As the iodinated contrast media shortage continues to have a significant adverse effect on radiology, these authors assess the pros and cons of emerging strategies and imaging alternatives.
Continued fallout from the global shortage of iodinated contrast media (ICM) has forced hospitals and providers to triage patients, reduce imaging utilization, switch imaging modalities, and postpone imaging studies. Effective strategies to blunt the impact of the ICM shortage are urgently needed as this crisis continues to have a profound impact on patients and health-care systems.
Like many other modern-day crises, the ICM shortage originated from the COVID-19 pandemic. A large percentage of the world’s ICM supply is manufactured in Shanghai, China. Strict pandemic lockdowns led to a near total cessation of manufacturing and shipment of the contrast media out of the country, which led to widespread shortages across the world. Although the Shanghai factory returned to full operation last month, some imaging facilities may continue to have challenges with shortages until their supplies of ICM are restored to optimal levels.1
Given this risk, it is prudent to develop and implement strategies that can effectively minimize the impact of the ICM shortage while maintaining high quality patient care. Multiple societies have put forward recommendations involving possible solutions, including triaging patients, using alternative imaging modalities, using alternative contrast agents, reducing overall imaging utilization, and creating central command structures.
(Editor's note: For related content, see "Lessons Learned from the Iodinated Contrast Media Shortage: A Neuroradiologist's Perspective" and "Emerging Strategies for Managing the Acute Shortage of Iodinated Contrast Media.")
One of the simplest but also most challenging of the recommended strategies involves changing what imaging tests are done and when. This can be achieved through triaging and delaying elective imaging. Triaging involves the difficult task of assigning a priority to each patient’s contrast needs. Keefe and colleagues proposed a three-category triage tier list, which includes emergent, delay for one month, and delay for three months.2 This novel strategy enables clinicians to ensure that patients with emergent needs are served quickly while also enabling health-care systems to extend their limited supplies until the crisis abates.
Another widely suggested remedy is the use of alternative imaging modalities. Possible alternatives include magnetic resonance imaging (MRI), ultrasound, and non-contrast computed tomography (CT) studies. Given the large overlap between MRI and contrast CT indications, increasing the use of MRI during this crisis has been broadly recommended.1 However, there are limitations to this substitution. The primary impediments are the limited number of MRI scanners, their relatively higher cost, and the nature of the pathology. One solution to this is the use of “focused” protocols that minimize overall MRI time, which can enable each scanner to serve a larger number of patients with appropriate disease conditions.
Using alternative contrast agents is another frequently prescribed solution to this problem. Multiple alternatives, including carbon dioxide (CO2) and gadolinium, have been suggested, particularly when it comes to interventional radiology.2 Each of these substitutes has benefits and drawbacks that must be carefully considered.
Using CO2 is beneficial because it is not allergenic nor nephrotoxic and has no dose limit due to excretion by the respiratory system. However, CO2 also has risks, such as organ ischemia and emboli. It is also contraindicated for multiple conditions and procedures.2 Gadolinium is another off-label, but well studied alternative to iodinated contrast dyes. Gadolinium is advantageous since it has a low risk of nephrotoxicity. However, it is restricted by the necessity of small dosages and has limited ability to generate high quality angiographic images.2
A final broad recommendation is the creation of a centralized hospital command for the allocation and distribution of iodinated contrast dye. Instead of leaving each department to handle the crisis on its own, the creation of a multidisciplinary, multispecialty, and centralized command that can effectively coordinate a hospital-wide response during this critical period is essential. This centralization of command can remove ambiguity and the burden of procurement and allocation from individual physicians and departments. This strategy can allow for more equitable and balanced distributions of limited resources.
In conclusion, although the current ICM shortage is cause for great concern, the future is promising. The Shanghai factory has reopened and other factories across the world have begun to ramp up their ICM supply to help mitigate the crisis.3 A combination of patience, effective triaging, alternative imaging, alternative contrast agents, and novel command structures will enable radiology to weather this storm and fully return to normal in the near future.
1. Reeder SB, Hess CP, Zaharchuk G, Moy L. Editorial for “Magnetic resonance imaging as an alternative to contrast-enhanced computed tomography to mitigate iodinated contrast shortages in the United States: recommendations from the International Society for Magnetic Resonance in medicine. J Magn Reson Imaging. 2022 Jun 2. doi: 10.1002/jmri.28282. Online ahead of print.
2. Keefe NA, Desai KR, Kohi MP, Salazar GM. Interventional radiology approach to contrast media preservation strategies. J Vasc Interv Radiol. 2022 May 19;S1051-0443(22)00940-X. doi: 10:1016/j.jvir.2022.05.011. Online ahead of print.
3. Hicks L. Global contrast media shortage blamed on COVID lockdown in China. Medscape. Available at: https://www.medscape.com/viewarticle/973810 . Published May 11, 2022. Accessed June 21, 2022.