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Caracterización Fisicoquímica Y Clínica De Los Medios De Contraste Intravasculares Iodados

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Caracterización Fisicoquímica Y Clínica De Los Medios De Contraste Intravasculares Iodados Anales de Radiología México 2008;2:129-140. ARTÍCULOS DE REVISIÓN Dra. Patricia Rodríguez Nava,1 Dr. Ernesto J. Dena Espinoza,1 Caracterización fisicoquímica y Dr. Roberto Basile Lenge,2 Dra. Margarita Fuentes García,3 clínica de los medios de contraste Dr. Gustavo Fink Josephi,4 Dr. Eduardo Marbez Namnum1 intravasculares iodados RESUMEN Objetivo: El propósito de sido aceptado por algunos ra- este artículo es realizar una re- diólogos. La lopromida puede Introducción: El uso de visión bibliográfica sobre las ca- ser considerada un agente uni- medios de contraste intravascu- racterísticas, clasificación, pro- versal para todas las explora- lares no iónicos (gas, sustancia piedades físico-químicas, así ciones y procedimientos radio- hidrosoluble o liposoluble) en como los efectos secundarios lógicos. imagenología ha proliferado (quimiotoxicidad) de los medios en los últimos años debido a su de contraste intravasculares no Palabras clave: Medios de excepcional tolerancia por los iónicos. contraste intravasculares ioda- pacientes. La baja osmolalidad Conclusiones: Un factor que dos, medios de contraste ióni- de este tipo de medios de con- interviene en la incidencia de cos, medios de contraste no ió- traste aporta beneficios como reacciones idiosincráticas o aler- nicos. bajo incremento del volumen goides puede ser el estado psi- sanguíneo, baja toxicidad, bajo cológico del paciente. El trata- efecto sobre la barrera hema- miento previo con antihitamíni- toencefálica. cos, corticosteroides o ambos ha continúa en la pág. 130 1 Del Servicio de Radiología e Imagen “Dr. Carlos Coqui” del Hospital General de México osmolalidad o iso-osmolares. En los Estados Unidos 2 3 O.D. De la Universidad de Buenos Aires Cardiología. De la Coordinación de Imagen de 1-3 la Secretaría de Salud del Gobierno del D.F. 4 Del Hospital Ángeles Interlomas. su utilización se aproximó a 90%. Copias (copies): Dra. Patricia Rodríguez Nava E-mail: [email protected] Medios de contraste intravasculares Introducción Desde hace algunos años se han introducido nue- Definición vos medios de contraste intravasculares no iónicos para Un medio de contraste (MC) puede definirse como uso en imagenología. Estos poseen una osmolalidad un elemento o una sustancia (gas o sustancia hidroso- más baja que los medios de contraste iónicos (monó- luble o liposoluble), que una vez inyectada en un vaso meros) convencionales que aparecieron en la década sanguíneo o cavidad del organismo humano permite de los años cincuenta. observar estructuras que normalmente no son visibles Los medios de contraste no iónicos han sido excep- o se observan deficientemente. Estos han venido sien- cionalmente bien tolerados en la mayoría de los pa- do utilizados en estudios con rayos X y tomografía cientes, con una reducida incidencia de reacciones computarizada, (gases, liposolubles e hidrosolubles yo- adversas de tipo anafilactoide. dados),4-7 asimismo han sido utilizados los agentes Los estudios clínicos han demostrado ventajas sig- paramagnéticos para resonancia magnética del tipo nificativas de estos medios de contrastes como son: el de los Quelatos de Gadolinio (paramagnético), Óxi- bajo incremento del volumen sanguíneo, baja cardio- dos de hierro superparamagnéticos (SPIO), Partícu- toxicidad, bajo efecto sobre la barrera hematoencefáli- las de óxido de hierro ultra pequeñas (USPIO) y partículas ca y el ser virtualmente indoloros en procedimientos de óxido de hierro muy pequeñas (VSOP).8-13 Además de angiográficos. los denominados ecorrealzadores o medios de con- A finales del año 2000, 92% de los medios de con- traste para ultrasonido (Microburbujas de Galactosa cu- traste utilizados en la Unión Europea fueron de baja biertas de ácido palmítico).14-17 Abril-Junio 2008 129 viene de la pág. 129 and low effect upon the hema- chological state. The previous to encephalic barrier (blood- treatment with antihistamine, brain). corticosteroids or both has ABSTRACT Objective: The purpose of been accepted by some radio- this article is to carry out a bi- logists. Lopromide can be con- Introduction: The use of in- bliographical revision on the sidered a universal agent for all travascular non-ionic contrast characteristics, classification, the explorations and radiological media (gas, hydrosoluble or li- physico-chemical properties, as procedures. posoluble substance) in the ima- well as the secondary effects ging area has proliferated in the (quimiotoxicity) of the intravas- last years due to its exceptional cular non-ionic contrast me- tolerance by the patients. The dium. low osmolality of this type of Conclusions: A factor that Key words: Iodized intravas- contrast media contributes with interferes in the incidence of cular contrast media, ionic con- benefits such as low increment idiosyncratic or allergic reactio- trast media, and non-ionic con- of blood’s volume, low toxicity, ns can be the patient’s psy- trast media. Medios de contraste. Estructura y propiedades y a los agentes colegráficos orales (estos últimos ac- tualmente en desuso). Clasificación de los Medios de Contraste Los MC Iónicos Dímeros incluyen los Agentes Co- Los Medios de Contraste (MC) se clasifican en ne- legráficos intravenosos (actualmente en desuso) y gativos y positivos. Los negativos comprenden gases los agentes angiográficos (sales del ácido ioxáglico). Los como el aire y el CO2, mientras los positivos incluyen al MC No Iónicos Monómeros, comprenden los medios de Sulfato de Bario y los MC Iodados, subdividiéndose contraste Uro-mielo-angiográficos, el primero que se estos últimos en tres grandes grupos: sintetizó fue la Metrizamida (actualmente en desuso), así como el Iopamidol y el Iohexol (Figura 3). • MC Liposolubles (Lipiodol). Para Uro-angiografía (Iopamidol, Iohexol, Ioversol, • MC Insolubles en agua (Diyodopiridina) [actualmen- Iobitridol, Iodixanol, así como la Iopromida, la cual es te en desuso] que forman suspensiones no esta- un medio de contraste no iónico aprobado para uso en bles en agua. angiografía –incluyendo la angiografía de sustracción • Derivados del Ácido Triyodobenzoico, que a su vez digital–, para administración intracavitaria, en explora- se clasifican en cuatro grupos: ciones de tomografía computarizada y en urografía a) MC Iónicos Monómeros. excretora) (Figura 3) todos ellos existentes en el mer- b) MC Iónicos Dímeros. cado mexicano en la actualidad. El Iopentol y el Iome- c) MC No Iónicos Monómeros. prol se comercializan en Europa. Aún se encuentran d) MC no Iónicos Dímeros (Figura 1). en desarrollo y perfeccionamiento una amplia gama de medios de contraste.4-7 Los Monómeros poseen un solo anillo de benceno y Por último, los MC No Iónicos Dímeros incluyen los los dímeros tienen dos. Los MC son Iónicos cuando al agentes Uro-angiográficos como el Iodixanol y Uro-mie- ponerse en contacto con la sangre o el agua se ionizan lo-angiográficos, como el Iotrolán.1-3,10 en dos cargas eléctricas, es decir, en un anión (-) y en Los MC también se clasifican en Orgánicos (hidro- un catión (+) (Figura 2) (tomado de: Mühlenkamp WB. solubles) e Inorgánicos (Sulfato de Bario), Yodados Chemistry of contrast media. Medizinische information (hidrosolubles) y No Yodados (sulfato de bario). Los Pharma Entwicklung of Schering; 1987). medios de contraste Triyodados por su Composición Los MC No Iónicos al ponerse en contacto con la Química se clasifican en Acetrizoatos (1950, Urokon y sangre o el agua, no se ionizan, es decir, se compor- Vasurix), Diatrizoatos (1953, Hypaque y Urografín, tan como partículas neutras (Figura 2). Los MC Iónicos 1958, Unipaque y Miokon, todos ellos descontinuados), Monómeros comprenden los agentes uro/angiográficos Metrizoatos (1962, Isopaque), Yodotalamatos (1962, 130 Abril-Junio 2008 Medios de contraste Negativos Positivos - Aire - CO 2 Insolubles Liposolubles Hidrosolubles - Orgánicos yodados - Derivados del ácido tryofobenzóico Piridonas* Lipiodol* No iónicos No iónicos No iónicos No iónicos Monómeros Dímeros Monómeros Dímeros Agentes Agentes Agentes Uro/angio/ Uro/angiográficos Uro/angiográficos mielográficos Uro/angio/mielográfico Uro/angiográfico - Sales de Yodo Lodixanol Lotrolán y meglumina - Sales de Lopamidol Vías de administración Vías de eliminación meglumina Lohexol - Intravenosa - Renal Loversol - Intra-arterial - Hepática Lopromida - Intramuscular - Otras Lobitridol - Intratecal (espacio Lopentol subaracnoideo) Lomeprol - Intraperitoneal * En desuso No presentes en México Loaxilán - Intra-articular Figura 1. Clasificación de los medios de contraste iodados en imagen. Tipo de Partículas Partículas Tipo de Conray), Iodamidatos (1965, Uromirón, descontinua- componente solvatadas en solución M de C do), Ioxitalamatos (1972, Telebrix y Vasobrix). Los MC Intravasculares asimismo se pueden clasi- 2 Solvente Anión Catión ficar por su vía de administración en intravenosos, in- trarteriales, intramusculares, intratecales (espacio subaracnoideo,) lntracavitarios (fistulografía), intrape- M de C 2 Agua Anión Ka Medio de ritoneales, etc. contraste monómero Por su vía de eliminación se clasifican principalmente iónico M de C Meg en renal y hepato-biliar, existiendo otras vías de elimi- Agua 2 Anión nación (Figura 1). Por su vía de acción se clasifican en agentes co- Medio de legráficos (actualmente en desuso), uroangiográfi- Agua 1 contraste M de C no monómero cos, mielográficos y de acuerdo al tipo de estudio iónico no iónico en Yodados (estudios de radiología convencional [urografía], tomografía computarizada, angiografía, Figura 2. Proceso de disociación de los medios
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