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The neglected fact: Metal allergy of vascular stents in emergency department

The neglected fact: Metal allergy of vascular stents in emergency department To the Editor:With the development of vascular and endovascular surgery, the treatment of vascular diseases has undergone tremendous changes. From open surgery to the application of various stents, patients have significantly less surgical trauma and postoperative complications. However, vascular stents are mainly made of various metal materials, which inevitably carries the risk of metal allergies and is also very easy to overlook in the emergency department. Among the vascular stent materials commonly used in vascular surgery, the main metal allergy hazardous substances are nickel, gold, chromium, and cobalt, of which nickel allergy is the most common. The incidence of nickel allergy in adults ranges from 8% to 19% in the general European population and in children and adolescents (mainly women) from 8% to 10%.1 Gold allergy is also common, occurring in 9.5% in North America and also predominating in women.2 Chromium and cobalt allergy are relatively rare, occurring in 6.2% and 2.3%, respectively.3 The mechanism of metal allergy is mainly type IV hypersensitivity reaction.4 The patch test is the criterion standard for diagnosing contact allergies caused by type IV hypersensitivity reactions, including metal allergy.5 The relationship between metal allergy in surgical implants and postoperative adverse effects in surgical patients is not well understood. Metal allergy may be associated with stent stenosis after coronary artery surgery.6 In addition to effects on local stents, metal allergy to stents has been found to cause local edema or extensive skin allergic reactions.4–6In addition to stent stenosis, stent metal allergy can induce local or anaphylaxis. The most common type of skin allergic reaction associated with metal implants is eczema, but urticaria and vasculitis are occasionally seen. Local manifestations are usually dermatitis, mainly involving the skin near the implant site, and systemic manifestations are usually eczema‐like.3–5 Systemic adverse effects associated with vascular stents have been reported sparsely, mainly in case reports. For possible metal allergy in stents, most literature does not support routine screening for patch testing in all patients awaiting surgery, only evaluation in patients with strong suspicion of metal allergy. At the same time, patch testing prior to stent implantation has been shown to be highly accurate in predicting postoperative metal allergy in patients at high risk of allergy.4 Therefore, preoperative patch testing can be evaluated in patients with a history of previous or suspected metal allergy. However, given the risks and harms of aneurysm rupture or vascular occlusion, it is worth taking the risk of metal allergy if necessary.CONFLICT OF INTEREST STATEMENTThe authors declare no conflicts of interest.REFERENCESAhlström MG, Thyssen JP, Wennervaldt M, Menné T, Johansen JD. Nickel allergy and allergic contact dermatitis: a clinical review of immunology, epidemiology, exposure, and treatment. Contact Dermatitis. 2019;81:227‐241.Schmidt M, Goebeler M. Nickel allergies: paying the toll for innate immunity. J Mol Med (Berl). 2011;89:961‐970.Warshaw EM, Belsito DV, Taylor JS, et al. North American contact dermatitis group patch test results: 2009 to 2010. Dermatitis. 2013;24:50‐59.Köster R, Vieluf D, Kiehn M, et al. Nickel and molybdenum contact allergies in patients with coronary in‐stent restenosis. Lancet. 2000;356:1895‐1897.Romero‐Brufau S, Best PJ, Holmes DR Jr, et al. Out‐comes after coronary stent implantation in patients with metal allergy. Circ Cardiovasc Interv. 2012;5:220‐226.Guéroult AM, Al‐Balah A, Davies AH, Shalhoub J. Nickel hypersensitivity and endovascular devices: a systematic review and meta‐analysis. Heart. 2022;108:1707‐1715. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Academic Emergency Medicine Wiley

The neglected fact: Metal allergy of vascular stents in emergency department

Liao, Jianyu; Wu, Zhoupeng
Academic Emergency Medicine , Volume 30 (11) – Nov 1, 2023
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References (6)

Publisher
Wiley
Copyright
Copyright © 2023 Society for Academic Emergency Medicine
ISSN
1069-6563
eISSN
1553-2712
DOI
10.1111/acem.14740
Publisher site
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Abstract

To the Editor:With the development of vascular and endovascular surgery, the treatment of vascular diseases has undergone tremendous changes. From open surgery to the application of various stents, patients have significantly less surgical trauma and postoperative complications. However, vascular stents are mainly made of various metal materials, which inevitably carries the risk of metal allergies and is also very easy to overlook in the emergency department. Among the vascular stent materials commonly used in vascular surgery, the main metal allergy hazardous substances are nickel, gold, chromium, and cobalt, of which nickel allergy is the most common. The incidence of nickel allergy in adults ranges from 8% to 19% in the general European population and in children and adolescents (mainly women) from 8% to 10%.1 Gold allergy is also common, occurring in 9.5% in North America and also predominating in women.2 Chromium and cobalt allergy are relatively rare, occurring in 6.2% and 2.3%, respectively.3 The mechanism of metal allergy is mainly type IV hypersensitivity reaction.4 The patch test is the criterion standard for diagnosing contact allergies caused by type IV hypersensitivity reactions, including metal allergy.5 The relationship between metal allergy in surgical implants and postoperative adverse effects in surgical patients is not well understood. Metal allergy may be associated with stent stenosis after coronary artery surgery.6 In addition to effects on local stents, metal allergy to stents has been found to cause local edema or extensive skin allergic reactions.4–6In addition to stent stenosis, stent metal allergy can induce local or anaphylaxis. The most common type of skin allergic reaction associated with metal implants is eczema, but urticaria and vasculitis are occasionally seen. Local manifestations are usually dermatitis, mainly involving the skin near the implant site, and systemic manifestations are usually eczema‐like.3–5 Systemic adverse effects associated with vascular stents have been reported sparsely, mainly in case reports. For possible metal allergy in stents, most literature does not support routine screening for patch testing in all patients awaiting surgery, only evaluation in patients with strong suspicion of metal allergy. At the same time, patch testing prior to stent implantation has been shown to be highly accurate in predicting postoperative metal allergy in patients at high risk of allergy.4 Therefore, preoperative patch testing can be evaluated in patients with a history of previous or suspected metal allergy. However, given the risks and harms of aneurysm rupture or vascular occlusion, it is worth taking the risk of metal allergy if necessary.CONFLICT OF INTEREST STATEMENTThe authors declare no conflicts of interest.REFERENCESAhlström MG, Thyssen JP, Wennervaldt M, Menné T, Johansen JD. Nickel allergy and allergic contact dermatitis: a clinical review of immunology, epidemiology, exposure, and treatment. Contact Dermatitis. 2019;81:227‐241.Schmidt M, Goebeler M. Nickel allergies: paying the toll for innate immunity. J Mol Med (Berl). 2011;89:961‐970.Warshaw EM, Belsito DV, Taylor JS, et al. North American contact dermatitis group patch test results: 2009 to 2010. Dermatitis. 2013;24:50‐59.Köster R, Vieluf D, Kiehn M, et al. Nickel and molybdenum contact allergies in patients with coronary in‐stent restenosis. Lancet. 2000;356:1895‐1897.Romero‐Brufau S, Best PJ, Holmes DR Jr, et al. Out‐comes after coronary stent implantation in patients with metal allergy. Circ Cardiovasc Interv. 2012;5:220‐226.Guéroult AM, Al‐Balah A, Davies AH, Shalhoub J. Nickel hypersensitivity and endovascular devices: a systematic review and meta‐analysis. Heart. 2022;108:1707‐1715.

Journal

Academic Emergency Medicine – Wiley

Published: Nov 1, 2023

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