Comparison of intra‐arterial digital subtraction angiography using carbon dioxide by ‘home made’ delivery system and conventional iodinated contrast media in the evaluation of peripheral arterial occlusive disease of the lower limbs

Abstract

To prospectively compare the feasibility, safety and diagnostic role of carbon dioxide (CO(2)) digital subtraction angiography (DSA) using a 'home made' delivery system with iodinated contrast medium (ICM) DSA in the evaluation of peripheral arterial occlusive diseases (PAOD) of lower limbs. Twenty-one patients (27 limbs; all men; mean age, 47.6 years) who presented with PAOD of lower limbs underwent DSA using both intra-arterial CO(2) and ICM. Conventional ICM DSA was performed first and used as gold standard. Carbon dioxide was then injected by hand using a locally improvised home made plastic bag delivery system. Patient tolerance was assessed subjectively. Arteries from aortic bifurcation to the ankle were independently evaluated by two radiologists and graded for stenosis using a five-point scale. For each patient, the quality of CO(2) DSA images were compared with the corresponding images of ICM DSA and an overall grade of 'good', 'acceptable' or 'poor' was assigned. Cohen's kappa coefficient was used to determine inter-observer agreement. Carbon dioxide opacified 86.2% (188/195) of major arteries and depicted stenosis adequately in 84.5% (191/226) of arterial segments. A good or acceptable image quality of CO(2) DSA was obtained in over 95% of patients. Infrapopliteal arteries were inadequately visualized. Mild pain was seen in six (28.6%) patients with both contrast agents; one patient developed severe pain during CO(2) DSA. Inter-observer agreement was good (k > 0.75) at 70% of the segments. Administration of CO(2) into lower limb arteries is well tolerated. Carbon dioxide DSA using the locally improvised home made delivery system is a feasible and safe alternative to ICM DSA in the evaluation of PAOD. It provides adequate imaging of arteries of lower extremities except infrapopliteal segments.

Contrast induced‐acute kidney injury following peripheral angiography with carbon dioxide versus iodinated contrast media: A meta‐analysis and systematic review of current literature

“…Fujihara et al reported an overall 17.3% rate (17 events out of 98 cases) of nonrenal events (limb pain/abdominal pain)—including two deaths attributable to CO 2 use . Kawasaki et al reported that 14.6% of patients undergoing CO 2 angiography complained of transient lower extremity pain, while Madhusudan reported this incidence to be 4.8% employing the use of a customized delivery system for intra‐arterial injections . The mechanisms underlying these effects in individual studies were not elucidated but likely involved either the vapor lock phenomenon or transient symptoms from blood displacement.…”

Safety and Efficacy of Endovascular Therapy With a Simple Homemade Carbon Dioxide Delivery System in Patients With Ileofemoral Artery Diseases

“…It provides adequate imaging of the arteries of lower extremities, except for infrapopliteal segments. 13 Rolland et al reported that the imaging quality of CO2 arteriograms was comparable to the iodinated contrast media arteriograms from the pelvis in 93% and at the thigh in 74% of the 120 arteries studied. 15 To obtain fine images of CO2 arteriograms, we have to kept to a minimum all motion during image acquisition.…”

“…Because the bag was used to transport the gas from the operating room to the DSA suite in this system, the procedures for preparing the system was complicated. 13 Unfortunately, the published CO2 delivery systems have been used only by a limited number of physicians and operators because of the complexity of the delivery system. Our delivery system is simpler and more user-friendly than the previously described published systems.…”

“…Madhusudhan et al experienced 1 (4.8%) patient who complained of severe pain and 6 (28.6%) patients who complained of mild pain during the CO2 injection. 13 It has been reported that pain led to the discontinuation of 18% of examinations when high volumes and flow rates were used. 14 In practice, warning the patient what to expect, giving a test injection, and reducing volume and flow rates minimizes the side effects and improves tolerance.…”

A Simple Homemade Carbon Dioxide Delivery System for Endovascular Procedures in the Iliofemoral Arteries

“…1 As Dr Mendes correctly concludes, our current method of aspirating CO2 has a higher probability of room air contamination as compared with methods of underwater aspiration. 2, 3 However, we have not experienced any complications related to air contamination in our study, which included 50 patients, of 70 cases.…”