Complications in Radiology and

intervention Radiology
 Barium studies

• Barium is an inert substance and is

incapable of triggering a reaction.
• salt is insoluble in water so is not
absorbed through the intestinal mucosa.
• This makes this salt nontoxic and safe for
human use.
 Barium studies
• Incidence of complication is 4.17%
• Hypersentivity reaction
• Impacton
• Perforation
• Aspiration
• Intestinal obstruction
• Failure of ileostomy/colostomy closure
 Hypersensitivity reactions
• Additives to provide properties of the
product.
• Generally a well-kept secret

- carboxymethylcellulose
Aluminum hydroxide gel, simethicone
Polyxethylene monooleate silica,
artificial sweeteners/flavors.
Impaction
 Prevention of Barium Impaction

 
• 2 before - low-residue diet and fluids to ensure
adequate hydration.
• Day of the examination - patient should drink
plenty of clear fluids
• Laxatives and Cleansing enemas.
 Prevention of Barium Impaction
• 75 percent barium - evacuated from the
rectum with the patient prone
• Cannula is left in place for 10 minutes to
allow further drainage of the barium.
• Patient is encouraged to evacuate his or
her bowels into the toilet.
 Perforation
• Colon or Rectum is a serious complication
of the barium enema examination,
occurring in 0.02% to 0.04% of patients.
 Perforation
• Intraperitoneal perforation is especially
devastating, due to the combination by
barium and bacterially loaded faecal
material within the peritoneal cavity. This
causes an intense peritoneal inflammatory
reaction leading to intravascular volume
depletion, tachycardia, hypotension and
shock.
 Perforation
• Extraperitoneal perforation is usually less
catastrophic
Perforation
Perforation
 Perforation
Four mechanisms of injury
1) Trauma from the enema tip
2) Overinflation of the balloon
3) Recent colonoscopic instrumentation
especially associated with biopsy
4) The presence of rectal mucosal disease
such as cancer, stricture, diverticulosis or
inflammatory bowel disease.
 Prevention
• Safe tip-balloon design should be used.
• Retention balloon should be inflated only
under fluoroscopic monitoring
• Barium studies should be avoided in
patients with active colitis.
 Prevention
• In cases of deep biopsy or polypectomy,
the examination should be delayed by at
least six days.

• Generation of pressure greater than that

created by a column of barium suspension
of one meter should be avoided
 Management
• Non-operative approach is safe in small
extra-peritoneal injuries.

• Extensive, extraperitoneal extravasation, if

not immediately treated, may cause a peri-
rectal tissue infection and lead to fatal
septicaemic shock within a few hours or
days.
• Less extensive contamination may lead to
pelvic sclerosis with later development of
rectal and ureteric stenosis
• Free intraperitoneal rupture - Rise to a
hypotensive state which can prove fatal.

• Adequate resuscitation and early resection or

primary repair and an aggressive effort to
evacuate as much barium as possible are
mandatory.
 Aspiration
• Aspiration of Barium Sulphate can lead to
fatal effect of aspiration pneumonia.
• Happen – old person and young children
- with obstructive/ motility disorders
Aspiration
 Aspiration
• Microscopically, most of the particles
accumulate in alveolar spaces and few in the
interstitium.

• Inert character does not stimulate inflammatory

reaction unless-
- Acid aspiration
-Barium HD (250 % W/V)
 Aspiration
• Hypersensitivity reactions caused by one of the many
additives to commercial
barium preparations can occur .

• Barium particles are phagocytized by alveolar

macrophages.

• If any fibrotic response occurs - barium sulfate

mixtures act as mechanically obstructive
material leading to emphysema only in rare cases.
 Aspiration- water soluble contrast
media
• If a mediastinal fistula is expected Gastrografin
can be used instead of barium sulfate to avoid
mediastinitis.

• Can induce pulmonary edema when introduced

directly into normal lungs

Not the material of choice when aspiration is

probable .
 Intravasation

- 0.004–0.04% of procedures.

• Barium may also intravasate into the venous drainage

of the large bowel and enters the circulation as a
‘‘barium embolus’’.

• 36 cases of barium intravasation have been reported in

the
last 50 years

The British Journal of Radiology (2006)

 Causes
• Thinning of the rectal wall with age and
proximity of the haemorrhoidal venous plexus
may contribute to intravasation.

• Colon affected by disease.

• when intraluminal pressure overcomes the

resistance of the colonic wall affected by
colitis, diverticulitis or intestinal obstruction.
Mortality- 26 -60 % more in systemic than portal embolization.
 Prevention
• Balloon inflation under fluroscopy
• Height of barium column.
• Insufflate little air or little barium in start of
procedure.
 Barium in intestinal obstruction
• BMFT is indicated in small bowel
obstruction as there is enough dilution of
barium in small bowel so does not lead to
intestinal obstruction
• Large bowel
Oral Barium Suftate in Partial Large-Bowel Obstruction - Radiology
Retained barium in appendix
Contrast media
 Contrast media

X-ray& CT Scan Ultrasound MRI

Positive Negative contrast Media Gadolinium

Contrast media . Air ,Co2 compounds etc

Iodinated Barium

Water based

High osmolar

Ionic monomer

Low osmolar

Ionic dimer

Non ionic monomer

Oil based Non ionic dimer

 Basic chemical structure of Iodinated contrast media

Iodine containing benzene ring

R1 Side chains in positions C1-C3-C5 are

important for the physicochemical
properties.
I
I

5
 C3 determines changes in the
solubility
3
 C5 influences the excretion
R3 R2

I
The physicochemical properties of CM play a key
role in determining their physiological and
untoward effects:
• Iodine concentration:
• Ionic charge
• Hydrophilic properties
• Viscosity
• Osmolality
 Ratio Iodine atoms Particles per Type
per molecule molecule Ionic monomer

3:2 3 2
•Diatriazoate
Osmolality- 1400 – 2000 mosm/kg water •Iothalamate
3:1 3 1 •
Non Metrizoate
Ionic monomer

Osmolality- 600-800 mosm/kg water •Iopamidol

•Iohexol

2
•Ioversol
Ionic Dimer
3:1 6
Osmolality- 600-650 mosm/kg water •Ioxaglate
1 Non Ionic Dimer
6:1 6
Osmolality- 320 mosm/kg water • Iodixanol
Osmolality of plasma
– 280 – 290 mosm/Kg water
 Contrast Media Reactions

1. Idiosyncratic/ Anaphylactoid Reactions

2. Non Idiosyncratic Reactions
3. Combined Reactions

ACR Contrast Media Manual 1991

 Incidence

1. Estimated that 8 million people receive RCM annually in U.S.

2. Overall frequency of adverse reactions is 5% to 8%

3. Life-threatening reactions occur less than 0.1% with older

(hyperosmolar) agents

4. Mortality estimated at 1 in every 75,000 patients

5. With advent of second generation agents (low-osmolar or iso-

osmolar agents) incidence of adverse reactions 1/5 that of first
generation agents

*Neuget AI. Ghatak AT. Miller RL. Anaphylaxis in the United

States: An investigation into its epidemiology.
Archives of Internal Medicine. 161(1):15-21, 2001 Jan 8.
 Definition of Terms

Anaphylactoid events vs. Anaphylaxis

1. Anaphylaxis: An immediate systemic reaction caused
by rapid, IgE-mediated immune release of potent
mediators from tissue mast cells and peripheral blood
basophils.

2. Anaphylactoid events: Immediate systemic reactions

that mimic anaphylaxis but are not caused by IgE-
mediated immune responses

Non Idiosyncratic reactions: Usually dose related

Possible Mechanisms for Idiosyncratic
Anaphylactoid Reactions
 Contrast Reactions

Minor

Intermediate

Severe
 Contrast Induced Nephropathy

Definition:- Is a condition in which an impairment in

renal function (increase in serum creatinine by 25%

or 44 mol /litre) occurs within 3 days following the

intravascular administration of a contrast medium in

the absence of an alternative etiology.

BJR August 2003,513 - 518

 Epidemiology

• The percentage of patients at risk 3.5 -15.5%

Depends on presence of a preexisting impaired renal function, diabetes
mellitus, congestive heart failure, and hypertension and on the volume
of contrast used.
Ital Heart J 2003; 4 (10): 668-676
• Third most common cause of hospital acquired renal failure 10% of
cases
• Incidence in general population – 2%
• Incidence among diabetics – 9-40 %
• Incidence among diabetics with renal insufficiency – 50-90%

AJR: 183, Dec 2004;1673-1689

• 10 – 25 % incidence for a transient need for
dialysis

• 30 % of pts , renal function fails to touch the

base line
RCNA July 2002
 Renal Handling of Contrast Media

• Elimination half life in normal individuals - 2 hrs

• 75% of administered dose excreted in - 4 hrs

• 98% of administered contrast excreted in - 24 hrs

• Less than 1 % excreted through extra renal route in

normal individuals
Formulas for Dose Calculation
Mechanism of Contrast Induced
Nephropathy
Mechanism of Contrast Induced Nephropathy
 Features
1. Oliguric / Non oliguric renal failure.
2. Rise in serum creatinine by 24 hrs and peaks
by 3-5 days .
3. Persistent nephrogram on Radiography or CT
scan 24 hrs after procedure.
- immediate dense and persistent nephrogram
- increasingly dense nephrogram.

4. Electrolyte imbalances
Risk Factors for Contrast Induced Nephropathy

AJR: 183, Dec 2004;1673-1689

 Contrast Induced Nephropathy
• Serum creatinine is insensitive
measurement in patients with normal
kidney functions.

• More than 50% reduction in GFR may

occur without any increase in serum
creatinine
( BJR- 1998)
 Contrast Induced Nephropathy
• Serum creatinine can be used as an
accurate test in patients with renal
impairment to access any further
deterioration.

• Relationship in fall of GFR and rise in serum

creatinine is more helpful after 50% decline
in GFR.
( Normal GFR= 125ml/sec)
 Contrast Induced Nephropathy
• Creatinine clearance
-GF
- Tubular secretion

so in general underestimate reduction in

GFR.
 Gadolinium
1. Gadolinium K-edge 50.2 Vs 33 Kev iodine ,allows
imaging with a higher Kvp (77- 96).

2. Recommended dose limit 0.3- 0.4 mmol/kg

dose for adequate visualization.

3. Best used for selective angiography of small&

medium vessels.

(Evaluation of A- V fistulas and vein

grafts,aortography ,visceral
angiography,genitourinary & biliary studies.
RCNA July 2002
 Gadolinium
Adverse effects-
• Most common side effects - nausea,
emesis & headache.
• Incidence <5 %
• Severe Adverse reactions < 1 %
(1 in 100,000 –
500,000)
• Can be nephrotoxic at doses >0.4 mmol/kg
Complications due to embolization
material
 Embolization

Therapeutic introduction of various substances

into the circulation to occlude vessels, either to
arrest or prevent hemorrhaging, to devitalize a
structure, tumor, or organ

-by occluding its blood supply, or to reduce

blood flow to an arteriovenous malformation
• Embolization may have 3 therapeutic goals

(1) An adjunctive goal- preoperative, adjunct

to chemotherapy or radiation therapy

(2) A curative goal- aneurysms,

arteriovenous fistulae (AVFs), arteriovenous
malformation (AVMs), and traumatic bleeding

(3) a palliative goal- relieving symptoms, such

as of a large AVM
 Material
• Coils
• Detachable balloons
• Small particulate material
- polyvinyl alcohol
-gelatin sponge
• Liquids
- glue
- alcohol and other sclerosants
 Coils
• can be grouped into
- Micro coils
- Macro coils
 Coils
• Macro coils - also called Gianturco coils
• Advantage - precisely positioned under
fluoroscopic control
• Occlusion – coil induce thrombosis rather
than mechanical occlusion of the lumen.
• Thrombogenic effect – increased with
dacron wool tails.
 Coils
• Local misplacement
• Distal migration.
• Collateralization is a potential
disadvantage of coil embolization
• Proximal occlusion occurs with coil
embolization
 Detachable balloons
• Premature deflation
• Accurate positioning may be difficult to
maintain because of balloon shape.

• Principle disadvantage with balloons –

multiple catheter exchanges.
 Polyvinyl alcohol
• Obtained by the reticulation of PVA (Ivalon)
with formaldehyde.
• Supplied in dried state and expands when
comes in contact with liquid.

• Histologically - agent causes intraluminal

thrombosis associated with an inflammatory
reaction, with subsequent organization of the
thrombus
 Polyvinyl alcohol
• Marketed in various sizes
• Non reabsorbable – permanent occlusive
agent
(though some recanalization do occur)
 Polyvinyl alcohol

• Administered in a mixture of contrast medium

and isotonic sodium chloride solution under
fluoroscopic guidance.

• Aggregation of PVA particles can be minimized

by using dilute contrast medium in a matched-
density suspension eg Omnipaque and sodium
chloride solution can be used in a ration of
1:0.4 for contour particle suspension.
 Polyvinyl alcohol
Complications parallel degree of devascularization
achieved.

Complete infarction is possible using it

however infarction of nontarget tissue can also occur if
check angiogram are not performed.

Non radiopaque substances are mixed with contrast

media to see flow pattern.
 Gelatin sponge (Gelfoam)
• water-insoluble, off-white, nonelastic, porous,
and pliable material.
• May be cut without fraying, and it can absorb
and hold many times its weight in blood.

• Acts as a matrix on which thrombus begin to

form and propagate.
 Gelatin sponge

• Vascular occlusion is expected to last for 3

weeks.
• Partial recanalization followed by complete
recanalization occurs – 30 to 35 days.
• degree of devascularization achieved with
gelatin is less: so complications are also
less.
 GLUE
• Cyanoacrylate- rapidly hardening liquid
adhesive.
• Substance hardens (polymerizes) immediately
on contact with blood or other ionic fluid.
Polymerization results in an exothermic
reaction that destroys the vessel wall.

• Foreign body inflammatory reaction is the

primary disadvantage
 Ethanol
• Absolute alcohol is the most commonly used
liquid agent.
• Has
-a direct toxic effect on the endothelium
- causes spasm along length of vessel

• Has a potential effect of causing reflux into non

target areas.
• Ethanol can be damaging if it reaches the
capillary bed of any given tissue
 Ethanol
• Slow, careful injections by using balloon
occlusion arterial catheters for delivery
• By applying manual compression on the
draining veins (or tourniquet control)
or balloon occlusion of the draining system

• 1 mg/kg is the maximum amount that can be

injected during a single session.
Complications because of embolization

Vessels requiring embolization can be broadly

grouped into
• Neoplastic vessels.
• Arteriovenous communication.
• Disrupted vessels with acute hemorrhage.
 Neoplastic vessels
• Mainly related to nature of embolic agent .
• Proximal occlusion- unlikely to be of any
benefit because of opening up of
collaterals.
• Organ failure.
 Arteriovenous communication
• Passage of embolic agent through shunt.
-if is on systemic side- eg in post biopsy renal
AV fistula : unlikely to cause major
complication
- If shunt is in pulmonary circulation- embolus
may pass into left heart, may lead to disaster.
 Disrupted vessel and acute
hemorrhage
• Objective is to achieve homeostasis
• Non selective embolization should be
avoided as far as possible to avoid
infarction of organs.
• Post embolization syndrome-
• Septicemia
• Abscess formation.
• Infarction of embolized organ.
• Ulceration in bowel
• DIC
Complications of diagnostic
angiography.
• Puncture site-
hematoma
occlusion
pseudoaneurysm
AV fistula
contrast extravasation
Non puncture site-
distal emboli
dissection of selected vessel
 Hematoma
• Faulty technique: eg puncture above or below
femoral head in femoral
puncture

• Inadequate compression: 20 minute or arterial

10 minutes for venous

• Laceration due to large size of needle and

patient coagulation profile.
 Thrombosis
• Usually due to catheter: size relative to lumen
type of catheter
length Exposed to blood

Other factors : extent of intimal damage,

vascular
spasm, patient coagulation state
 Pseudoaneurysm
• Pseudoaneurysm is a pulsating Hematoma
that results from disruption of a portion of the
arterial wall.

• Clotting occurs in the peripheral limits of the

Hematoma, while the center remains fluid and
communicates with the arterial lumen causing a
pulsatile mass.
Pseudoaneurysm

Right femoral arteriogram

Demonstrating Pseudoaneurysm
of SFA
 conclusion

Awareness of complications of a
procedure is the first requirement to
reduce incidence of complications.