Carbon dioxide-angiography for patients with peripheral arterial disease at risk of contrast-induced nephropathy

Abstract

Patients with peripheral arterial disease (PAD) and critical limb ischemia are at risk for limb amputation and require urgent management to restore blood flow. Patients with PAD often have several comorbidities, including chronic kidney disease, diabetes mellitus, and hypertension. Diagnostic and interventional angiography using iodinated contrast agents provides excellent image resolution but can be associated with contrast-induced nephropathy (CIN). The use of carbon dioxide (CO₂) as a contrast agent reduces the volume of iodine contrast required for angiography and reduces the incidence of CIN. However, CO₂ angiography has been underutilized due to concerns regarding safety and image quality. Modern CO₂ delivery systems with advanced digital subtraction angiography techniques and hybrid angiography have improved imaging accuracy and reduced the incidence of CIN. Awareness of the need for optimal imaging conditions, contraindications, and potential complications have improved the safety of CO₂ angiography. This review aims to highlight current technological advances in the delivery of CO₂ in vascular angiography for patients with PAD and critical limb ischemia, which result in limb preservation while preventing kidney damage.

Keywords: Angiography; Carbon dioxide; Chronic kidney disease; Digital subtraction; Endovascular procedures; Peripheral artery disease.

Figure 1

The pre-assembled portable medical AngiAssist^® delivery system consisting of two one-way valves, a reservoir syringe, a delivery syringe, proprietary K-valve, and afferent and efferent tubing.

Figure 2

Carbon dioxide angiography imaging findings. A-C: Carbon dioxide angiography imaging findings of lower extremity vessels of a 71-year-old male with peripheral arterial disease. AO: Aorta; CIA: Common iliac artery; EIA: External iliac artery; SFA: Superficial femoral artery; TP Trunk: Tibioperoneal trunk; ATA: Anterior tibial artery; PTA: Posterior tibial artery.

Figure 3

Average contrast used per endovascular procedure. Data from our Office Based Lab shows a reduction in Total Iodine Contrast used per procedure after adopting Hybrid CO₂ Angiography.