Some hospitals and neuroradiologists are in “triage mode” since supply chain problems created a logjam of shipments of contrast dye for imaging. In some cases, the shortage has led to delays in elective and interventional procedures; in others, the delays have resulted in alternative strategies for diagnosing neurocritical and neurovascular disorders.

Despite the return of a Shanghai facility to 100 percent production capacity in June, and despite neuroradiologists' efforts to conserve their supplies of iodinated contrast media, shortages continued to plague certain facilities across North America as of mid-July, an informal survey by Neurology Today found.

Not all neuroradiology units were still affected, with only two of seven contacted by the newspaper reporting continued shortages. But representatives at those two hospitals said the effect has been deeply troubling for patients and providers alike.

“We are in triage mode,” said Manraj K.S. Heran, MD, a diagnostic and interventional neuroradiologist at Vancouver General Hospital, and associate professor at the University of British Columbia. “We are having to ration the use of contrast [dye] and select people on the basis of who is most urgent.”

The current supply at his hospital, Dr. Heran said, is expected to last just two to four weeks, with no certainty that a new shipment will be arriving by then.

“That has resulted in the postponement of our elective diagnostic and interventional procedures,” he said. “Someone who has symptomatic carotid stenosis is going to be treated, but someone with asymptomatic stenosis is going to wait. The question is for how long. It's terrible for everyone involved, but it's the patients who suffer most.”

Other neuroradiologists, however, said they have discovered a silver lining in the process of responding to the shortage.

“We had to learn to optimize the doses of contrast, to use that dye much more efficiently,” said William Zucconi, DO, section chief of neuroradiology at Yale Medicine and associate professor of radiology and biomedical imaging. “We found we could reduce our contrast for some CT scans by almost 20 percent without sacrificing image quality. Now we're going to be able to lock in some of those changes.”

With contrast media costing anywhere from one to three dollars per cubic centimeter (CC), depending on the vendor and buying power of the health system, the savings could be substantial, said Joni Larson, director of the radiology department at Providence St. Patrick Hospital in Missoula, Montana.

“I do think it changed the way we look at how much contrast we need to give,” Larson said. “Instead of giving 100 CCs of volume, we might give 80. The radiologists were still able to read the exams.”

In response to continuing disruptions in the supply of contrast media at some institutions, the US Food and Drug Administration (FDA) announced in June that it was allowing US providers to buy foreign-labeled version of Bayer's iopromide (Ultravist).

In a letter to physicians, the FDA explained that the foreign-labeled product is identical to the product sold in the US, but without the current FDA-approved labeling.

The shortage began in early April, when Chinese officials in Shanghai ordered a city-wide lockdown under the country's “zero COVID” policy. A GE Healthcare manufacturing facility there was forced to shut down for over a month.

With an estimated 50 percent of US hospitals using the GE product, shortages soon developed not only in the United States but also around the world. In response, the American College of Radiology issued a statement from its Committee on Drugs and Contrast Media on mitigation strategies to help radiologists preserve as much of their supply as possible.

Those strategies included using alternative tests when feasible, such as non-contrast CT or MRI; seeking supplies from other vendors or brands of iodinated contrast media; reducing dosages when possible; minimizing single-use vials to reduce waste; and exploring guidelines for the safe use of single-use vials for more than one patient.

On June 9, two radiologists and two biostatisticians published a letter in JAMA, describing their analysis of how much contrast media could be saved by using a variety of measures. They concluded that weight-based dosing rather than fixed dosing would reduce use by 12 percent. Lowering tube voltage and contrast dose would save another 25 percent. By combining both those methods with the use of non-enhanced CT whenever a moderate reduction in accuracy is acceptable, the total reduction in contrast dye compared to standard practice would be an extraordinary 83 percent.

Many of those strategies were quickly adopted by neuroradiologists across the country. “We saw a shortage, but we were able to conserve and adapt so it had negligible impact on patient care,” said Steven Warach, MD, PhD, FAHA, professor of neurology at the University of Texas at Austin, and executive director of the Seton Dell Medical School Stroke Institute.

Patient care has been affected at some hospitals, said Steven R. Messé, MD, FAAN, FAHA, professor of neurology at the Hospital of the University of Pennsylvania and associate director of its vascular neurology fellowship.

“Fortunately, it has had had no impact whatsoever on our clinical practice, since our supply of contrast was not affected, but people I have spoken with said it definitely impacted the way they were caring for patients,” Dr. Messé said. “With stroke patients, when someone comes in within 24 hours, we would typically perform a non-contrast CT, a CT angiogram, and CT perfusion. The latter studies each require contrast media. If they don't have enough contrast, they could go for an MRI instead. But patients may not tolerate it, the machine might not be available, and it likely will take longer. With stroke, time to treatment is critical.”

David Liebeskind, MD, FAAN, professor and director of the UCLA Comprehensive Stroke Center, said the challenge to standard practices has been useful.

“It has really forced clinicians to think hard about how they formulate a decision in the setting of acute stroke, and how they use imaging,” Dr. Liebeskind said. “I would argue it's been a healthy experience. It's made us ask ourselves why we have done things the way we have, and if there is a need for a new normal.”

By June 8, GE Healthcare's manufacturing facility in Shanghai was back to operating at 100 percent of production capacity, the company announced. But over a month later, supply-chain problems had yet to fully resolve.

“We are still seeing contrast shortages,” said James Lane, imaging manager at Down East Community Hospital in Machias, ME. The 25-bed hospital is located over 200 miles northeast of Portland and is not affiliated with any larger health system.

“We have been speaking with our physicians constantly, seeing if a test can be done by MRI or ultrasound,” Lane said. “Any time a study is ordered, my technologist and I speak with the radiologist to see if we can get the same results without impinging on patient care.”

In Vancouver, the continuing shortage has been extremely stressful for staff. “If someone has an aneurysm that isn't ruptured and you scheduled them for management, now they might need to be told it will be rescheduled,” Dr. Heran said. “That's very difficult for the medical provider who is trying to advocate for their patients. It puts a great amount of strain and anxiety on the entire team.”

He compared the dye shortage to the early days of the pandemic when tests and masks were in short supply. “You'll remember how much anxiety that produced, and how uncomfortable it was,” Dr. Heran said.

Perhaps most unsettling is that no one has been able to tell him when the shortage will end.

“It's a very unpredictable situation,” Dr. Heran said. “There's a bottleneck somewhere. All you know is you're faced with a situation where you just don't have what you usually have. We want to do right by every single one of our patients. The fact that we are handcuffed by a shortage of something vital for performing diagnostic and interventional procedures makes it extremely frustrating and disappointing.”

He added, however, “We have also learned to conserve contrast media, so the silver lining is a perspective we share.”

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Vol. 22, Issue 16 - p. 1-22

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