Feasibility and safety of automated CO2 angiography in peripheral arterial interventions

Abstract

Carbon dioxide (CO2) gas is an established alternative to iodine contrast during angiography in patients with risk of postcontrast acute kidney injury and in those with history of iodine contrast allergy. Different CO2 delivery systems during angiography are reported in literature, with automated delivery system being the latest. The aim of this study is to evaluate the safety, efficacy, and learning curve of an automated CO2 injection system with controlled pressures in peripheral arterial interventions and also to study the patients’ tolerance to the system. From January 2018 to October 2019 peripheral arterial interventions were performed in 40 patients (median age-78 years, interquartile range: 69–84 years) using an automated CO2 injection system with customized protocols, with conventional iodine contrast agent used only as a bailout option. The pain and tolerance during the CO2 angiography were evaluated with a visual analog scale at the end of each procedure. The amount of CO2, iodine contrast used, and radiation dose area product for the interventions were also systematically recorded for all procedures. These values were statistically compared in 2 groups, viz first 20 patients where a learning curve was expected vs the rest 20 patients. All procedures were successfully completed without complications. All patients tolerated the CO2 angiography with a median total pain score of 3 (interquartile range: 3–4), with no statistical difference between the groups (P = .529). The 2 groups were statistically comparable in terms of comorbidities and the type of procedures performed (P = .807). The amount of iodine contrast agent used (24.60 ± 6.44 ml vs 32.70 ± 8.70 ml, P = .006) and the radiation dose area product associated were significantly lower in the second group (2160.74 ± 1181.52 μGym2 vs 1531.62 ± 536.47 μGym2, P = .043). Automated CO2 angiography is technically feasible and safe for peripheral arterial interventions and is well tolerated by the patients. With the interventionalist becoming familiar with the technique, better diagnostic accuracy could be obtained using lower volumes of conventional iodine contrast agents and reduction of the radiation dose involved.

SVM Communications: Contrast media shortage and Society updates

“…CO 2 angiography has traditionally had a role in endovascular therapies, particularly for patients with chronic kidney disease where contrast use needs to be limited. 11 We found this to be a good resource during the contrast media shortage, particularly for the more proximal iliofemoral vessels. However, image quality remains imperfect in below-the-knee vessels, where smaller diseased vessels can be difficult to visualize, and collateral vessels can be more prominent.…”

Quiescent-Interval Single-Shot Magnetic Resonance Angiography May Outperform Carbon-Dioxide Digital Subtraction Angiography in Chronic Lower Extremity Peripheral Arterial Disease

“…In total, 523 segments were evaluated for subjective image quality in 164 prioritized regions (aortoiliac, femoropopliteal, tibioperoneal). Following the consensus assessment, QISS MRA performed better than CO2 DSA in terms of image quality in all regions when comparing the two modalities (QISS MRA vs. CO2 DSA-good (4 [4][5]) vs. acceptable (3 [3-4]; p < 0.001), and was rated superior in the aortoiliac (good (4 [4][5]) vs. acceptable (3 [3-4]); p < 0.001), femoropopliteal (good (4 [4][5]) vs. good (4 [3][4]); p < 0.001) and tibioperoneal (good (4 [3][4][5]) vs. acceptable (3 [2-3]); p < 0.001) regions as well (Table 2. Per-artery comparison of interpretability between CO2 DSA and QISS MRA is shown in Table 3.…”

“…Patients with diabetes and consequent renal failure are particularly prone to PAD [ 3 , 4 ], thus the use of nephroprotective imaging is crucial in the diagnosis. Carbon-dioxide digital subtraction angiography (CO2 DSA) is a well-established imaging tool in lower extremity PAD [ 5 , 6 ] and is considered as a reference standard due to its great spatial resolution. Being an invasive modality, however, it may cause complications associated with either the arterial puncture or the use of ionizing radiation [ 7 , 8 , 9 ].…”

Calibrated Hydraulic Resistance Adjuncts for Carbon Dioxide Angiography Optimization

“…Moreover, the optimized injection of the gas reduces the gas volume and the local pressure increase, avoiding the local gas "explosion" in the injection site [24] with benefits for patient pain reduction, representing an open issue. In most scientific papers about CO 2 angiography, percentages of adverse events are always reported (more frequently, pain, nausea, or vomiting) [22,26,27]. These events are generally related to the increase in local pressure at the injection site, the occlusion of the vessel under investigation, and any anterior peripheral vascular branches occluded by reflux.…”

“…The pulsatile condition started activating the motor. After stabilization, the gas injection (20 mL) was performed (with gas flushing [13,22] of 1 mL), and pressures, flow, and bubble sequence captured by the camera were continuously monitored. The process has been repeated with only the standard line and the three resistance adjuncts.…”