisory boards for Boston Scientific, Abiomed, Abbott Vascular, Inari Medical, Biosense Webster, and Recor Medical. Dr Rymer has served on the advisory board for Chiesi; has received a research grant from Chiesi; and receives research funding from Idorsia, Pfizer, and Abbott. Dr Bangalore discloses has served on the advisory board for Abbott Vascular, Boston Scientific, Amgen, Pfizer, Merck, Inari, and Truvic. Dr Wang has received research grants to the Duke Clinical Research Institute from Abbott, AstraZeneca, Bristol Myers Squibb, Boston Scientific, Artivion (formerly Cryolife), Chiesi, Merck, Portola, and Regeneron; and has received consulting honoraria from AstraZeneca, Bristol Myers Squibb, Artivion (formerly Cryolife), CSL Behring, and Novartis. Dr Curtis has an institutional contract with the American College of Cardiology for his role as chief scientific adviser of the NCDR; and has equity in Medtronic. Dr Spertus has provided consultative services on patient-reported outcomes and evidence evaluation to Alnylam, AstraZeneca, Bayer, Merck, Janssen, Bristol Meyers Squibb, Edwards Lifesciences, Kineksia, 4DT Medical, Terumo, Cytokinetics, Imbria, and United Healthcare; holds research grants from Bristol Meyers Squibb, Abbott Vascular, and Janssen; owns the copyright to the Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, and Peripheral Artery Questionnaire; and serves on the Board of Directors for Blue Cross Blue Shield of Kansas City. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The effect of iodinated contrast material (CM) temperature on injection pressures and viscosity has been well established. However, the effect of extrinsic warming of CM on allergic reactions and extravasations remains unclear. The purpose of this study is to compare the rates of allergic reactions and extravasations between warmed CM to room temperature CM., Methods: We conducted a comprehensive systematic search using PubMed, Embase, and Web of Science databases for all studies that assess the impact of warmed CM on adverse reactions. The primary outcomes of our study were allergic reaction and extravasation rates. We calculated weighted pooled odds ratios (OR) and 95% confidence intervals (CI) for all outcomes using the random-effects model. A P-value <0.05 was considered statistically significant. We conducted subgroup analyses based on the viscosity of the CM., Results: A total of five studies, including 307,329 CM injections (86,676 at room temperature and 220,653 warmed to 37 °C), were included in the analysis. For high viscosity CM, pre-warming was associated with significantly lower allergic reaction rates (OR: 0.59, 95% CI: 0.49-0.72, P < 0.00001). There was no significant difference in rates of extravasation for high viscosity CM (OR: 0.53, 95% CI: 0.20-1.43, P = 0.21)., Discussion: Our meta-analysis suggests that warming CM to 37 °C is a safe and effective approach to reduce the risk of allergic reactions and physiologic reactions during injection of high-viscosity CM. However, there was no significant difference in extravasation rates between warmed and room temperature CM, regardless of viscosity., Competing Interests: Declaration of competing interest All authors declare no competing interests., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: To retrospectively evaluate the feasibility and effectiveness of the endovascular treatment of patients with abdominal aortic aneurysm and chronic kidney disease (CKD) without the need for using iodinated contrast media throughout the diagnostic, therapeutic, and follow-up pathway., Methods: A retrospective review of prospectively collected data concerning 251 consecutive patients presenting an abdominal aortic or aorto-iliac aneurysm who underwent endovascular aneurysm repair (EVAR) from January 2019 to November 2022 at our academic institution was performed in order to identify patients with feasible anatomy with respect to manufacturer's instructions for use and with CKD. Patients whose preoperative workout included duplex ultrasound and plain computed tomography for preprocedural planning were extracted from a dedicated EVAR database. EVAR was performed with the use of carbon dioxide (CO 2 ) as the contrast media of choice, whereas follow-up examinations consisted of either duplex ultrasound, plain computed tomography, or contrast-enhanced ultrasound. Primary endpoints were technical success, perioperative mortality, and early renal function variations. Secondary endpoints were all-type endoleaks and reinterventions, midterm aneurysm-related and kidney-related mortality., Results: Forty-five patients had CKD and were treated electively (45/251, 17.9%). Of them, 17 patients were managed with a total iodinated contrast media-free strategy and constituted the object of the present study (17/45, 37.8%; 17/251, 6.8%). In 7 cases, an adjunctive planned procedure was performed (7/17, 41.2%). No intraoperative bail-out procedures were needed. This extracted cohort of patients presented similar mean preoperative and postoperative (at discharge) glomerular filtration rate values, 28.14 (SD 13.09; median 28.06, interquartile range (IQR) 20.25) ml/min/1.73 m 2 and 29.33 (SD 14.61; median 27.35, IQR 22) ml/min/1.73 m 2 , respectively (P = 0.210). Mean follow-up was 16.4 months (SD 11.89; median 18, IQR 23). During follow-up, no graft-related complications occurred in terms of either thrombosis, type I or III endoleaks, aneurysm rupture, or conversion. The mean glomerular filtration rate at follow-up was 30.39 ml/min/1.73 m 2 (SD 14.45; median 30.75, IQR 21.93), with no significant worsening in comparison with preoperative and postoperative values (P = 0.327 and P = 0.856 respectively). No aneurysm- or kidney-related deaths occurred during follow-up., Conclusions: Our initial experience shows that total iodine contrast-free abdominal aortic aneurysm endovascular management in patients with CKD may be feasible and safe. Such an approach seems to guarantee the preservation of residual kidney function without increasing the risks of aneurysm-related complications in the early and midterm postoperative periods, and it could be considered even in the case of complex endovascular procedures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Patients with chronic kidney disease (CKD) who undergo peripheral vascular interventions (PVI) with iodinated contrast are at higher risk of post-contrast acute kidney injury (PC-AKI). Carbon dioxide (CO 2 ) angiography can reduce iodinated contrast volume usage in this patient population, but its impact on PC-AKI has not been studied. We hypothesize that CO 2 angiography is associated with a decrease in PC-AKI in patients with advanced CKD., Methods: The Vascular Quality Initiative PVI dataset from 2010 to 2021 was reviewed. Only patients with advanced CKD (estimated glomular filtration rate <45 ml/min/1.73 m 2 ) treated for peripheral arterial disease were included. Propensity matching and multivariate logistic regression based on demographics, comorbidities, CKD stage, and indications were used to compare the outcomes of patients treated with and without CO 2 ., Results: There were 20,706 PVIs performed in patients with advanced CKD, and only 22% utilized CO 2 angiography. Compared with patients treated without CO 2 , patients who underwent CO 2 angiography were younger and less likely to be women or White, and more likely to have poor renal function, diabetes, cardiac comorbidities, and present with tissue loss. Propensity matching yielded well-matched groups with 4472 patients in each group. The procedural details after matching demonstrated 50% reduction in the volume of contrast used (32±33 vs 65±48 mL; P < .01). PVI with CO 2 angiography was associated with lower rates of PC-AKI (3.9% vs 4.8%; P = .03) and cardiac complications (2.1% vs 2.9%; P = .03) without a significant difference in technical failure or major/minor amputations. Low contrast volumes (≤50 mL for CKD3, ≤20 mL for CKD4, and ≤9 mL for CKD5) are associated with reduced risk of PC-AKI (hazard ratio, 0.59; P < .01)., Conclusions: CO 2 angiography reduces iodinated contrast volume usage during PVI and is associated with decreased cardiac complications and PC-AKI. CO 2 angiography is underutilized and should be considered for patients with advanced CKD who require endovascular therapy., (Copyright © 2023 Society for Vascular Surgery. All rights reserved.)

Objectives: Carbon dioxide (CO 2 ) angiography for endovascular aortic repair (CO 2 -EVAR) is used to treat abdominal aortic aneurysms (AAAs), especially in patients with chronic kidney disease or allergy to iodinated contrast medium (ICM). However, some technical issues regarding the visualization of the lowest renal artery (LoRA) and the best quality image through angiographies performed from pigtail or introducer sheath are still unsolved. The aim of this study was to analyze different steps of CO 2 -EVAR to create an operative standardized protocol., Methods: Patients undergoing CO 2 -EVAR were prospectively enrolled in five European centers from 2019 to 2021. CO 2 -EVAR was performed using an automated injector (pressure, 600 mmHg; volume, 100 cc); a small amount of ICM was injected in case of difficulty in LoRA visualization. LoRA visualization and image quality (1 = low, 2 = sufficient, 3 = good, 4 = excellent) were analyzed at different procedure steps: preoperative CO 2 angiography from pigtail and femoral introducer sheath (first step), angiographies from pigtail at 0%, 50%, and 100% of proximal main body deployment (second step), contralateral hypogastric artery (CHA) visualization with CO 2 injection from femoral introducer sheath (third step), and completion angiogram from pigtail and femoral introducer sheath (fourth step). Intraoperative and postoperative CO 2 -related adverse events were also evaluated. χ 2 and Wilcoxon tests were used for statistical analysis., Results: In the considered period, 65 patients undergoing CO 2 -EVAR were enrolled (55/65 [84.5%] male; median age, 75 years [interquartile range (IQR), 11.5 years]). The median ICM injected was 17 cc (IQR, 51 cc); 19 (29.2%) of 65 procedures were performed with 0 cc ICM. Fifty-five (84.2%) of 65 patients underwent general anesthesia. In the first step, median image quality was significantly higher with CO 2 injected from femoral introducer (pigtail, 2 [IQR, 3] vs introducer, 3 [IQR, 3]; P = .008). In the second step, LoRA was more frequently detected at 50% (93% vs 73.2%; P = .002) and 100% (94.1% vs 78.4%; P = .01) of proximal main body deployment compared with first angiography from pigtail; similarly, image quality was significantly higher at 50% (3 [IQR, 3] vs 2 [IQR, 3]; P ≤ .001) and 100% (4 [IQR, 3] vs 2 [IQR, 3]; P = .001) of proximal main body deployment. CHA was detected in 93% cases (third step). The mean image quality was significantly higher when final angiogram (fourth step) was performed from introducer (pigtail, 2.6 ± 1.1 vs introducer, 3.1 ± 0.9; P ≤ .001). The intraoperative (7.7%) and postoperative (12.5%) adverse events (pain, vomiting, diarrhea) were all transient and clinically mild., Conclusions: Preimplant CO 2 angiography should be performed from femoral introducer sheath. Gas flow impediment created by proximal main body deployment can improve image quality and LoRA visualization with CO 2 . CHA can be satisfactorily visualized with CO 2 alone. Completion CO 2 angiogram should be performed from femoral introducer sheath. This operative protocol allows performance of CO 2 -EVAR with 0 cc or minimal ICM, with a low rate of mild temporary complications., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To examine follow-up care in patients with a history of acute allergic-like reaction to iodinated contrast material (ICM), including subsequent imaging management, allergy consultation, and repeat ICM exposure and reactions., Methods: All patients who had a moderate or severe acute allergic-like reaction to ICM after contrast-enhanced CT (CECT) examination from June 1, 2009, to January 1, 2022, at our institution were included. Chart review was performed to determine (1) whether subsequent imaging was not performed or was altered in these patients, (2) whether the patient underwent a subsequent CECT examination, and (3) whether the patient had an allergist consultation., Results: A total of 251 patients were identified. One-third of patients (90 of 251, 36%) had at least one change to their subsequent imaging management due to their reaction, including performing an unenhanced CT (62 of 251, 25%) or MRI (22 of 251, 8.8%) instead of a CECT or not performing a CECT when otherwise clinically indicated (20 of 251, 8.0%). Patients with a prior severe reaction were more likely to have a change in management than patients with a prior moderate reaction (severe: 22 of 32 [69%] versus moderate: 68 of 219 [31%], P < .0001). Only 17 patients (6.8%) had an allergy consult for their ICM reaction. A total of 90 patients underwent 274 subsequent CECT examinations. Repeat allergic-like reactions were observed in one quarter of patients (24 of 90, 27%) and a tenth of CECT examinations (29 of 274, 11%)., Discussion: One-third of patients with a history of a moderate or severe allergic-like reaction to ICM had their subsequent imaging care modified due to their reaction., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Concerns have been raised about prenatal exposure to magnetic resonance imaging with gadolinium-based contrast agents because of nonclinical findings of gadolinium retention in fetal tissue and 1 population-based study reporting an association with adverse pregnancy outcomes., Objective: This study aimed to evaluate the association between prenatal magnetic resonance imaging exposure with and without gadolinium-based contrast agents and fetal and neonatal death and neonatal intensive care unit admission., Study Design: We constructed a retrospective cohort of >11 million Medicaid-covered pregnancies between 1999 and 2014 to evaluate the association between prenatal magnetic resonance imaging exposure with and without gadolinium-based contrast agents and fetal and neonatal death (primary endpoint) and neonatal intensive care unit admissions (secondary endpoint). Medicaid claims data were linked to medical records, Florida birth and fetal death records, and the National Death Index to validate the outcomes and gestational age estimates. Pregnancies with multiples, concurrent cancer, teratogenic drug exposure, magnetic resonance imaging focused on fetal or pelvic evaluation, undetermined gadolinium-based contrast agent use, or those preceded by or contemporaneous with congenital anomaly diagnoses were excluded. We adjusted for potential confounders with standardized mortality ratio weighting using propensity scores., Results: Among 5991 qualifying pregnancies, we found 11 fetal or neonatal deaths in the gadolinium-based contrast agent magnetic resonance imaging group (1.4%) and 73 in the non-gadolinium-based contrast agent magnetic resonance imaging group (1.4%) with an adjusted relative risk of 0.73 (95% confidence interval, 0.34-1.55); the neonatal intensive care unit admission adjusted relative risk was 1.03 (0.76-1.39). Sensitivity analyses investigating the timing of magnetic resonance imaging or repeat magnetic resonance imaging exposure during pregnancy and simulating the impact of exposure misclassification corroborated these results., Conclusion: This study addressed the safety concerns related to prenatal exposure to gadolinium-based contrast agents used in magnetic resonance imaging and the risk thereof on fetal and neonatal death or the need for neonatal intensive care unit admission. Although the results on fatal or severe acute effects are reassuring, the impact on subacute outcomes was not evaluated., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Rotational atherectomy (RA) is a complex procedure often associated with high contrast load. Known risk scores do not predict contrast-induced acute kidney injury (CI-AKI) before RA. We aim to investigate pre-procedural predictors of CI-AKI after RA, and the role of the target vessel SYNTAX score (tvSS)., Methods: Among 295 patients who underwent RA between 01.2010 and 02.2019 at a single center, 49 developed CI-AKI. Those who were on chronic hemodialysis or with no available 48-h' kidney function tests were excluded. Predictors of CI-AKI were assessed in the whole cohort and those with no basal renal impairment., Results: The rate of CI-AKI was 16.6 %. The tvSS was 18 [14-23] vs. 12 [9-18] in patients with vs. without CI-AKI (p < 0.001). The tvSS cut-off value of 15 provided 75 % sensitivity and 60 % specificity for predicting CI-AKI. Consequently, a tvSS ≥15 emerged as an independent pre-procedural predictor for CI-AKI (adjusted OR: 4.94, 95 % CI: 2.38-10.20, p < 0.001), along with left ventricular ejection fraction (LVEF) ≤35 % (p = 0.016) and glomerular filtration rate (GFR) <45 ml/min (p = 0.004). TvSS was the only independent pre-procedural predictor for CI-AKI in patients with GFR ≥60 ml/min (p < 0.001). The contrast volume/GFR ratio and peri-procedural myocardial infarction (MI) were independent procedural predictors for CI-AKI in the whole cohort and in patients with basal GFR ≥60 ml/min., Conclusion: CI-AKI after RA is frequent. The tvSS is an efficient pre-procedural predictor for CI-AKI after RA, along with LVEF ≤35 % and GFR <45 ml/min. Contrast volume/GFR ratio and peri-procedural MI emerged as procedural predictors for CI-AKI., Competing Interests: Declaration of competing interest Dr. Hemetsberger received a speaker's honoraria from Boston Scientific. Dr. Abdel-Wahab reports that his hospital receives speaker's honoraria and/or consultancy fees on his behalf from Medtronic and Boston Scientific. Dr. Richardt received an institutional research grant from Boston Scientific. Dr. Allali is a proctor for Boston Scientific. The other authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The primary objective was to compare the accuracy of dynamic computed tomography (CT) angiography (d-CTA) with standardized triphasic contrast enhanced CT angiography (t-CTA) in diagnosing endoleak type after endovascular aortic repair (EVAR) using digital subtraction angiography (DSA) as reference standard. The secondary objective was to study the impact of d-CTA on image fusion-guided endoleak embolization., Methods: A retrospective review of patients who underwent d-CTA imaging after EVAR between March 2019 and July 2021 was performed. Deidentified images were independently reviewed by two-two blinded readers to document endoleak type and target vessels. An impact of d-CTA-guided embolization was evaluated by a number of planning angiograms, radiation exposure, and accuracy of target vessel overlay., Results: During the study period, 52 patients underwent d-CTA and 19 had all 3 modalities available for analysis. DSA imaging confirmed 4 (21.0%) type-I, 14 (73.7%) type-II, and 1 (5.3%) type-III endoleak. Findings from d-CTA matched with DSA in 19/19 cases (100%), whereas t-CTA matched in 14/19 cases (73.7%). In type-II endoleaks, the number of target vessels identified by d-CTA, t-CTA, and DSA were 23, 17, and 16, respectively. Mean dose-length product from d-CTA and t-CTA was 1,445 ± 551 and 1,612 ± 530 mGy × cm (P = 0.26). Nine patients underwent d-CTA-guided type-II endoleak embolization, using a median of 1 (range: 1-4) planning angiogram before embolization using 21.6 (± 8.7)% of total procedural radiation dose. Target vessel overlay was accurate in 9/9 (100%) cases., Conclusions: Dynamic, time-resolved CTA is more accurate compared to standardized triphasic contrast enhanced CTA in diagnosing endoleak type after EVAR. In type-II endoleak, d-CTA better identified target vessels and enabled safe, targeted embolization., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Multiple exposures to gadolinium-based contrast agents (GBCAs) is known to be associated with gadolinium deposition in the brain in certain patients. Such deposition has been correlated with specific brain MRI findings, although most available data is in patients with underlying neurologic disorders. We aim to prospectively evaluate brain MRI signal changes as well as neurologic and neuropsychologic testing results in women undergoing screening breast MRI., Methods: In this IRB-approved, HIPAA-compliant prospective study, 9 women with 5 or more exposures to linear and/or macrocyclic GBCA due to screening breast MRI underwent noncontrast brain MRI, neurologic exam and neuropsychologic testing. Women with underlying neurologic, psychologic, hepatic or renal disorders were excluded., Results: The mean total number of GBCA exposures was 8 (standard deviation 2.7), with 63/72 (87%) of the exposures being linear agents. There was no association between brain MRI signal changes and abnormalities on neurologic or neuropsychologic examination. There was no association between total number of GBCA exposures and abnormalities on neurologic or neuropsychologic examination., Conclusion: In this prospective exploratory study of 9 women with 5 or more GBCA exposures due to screening breast MRI, there was no association between brain MRI signal changes and clinical abnormalities on neurologic or neuropsychologic examination. While larger studies are needed in this patient population, the lack of clinical impact of multiple GBCA exposures in this study is reassuring., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Magnetic resonance imaging (MRI) poses some risk when adequate safety measures are not adhered to. Despite efforts on MRI safety, incidents still occur in MRI. Extensive training on MRI safety is essential to protect patients, staff and the public from the risks associated with magnetic fields. Safety issues in MRI include projectile and torque effects on ferromagnetic objects, thermal effects, claustrophobia and adverse reactions to contrast agents. Radiographers operating MRI scanners play a vital role in ensuring that all who enter the MRI environment adhere to the safety measures. However, radiographers are faced with challenges that impact how safety issues are monitored. This Continuing Professional Development article is aimed at highlighting these challenges and providing radiographers with some practical guidelines for these challenges., (Copyright © 2022. Published by Elsevier Inc.)

Aims: Oxidative stress and inflammatory response play a vital role in the pathogenesis of contrast-induced acute kidney injury (CI-AKI). This study investigated the effects of edaravone in rats with CI-AKI., Main Methods: Male Sprague Dawley rats were randomly assigned into four groups (n = 11-14/group): control, edaravone (30 mg/kg/day intraperitoneally (IP)), CI-AKI, and edaravone with CI-AKI. The induction of CI-AKI was performed by dehydration and the administration of contrast media (iohexol) and inhibitors of prostaglandin (indomethacin) and nitric oxide synthesis (L-NAME: N-nitro L-arginine methyl ester). Edaravone was administered for two weeks before the induction of CI-AKI. Serum creatinine and urea, renal oxidative stress and inflammatory biomarkers, and histopathological alterations were evaluated after 48 h of contrast exposure., Key Findings: Rats with CI-AKI showed a significant increase in serum creatinine and urea. The levels of antioxidant biomarkers including glutathione peroxidase, superoxide dismutase and reduced glutathione were significantly decreased in CI-AKI group versus control. Pre-treatment of rats with edaravone normalized kidney function and protected the kidney from oxidative damage as demonstrated by normalization of previous biomarkers. Furthermore, edaravone partially ameliorated renal histopathological alterations relative to the CI-AKI group, notably in the nephrons. No changes were observed in inflammatory biomarkers including tumour necrosis factor-alpha and interleukin-6 among all groups., Significance: The current findings suggest that edaravone could be a potential strategy to ameliorate developing CI-AKI possibly by improving renal antioxidant capacity. Further studies are warranted to expand the current understanding of the use of edaravone in the various models of AKI., Competing Interests: Declaration of competing interest The authors report that they have no conflict of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Despite an often favorable risk/benefit ratio, patients with severe chronic kidney disease are sometimes declined for interventional coronary procedures, due to the risk of acute kidney injury post-contrast (AKI-PC). A large preventive supply of intravenous fluid may be problematic in this population. The RenalGuard® system allows hyperhydration by maintaining a stable volemia through an enhanced diuresis., Methods and Results: This work reports the evaluation of the RenalGuard® system in 25 consecutive patients with chronic kidney disease (glomerular filtration rate < 40 mL/min/1.73 m²) requiring an interventional coronary procedure (coronary angiography and/or percutaneous coronary intervention) and at high risk of IRA-PC. An increase in serum creatinine ≥ 26.5 µmol/L at 48-72 hours (AKI-PC definition) was observed in 4 patients (16%). The mean glomerular filtration rate was 26 ± 8 mL/min/1.73 m² at 48-72 hours versus 25 ± 8 mL/min/1.73 m² at baseline. No patient presented with an increase in serum creatinine ≥ 1.5 from baseline, stage 2 or 3 AKI, or acute pulmonary edema. No renal replacement therapy was necessary. One death unrelated to AKI-PC occurred during hospital stay., Conclusions: This single-center observational study suggests that the RenalGuard® system, allowing diuresis-adjusted hyperhydration, is safe and useful for patients at high risk of AKI-PC after an interventional coronary procedure., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Objective: Intravenous administration of gadolinium-based contrast agents (GBCA) in patients with impaired renal function has been of concern to primary care physicians due to the potential worsening of renal dysfunction and nephrogenic systemic fibrosis (NSF). Our objective was to compare the potential change in estimated glomerular filtration rate (eGFR) in patients with known severe renal dysfunction (eGFR <30 ml/min), following Gadoterate meglumine (GM) administration with patients who do not receive contrast., Methods: An IRB-approved retrospective analysis of all patients who underwent MRI examination at our institution, for any indication, between January 2016 and September 2020., Inclusion Criteria: pre-MRI eGFR <30 ml/min within 24 h of MRI, follow-up eGFR between 48 and 96 h post-MRI, and absence of peritoneal or hemodialysis. The individuals who received GM (492 scans) were identified as cases, and those who did not receive contrast (1101 scans) were identified as controls for our study. Delta-eGFR response was calculated and covariate-adjusted, and propensity score analysis was performed., Results: No significant eGFR decrease was observed in patients who received GM compared to those who did not receive GM in our study. Also, no relationship between comorbidity, severity and contrast selection was observed., Conclusion: The use of Gadolinium contrast in MRI is often of critical importance for determining accurate anatomic relationships, differentiation of benign from malignant lesions, or determination of resolving vs. worsening disease. Though the risk of contrast administration can never be entirely ignored, especially in patients with low eGFR, our study indicates that safe administration of GM can be performed even in patients with severe kidney disease., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Cardiac catheterization procedures require intra-arterial contrast agent administration. The amount of utilized contrast agent volume (CAV) is a risk factor for contrast-induced side-effects. In this study, we assess trends and associations of CAV utilization in diagnostic cardiac catheterization (DCC) and percutaneous coronary intervention (PCI)., Methods: All cardiac catheterization procedures reported for quality assurance between 2008 and 2018 in Germany were included. Available site, patient, and procedural parameters were analyzed. CAV was reported by interventional cardiologists after the procedure. Multivariate linear regression analysis was used to identify associated factors with clinically relevant CAV change (defined >10 ml)., Results: We included 9,106,511 procedures (DCC: 5,401,525, PCI: 3,704,986). Median CAV of all DCCs was 80 (interquartile range, IQR 60-110) ml. CAV for DCC significantly lowered by 22% during the retrospective observational period (p < 0.001) and significantly varied according to the leading diagnosis (p < 0.001). We observed significant 2.5-fold variability of CAV between the catheterization laboratories (5th percentile: 40 ml, 95th percentile: 100 ml, p < 0.001). Median CAV for PCIs was 170 (IQR 120-223) ml. Independent associated factors for clinically relevant higher CAV use in PCI were male gender, coronary-artery-bypass-graft surgery, total coronary occlusion, ostial lesions, and multi-vessel coronary artery disease (all p < 0.001)., Conclusions: The results of this large, multi-center study show significant lowering of CAV in clinical routine DCC, however, the large inter-site variability demonstrates the need for additional CAV reduction to further lower the risk of adverse side-effects. In PCI practice, CAV should be limited in the presence of the identified high contrast-dose scenarios., Competing Interests: Declaration of Competing Interest TJ Stocker and S Massberg report no relevant disclosures. J Hausleiter received speaker honoraria and research support of Abbott Vascular and Edwards Lifesciences outside the submitted work., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Little is known about the incidence and clinical relevance of postprocedural acute kidney injury (AKI) in patients undergoing transcatheter edge-to-edge repair (TEER) for tricuspid regurgitation (TR)., Objectives: The aim of this study was to investigate the prognostic impact of postprocedural AKI following TEER for TR., Methods: Two hundred sixty-eight patients who underwent TEER for TR at 2 centers were retrospectively analyzed. Postprocedural AKI was defined as an increase in serum creatinine of ≥0.3 mg/dL within 48 hours or ≥50% within 7 days after the procedure compared with baseline. The association between AKI and the composite outcome, consisting of all-cause mortality and rehospitalization for heart failure within 1 year after the procedure, was determined., Results: The mean age of the patients was 79.0 ± 6.8 years, and 43.3% were men. Postprocedural AKI occurred in 42 patients (15.7%). Age, male sex, an estimated glomerular filtration rate of <60 mL/min/1.73 m 2 , and absence of procedural success were associated with the occurrence of AKI. Patients with AKI had a higher incidence of in-hospital mortality than those without AKI (9.5% vs 0.9%; P = 0.006). Moreover, AKI was associated with the incidence of the composite outcome within 1 year after TEER for TR (adjusted HR: 2.39; 95% CI: 1.45-3.94; P = 0.001)., Conclusions: Postprocedural AKI occurred in 15.7% of patients undergoing TEER for TR, despite the absence of iodinated contrast agents, which was associated with worse clinical outcomes. These findings highlight the clinical impact of AKI following TEER for TR and should help in identifying patients at high risk for AKI., Competing Interests: Funding Support and Author Disclosures Dr Tanaka was financially supported in part by fellowships from the Japanese College of Cardiology and the Uehara Memorial Foundation. Dr Sugiura has received honoraria for lectures from Edwards Lifesciences. Dr Weber has received lecture or proctoring fees from Abbott and Edwards Lifesciences. Drs Nickenig and Zimmer have received research funding from Deutsche Forschungsgemeinschaft, the German Federal Ministry of Education and Research, the European Union, Abbott, Edwards Lifesciences, and Medtronic; and have received honoraria for lectures or advisory boards from Abbott, Edwards Lifesciences, and Medtronic. Dr Horn has received travel support from Abbott and Edwards Lifesciences; and has received an unrestricted research grant from Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to investigate if administration of iodinated contrast during endovascular interventions in arteriovenous fistula (AVF) in patients not requiring dialysis (predialysis patients) (1) negatively affects their renal function and (2) if oral hydration has a protective effect., Methods: All pre-dialysis patients who underwent endovascular interventions in AVF between August 2010 and April 2019 were included in the study. During the procedures, 35 to 50 mL of Iodixanol were administered. A pre-hydration protocol was introduced in March 2015. Data were grouped before and after this date. The difference between pre- and post-contrast estimated glomerular filtration rate (eGFR) and the difference between the eGFR of hydrated and non-hydrated groups were calculated., Results: Eighty-four patients who underwent 151 procedures were included in the study. In 60.3% of procedures, a mean decrease of 1.35 mL/min/1.73 m 2 in eGFR was noted (95% confidence interval [CI], 1.02-1.69 mL/min/1.73 m 2 ), whereas in 35.1% of procedures, there was a mean increase of 1.06 mL/min/1.73 m 2 (95% CI, 0.84-1.28 mL/min/1.73 m 2 ). The mean difference between pre- and post-procedure eGFR was -0.44 mL/min/1.73 m 2 (95% CI, -0.72 to -0.16 mL/min/1.73 m 2 ; P = .002). Oral hydration was associated with a smaller mean change in eGFR of -0.32 mL/min/1.73 m 2 (95% CI, -0.62 to -0.03 mL/min/1.73 m 2 ) compared with the non-hydrated group, with mean change of -0.47 mL/min/1.73 m 2 (95% CI, -0.91 to -0.03 mL/min/1.73 m 2 ), but this was not statistically significant (P = .586)., Conclusions: This study demonstrates that administration of up to 50 mL of iodinated contrast for endovascular interventions in AVF in predialysis patients has minimal adverse effect on the eGFR with questionable clinical significance. In addition, oral hydration before and after the procedure has only a mild protective effect against a decrease in eGFR., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Contrast-induced nephropathy (CIN) is a major inconvenience in the use of iodinated contrast media (ICM) and it is associated with a significant increase in morbidity and mortality and cost of hospitalization. Remote ischemic preconditioning (RIPC) is a noninvasive and cost-effective tissue protection technique that has showed to be beneficial in decreasing renal insult in patients receiving intravascular contrast., Aim: The primary outcome of this study is to evaluate the impact of RIPC on the incidence of CIN in patients undergoing endovascular aneurysm repair., Methods: Patients suffering from aortic aneurysm were recruited prior to the administration of ICM. Randomization was used to assign patients into the control/RIPC groups. Biochemical parameters determined renal function before and after surgery in immediate (24-72 hr) and at 30 days of follow-up., Results: Of the 120 patients included in the study, 98,3% were male. Mean age was 73 years (range: 56-87 years). Diabetes and chronic renal failure (considering estimated glomerular filtration [eGFR] <60) was present prior to administration of ICM in 29.16% and 38.33%, respectively. RIPC was applied in 50% (n = 60) of the patients. A total of 24.17% developed CIN regardless of fluidotherapy, RIPC, and other protective strategies. RIPC did not influence outcomes in terms of incidence on CIN, serum creatinine, urea, eGFR, or microalbuminuria in immediate postoperative period. However, the group of RIPC patients showed a statistically significant benefit in renal function in terms of serum creatinine (1.46 ± 0.3 vs. 1.03 ± 0.5; P < 0.001), urea (61.06 ± 27.5 mg/dL vs. 43.78 ± 12.9 mg/dL; P = 0.003), and an increase in eGFR (56.37 ± 23.4 mL/min/1.73 m 2 vs. 72.85 ± 17.7 mL/min/1.73 m 2 ; P = 0.004) at 30 days of follow-up., Conclusions: RIPC seems to be a reasonable, effective, and low-cost technique to alleviate effects of ICM on the renal parenchyma in endovascular aneurysm repair procedures during short-term postoperative period., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Acute abdominal pain is a common cause of ED visits and often requires imaging to identify a specific diagnosis. Prompt and appropriate imaging plays a crucial role in patient management and leads to improved patient outcomes, decreased hospital stay, and improved ED workflow. There are many cases of abdominal pain in the ED with delayed diagnosis and management secondary to a combination of institutional policies and knowledge deficits in current imaging guidelines. Inappropriate use of abdominal radiographs, use of oral contrast for CT abdomen and pelvis, and concern for iodinated contrast-induced acute kidney injury are three of the more commonly encountered roadblocks to prompt imaging diagnosis of abdominal pain. The purpose of this review is to discuss why these potential causes of delayed diagnosis occur and how radiologists can help improve both imaging and ED workflow by utilizing the most up-to-date imaging guidelines such the American College of Radiology (ACR) Appropriateness Criteria and ACR Manual on Contrast Media to assist clinicians working in the emergency setting., Competing Interests: Declaration of competing interest The authors do not have any competing or conflicting interests to declare in the writing and submission of this review manuscript., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background and Objective: lthough intravenous contrast in neuroimaging has become increasingly important in selecting patients for stroke treatment, clinical concerns remain regarding contrast-associated acute kidney injury (CA-AKI). Given the increasing utilization of CT angiography and/or perfusion coupled with cerebral angiography, the purpose of this study was to assess the association of CA-AKI and multi-dose iodinated contrast in acute ischemic stroke (AIS) patients., Materials and Methods: etrospective review of AIS patients at a comprehensive stroke center was performed from January 2018 to December 2019. Data collection included patient demographics, stroke risk factors, stroke severity, discharge disposition, modified Rankin Scale, contrast type/volume, and creatinine levels (baseline, 48-72 h). CA-AKI was defined as creatinine increase ≥ 25 % from baseline. Bivariate analyses and multivariable logistic regression models were implemented to compare AIS patients with multi-dose and single-dose contrast., Results: Of 440 AIS patients, 215 (48.9 %) were exposed to a single-dose contrast, and 225 (51.1 %) received multi-dose. In single-dose patients, CA-AKI at 48/72 h was 9.7 %/10.2 % compared to 8.0 %/8.9 % in multi-dose patients. Multi-dose patients were significantly more likely to receive a higher volume of contrast (mean 142.1 mL versus 80.8 mL; p &lt; 0.001), but there was no significant difference in their creatinine levels or CA-AKI. NIHSS score (OR=1.08, 95 % CI=[1.04,1.13]), and patient transfer from another hospital (OR=3.84, 95 % CI=[1.94,7.62]) were significantly associated with multi-dose contrast., Conclusions: No significant association between multi-dose iodinated contrast and CA-AKI was seen in AIS patients. Concerns of CA-AKI should not deter physicians from pursuing timely and appropriate contrast-enhanced neuroimaging that may optimize treatment outcomes in AIS patients., Competing Interests: Conflict of interest information Maria X. Sanmartin and Artem Boltyenkov hold Visiting Scholar appointments at the Feinstein Institutes for Medical Research in the Center for Health Innovations and Outcomes Research and are employees of Siemens Medical Solutions USA Inc. Maria X. Sanmartin and Artem Boltyenkov are shareholders of Siemens Healthineers. Jeffrey M. Katz, Jason J. Wang, and Pina C. Sanelli receive research support from Siemens Healthineers., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objectives: This prospective, randomized study assessed short-term outcomes and safety of ultra-low contrast percutaneous coronary intervention(ULC-PCI) vs conventional PCI in high risk for contrast induced acute kidney injury(CI-AKI) patients presenting with acute coronary syndrome(ACS)., Background: Patients at an increased risk of developing CI-AKI can be identified prior to PCI based on their pre-procedural risk scores. ULC-PCI is a novel contrast conservation strategy in such high risk patients for prevention of CI-AKI., Methods: 82 patients undergoing PCI for ACS were enrolled having estimated glomerular filtration rate(eGFR) < 60 ml/min/1.73 m 2 and moderate to very high pre-procedural risk of developing CI-AKI as calculated by Maioli risk calculator. They were randomized into two groups of 41 patients each of ULC-PCI (contrast volume ≤ patient's eGFR) and conventional PCI (contrast volume ≤ 3xpatient's eGFR). Primary end point was development of CI-AKI., Results: Baseline clinical and angiographic characteristics were similar between groups. Primary outcome of CI-AKI occurred more in patients of the conventional PCI group [7 (17.1%)] than in the ULC PCI group [(0 patients), p = 0.012]. Contrast volume (41.02 (±9.8) ml vs 112.54 (±25.18) ml; P < 0.0001) was markedly lower in the ULC-PCI group. No significant difference in secondary safety outcomes between two study arms at 30 days. IVUS was used in 17% patients in ULC PCI., Conclusion: ULC-PCI in patients with increased risk of developing CI-AKI is feasible, appears safe, and has the potential to decrease the incidence of CI-AKI specially in resource limited setting such as ours where coronary imaging by IVUS is not possible in every patient., (Copyright © 2022 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Background: Contrast-induced nephropathy (CIN) can occur after cardiovascular procedures using contrast media, which is associated with increased morbidity and mortality. RenalGuard is a closed-loop system designed to match intravenous hydration with diuretic-induced diuresis that has shown mixed results in the prevention of CIN in previous randomized controlled trials., Objectives: The STRENGTH (Study Evaluating the Use of RenalGuard to Protect Patients at High Risk of AKI) study assessed whether RenalGuard (PLC Medical Systems) is superior to standard intravenous hydration for CIN prevention in patients with chronic kidney disease undergoing complex cardiovascular procedures., Methods: STRENGTH is a multicenter, international, open-label, postmarket, prospective, randomized (1:1) study monitored by the Cardiovascular European Research Center (Massy, France) that included a total of 259 patients with moderate to severe chronic kidney disease (estimated glomerular filtration 15-40 mL/min/m 2 ) requiring a complex coronary, structural, or peripheral procedure with an expected contrast injection of at least 3 times the estimated glomerular filtration rate. Patients were randomized to either RenalGuard or intravenous saline hydration according to current guidelines., Results: The primary endpoint, the incidence of CIN at day 3 after the procedure, was similar between the 2 groups (17/107 [15.9%] in the RG group vs 15/110 [13.9%] in the control group; P = 0.62). In addition, none of the secondary endpoints differed between the 2 groups., Conclusions: In high-risk patients undergoing complex cardiovascular interventions in experienced centers, furosemide-induced high urine output with matched hydration using the RenalGuard system did not reduce the risk of CIN and adverse outcomes at 12 months compared with conventional intravenous hydration., Competing Interests: Funding Support and Author Disclosures The STRENGTH study was funded by RenalGuard Solutions Inc. Dr Sievert has received study honoraria to institution, travel expenses, consulting fees <25.000 €: 4tech Cardio, Abbott, Ablative Solutions, Ancora Heart, Append Medical, Axon, Bavaria Medizin Technologie GmbH, Bioventrix, Boston Scientific, Carag, Cardiac Dimensions, Cardiac Success, Cardimed, Celonova, Contego, Coramaze, Croivalve, CVRx, Dinova, Edwards, Endobar, Endologix, Endomatic, Hangzhou Nuomao Medtech, Holistick Medical, Intershunt, Intervene, K2, Lifetech, Magenta, Maquet Getinge Group, Medtronic, Metavention, Mitralix, Mokita, NXT Biomedical, Occlutech, Recor, Renal Guard, Terumo, Trisol, Vascular Dynamics, Vectorious Medtech, Venus, Venock, Vivasure Medical, Vvital Biomed, and Whiteswell. Dr Mahfoud has received grants from RenalGuard Solutions Inc during the conduct of the study; has received grants from Deutsche Gesellschaft für Kardiologie; has received grants from Deutsche Forschungsgemeinschaft (SFB TRR219); has received grants and personal fees from Bayer; grants and personal fees from Boehringer Ingelheim; has received grants and personal fees from Medtronic; and has received grants and personal fees from ReCor Medical outside the submitted work. Dr Morice is the CEO and a shareholder of CERC; the CRO in charge of the trial; and a minor shareholder of Electroducer. Dr Garot is a medical director and a shareholder of CERC; and has received minor speaker’s fees from Abbott, Biosensors, Boston, and Edwards outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Reducing fluoroscopy times and iodine contrast administration during endovascular repair (EVAR) of infrarenal aortic aneurysms remains a challenge. The purpose of this study is to evaluate the preliminary results of a fully ultrasound-assisted EVAR without iodine contrast administration., Methods: Twenty-seven consecutive patients underwent an elective intravascular ultrasound (IVUS)-assisted EVAR with final contrast-enhanced ultrasound (CEUS) control of correct aneurysm exclusion. In no case intraprocedural injection of iodine contrast medium was performed. The primary study's end points were the overall duration of the procedure, duration of fluoroscopy, cumulative radiation dose, the length of intraoperative CEUS control, and the comparison of findings between intraoperative CEUS and computed tomography (CT) scan at 1 month., Results: Mean duration of the procedure was 130 ± 35 min. Overall duration of fluoroscopy was 22 ± 18 min. Mean radiation dose was 66 mGy (range 24-82). The mean length of CEUS final control was 8 ± 2 min. No type I or type III endoleak was detected either at CEUS or at angio-CT scan at 1 month from EVAR. CEUS revealed a type II endoleak in 6 patients (22%), compared to 9 type II endoleaks (33%) detected at angio-CT scan 1 month after the procedure (P = 0.5)., Conclusions: Fully ultrasound (IVUS and CEUS)-assisted EVAR is safe, feasible, and reliable, completely eliminating the need for iodine contrast medium and reducing the radiation exposure for both patients and surgeons., (Copyright © 2022 Elsevier Inc. All rights reserved.)