Papers


ACDA Type II Endoleaks Detection

Title :
The Assessment of Carbon Dioxide Automated Angiography in Type II Endoleaks Detection: Comparison with Contrast-Enhanced Ultrasound

 Author(s) :
Chiara Mascoli , Gianluca Faggioli , Enrico Gallitto, Vincenzo Vento, Giuseppe Indelicato, Rodolfo Pini, Andrea Vacirca, Andrea Stella, and Mauro Gargiulo

Vascular Surgery, DIMES,University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy

Issue Number :

Contrast Media & Molecular Imaging, Volume 2018, Article ID 7647165

Abstract

Introduction. Iodinated contrast media completion angiography (ICM-A) may underestimate the presence of type II endoleak (ELII) after endovascular aortic repair (EVAR), particularly if they are at low flow. Contrast-enhanced ultrasound (CEUS) has been proposed as the gold standard in ELII detection during EVAR follow-up. Intraprocedural carbon dioxide (CO2) angiography has been shown to be useful in this setting; however no comparative studies including these three techniques are currently available.Our aim was to investigate the accuracy of a new automated CO2 angiographic (CO2-A) system in the detection of ELII, by comparing it with ICM-A and CEUS.

Methods. A series of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) were enrolled and submitted to ICM-A and CO2-A during the procedure.The iodinated contrast media were delivered through an automatic injector connected to a pigtail catheter in the suprarenal aorta. CO2 was delivered through a recently available automatic injector connected to a 10 F sheath positioned in the external iliac artery. All patients were blindly evaluated by CEUS within postoperative day 1. The ICM-A and CO2-A ability to detect ELII was compared with that of CEUS through Cohen’s concordance Index ().

Results. Twenty-one patients were enrolled in the study. One (5%), seven (33%), and four (19%) ELII were detected by ICM-A, CO2-A, and CEUS, respectively. The only ELII detected by ICM-A was also detected by CO2-A and CEUS. Three cases of ELII detected by CO2-A were not detected by CEUS. All ELII detected by CEUS were visualized by CO2-A. CEUS and ICM-A showed a poor agreement (Cohen’s : 0.35) while CEUS and CO2-A showed a substantial agreement (Cohen’s : 0.65) for ELII detection.

Conclusion. CO2-A is safe and effective method for ELII detection in EVAR, with a significantly higher agreement with CEUS if compared with ICM-A. This trial is registered with 155/2015/U/Oss.

Endovascular Treatment in al CLI and CKD Patient

Title :
Endovascular Treatment Of A Severe Calcified Popliteal Artery Lesion By Endovascular Lithoplasty And Drug-Coated Balloon Angioplasty In A Patient With Critical Limb Ischemia And Chronic Kidney Disease

 Author(s) :
Konstantinos Stavroulakis, MD; Theodosios Bisdas, MD, PhD; Efthymios Beropoulis, MD
Department of Vascular and Endovascular Surgery, University of Münster, Germany, and Department of Vascular Surgery, St. Franziskus-Hospital GmbH, Münster, Germany

Issue Number :

VASCULAR DISEASE MANAGEMENT 2018;15(6):E53-E55.

Abstract

Chronic kidney disease (CKD) carries a well-established risk for adverse events during revascularization of the lower extremities and is an important determinant of patient prognosis in critical limb ischemia (CLI). Although endovascular therapy offers a minimally invasive approach in this high-risk group of patients, the administration of nephrotoxic contrast agent can lead to further deterioration of the renal function. Thus, the development of strategies that can minimize the risk for renal injury during endovascular procedures remains crucial.

We report a case of a patient who presented at our institution with CLI (Rutherford class 5) and CKD stage IV. Carbon-dioxide angiography revealed a severely calcified lesion of the popliteal artery with a single vessel run-off through the peroneal artery. Endovascular lithoplasty followed by drug-coated balloon (DCB) angioplasty was selected for the treatment of the severely calcified popliteal artery.

Key words : chronic kidney disease, critical limb ischemia, endovascular lithoplasty, CO2-angiography, drug-coated balloon

Standardization of EVAR Procedures

Title :
Standardization of a Carbon Dioxide Automated System for Endovascular Aortic Aneurysm Repair

 Author(s) :
Chiara Mascoli, Gianluca Faggioli, Enrico Gallitto, Vincenzo Vento, Rodolfo Pini, Andrea Vacirca, Giuseppe Indelicato, Mauro Gargiulo, and Andrea Stella.Vascular Surgery, DIMES, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.

Issue Number :

Ann Vasc Surg 2018; -: 1–9

Abstract

Background: Endovascular aortic repair (EVAR) is presently the preferred treatment for abdominal aortic aneurysm; however, it requires the injection of a contrast medium, which can hamper the renal function. Other nontoxic agents such as carbon dioxide (CO2) have been sporadically tested in this setting with uncertain results. The aim of the study is to investigate the efficacy of a new standardized CO2 injection method in standard EVAR procedures.
Methods: Between August and October 2016, 31 consecutive patients (median age 76.1 [interquartile range {IQR}: 7.4] years) were submitted to standard EVAR. Proximal and distal endograft landing zones were identified by the injection of 100 mL of CO2 at 300 mm Hg, through an 11 cm 10F femoral sheath by a specifically manufactured automated injection device (Angiodroid Srl, San Lazzaro, Bologna, Italy). Before EVAR deployment, a confirmative injection with a conventional contrast medium was accomplished. The possibility of precisely visualizing the proximal and distal landing zones by CO2 digital subtraction angiography (DSA) was evaluated considering the contrast medium injection obtained in the same procedure as a gold standard. Similarly, the possible presence of endoleak was assessed at the end of the procedure by the 2 techniques.
Results: CO2 DSA allowed to identify the juxtarenal landing zone of the endograft in 19/31 cases (61%) and the distal one in 31/31 (100%). In 12 (39%) cases, CO2 injection failed to visualize at least the lowest renal artery. This occurred in large aneurysms with scarce thrombotic apposition and a luminal volume greater than 95.9 (IQR: 25.2) mm3. Completion CO2 DSA detected type II endoleaks (ELIIs) in 10 cases compared with 2 of conventional contrast media.
Conclusions: The injection of nontoxic CO2 through an automated device allowed to perform EVAR procedures effectively, in the majority of cases. In some cases, a single injection of a minimum amount of conventional contrast medium can be used to overcome the lack of renal artery visualization by CO2. ELIIs are more frequently visualized with CO2 compared with standard contrast medium. Although the CO2 injection technique needs further amelioration particularly in the renal arteries detection, this technique appears promising and possibly substitutive of the standard contrast medium, with significant benefit for the renal function.

Zero Contrast TAVI

Title :
Contrast-Zero Transcatheter Aortic ValveReplacement for Patients With Severe Renal Dysfunction

 Author(s) :
Fausto Castriota, Roberto Nerla, Antonio Micari, Angelo Squeri, Alberto Cremonesi,

*Interventional Cardiovascular UnitGVMCare&Research, Maria Cecilia Hospital, Via Corriera 1, 48033 Cotignola, Ravenna, Italy

Issue Number :
JACC: Cardiovascular Interventions Vol.11, No.8, 2018, April 23, 2019:814-22

Summary

From November 2016 to September 2017 a total of 20 patients (age 81.8  5.4; 60% males; glomerular filtration rate 27.4  3.1 ml/min; Society of Thoracic Surgeons mortality score 14.3  4.5) were included in the contrast-zero population. Following CO2 angiographic pictures analysis, femoral access was used in all patients. All procedures were successfully performed with no use of contrast dye.

CO2 Angiography in Diabetic CLI patients

Title :
CO2 Angiography in Diabetic Critical Limb Ischemia Patients

Authors :
Marco Manzi, Luis Mariano Palena

Issue Number :
European Heart Journal Supplements (2015) 17 (Supplement A), A18–A22

Introduction
The use of digital subtraction angiography with iodinated contrast is a common invasive imaging technique for diagnostic and interventional vascular procedures. However, this approach is associated with an increased risk of contrast-induced acute kidney injury (CI-AKI) among diabetic patients with baseline chronic kidney disease (CKD).1,2 The reported incidence of CI-AKI is 5.1% in patients with baseline CKD who undergo peripheral interventions.3 Because of its lack of nephrotoxicity and potential for allergic reactions, carbon dioxide (CO2) has been used as a contrast medium for evaluating patients with renal dysfunction.4-8 To decrease procedure-related complications such as CI-AKI and allergic reactions, we have focused on the potential benefits of CO2 as a contrast agent during invasive diagnostic procedures in the lower limbs.

New imaging modalities in peripheral interventions

Title :
New imaging modalities in peripheral interventions

Authors :
Antonio Micari1, Paolo Sbarzaglia, M.D.M.E. Meeks, Armando Liso,
Marco Riina, Maria Letizia Lunetto, Giuseppe Roscitano, and Giuseppe Vadalà

Issue Number :
European Heart Journal Supplements (2015) 17 (Supplement A), A18–A22

Abstract
The aim of this article is to evaluate the feasibility and results of our peripheral revascularization
where we used non-conventional intra-procedural imaging techniques.
Between January 2014 and September 2014, 45 patients were imaged with CO2 angiography and/or optical coherence tomography (OCT) or 2D perfusion imaging. The scop was to minimize the use of contrast and obtain additional information to improve the outcome. CO2 angiography was used in all patients with impaired renal function. Twodimensional
perfusion was used in all patients with critical limb ischaemia before and
after revascularization to quantify angiosome blood supply improvement at wound level. Optical coherence tomography was performed in superficial femoral arteries and popliteal arteries to disclose vessel microstructure and characterize plaque structure. In
all patients, the invasive imaging was feasible and safe. In those patients studied with CO2, the creatinine serum level after procedure increased by 0.11+0.05. None of the patients received dialysis. The procedural success rate was 100% and was no different from the historical sample of the cath lab. Procedural time was not significantly affected by this supplemental technique. The 2D perfusion showed an incremental blood supply at wound level and OCT provided encouraging details regarding dissections and their clinical
relevance. Our early experience with supplementary imaging techniques showed safety and feasibility. The peripheral angioplasty success rate was not different fromthe historical
sample and the reduction of the contrast media dose resulted in an encouraging
outcome in terms of renal protection. Two-dimensional perfusion added objective information regarding blood supply improvement and guided re-perfusion strategy.

Mechanical aspects of CO2 angiography

Title:
Mechanical aspects of CO2 Angiography

 Authors:
Ivan Corazza, Pier Luca Rossi, Giacomo Feliciani, Luca Pisani, Sebastiano Zannoli, Romano Zannoli

Issue Number:
European Journal of Medical Physic, Published Online: December 05, 2011

Abstract
The aim of this paper is to clarify some physical–mechanical aspects involved in the carbon dioxide angiography procedure (CO2 angiography), with a particular attention to a possible damage of the vascular wall.

CO2 angiography is widely used on patients with iodine intolerance. The injection of a gaseous element, in most cases manually performed, requires a long training period. Automatic systems allow better control of the injection and the study of the mechanical behaviour of the gas.

CO2 injections have been studied by using manual and automatic systems. Pressures, flows and jet shapes have been monitored by using a cardiovascular mock. Photographic images of liquid and gaseous jet have been recorded in different conditions, and the vascular pressure rises during injection have been monitored.

The shape of the liquid jet during the catheter washing phase is straight in the catheter direction and there is no jet during gas injection. Gas bubbles are suddenly formed at the catheter’s hole and move upwards: buoyancy is the only governing phenomenon and no bubbles fragmentation is detected. The pressure rise in the vessel depends on the injection pressure and volume and in some cases of manual injection it may double the basal vascular pressure values.

CO2 angiography is a powerful and safe procedure which diffusion will certainly increase, although some aspects related to gas injection and chamber filling are not jet well known. The use of an automatic system permits better results, shorter training period and limitation of vascular wall damage risk.

CO2 DSA – Vascular Disease Management

Title :
Carbon Dioxide Digital Subtraction Angiography (CO2 DSA): A Comprehensive User Guide for All Operators

Author(s) :
James G. Caridi, MD, FSIR1; Kyung J. Cho, MD2; Christian Fauria, MD, MSW, MPH1; Navid Eghbalieh, MD1 From the 1Tulane University Medical Center, New Orleans, Louisiana and the 2University of Michigan Health System, Ann Arbor, Michigan.

Issue Number : 
VASCULAR DISEASE MANAGEMENT 2014;11(10):E221-E256

Abstract

In 1971 during a routine celiac axis injection, 70 cc of room air was inadvertently injected into a patient instead of iodinated contrast. Fortunately, there were no ill effects and despite the use of cut film at the time, Hawkins visualized the celiac axis and its branches as a negative image. Because of this incident, in combination with his previous knowledge of carbon dioxide (CO2) in venous imaging, he began to study the intra-arterial use of CO2 in animals. Following the safe, successful use in animals he applied the same principles to humans. Unfortunately, technology lagged behind his genius and the initial imaging was poor. Later, during the 1980s, there was the development of digital subtraction angiography, tilting tables and a safe, reliable CO2 delivery system. As technology continued to improve, CO2 evolved into a viable vascular imaging agent. Although used initially for renal failure and iodinated contrast allergy, the many unique properties of CO2 yielded multiple advantages, which are now used in a multitude of scenarios alone or in combination with traditional contrast. It has now been used with great success in both adults and children for more than 3 decades with only limited reportable complications. Its safe use in children has been described and when performed in this age group the same principles apply as for adults. This paper describes the history and technique of CO2 angiography for vascular procedures.

Peripheral Procedure with automated Injection System

Title:
Peripheral diagnostic and interventional procedures using an automated injection system for carbon dioxide (CO2): case series and learning curve

 Author(s):
A. Giordano1 , S. Messina1 , M. Polimeno1 , N. Corcione1 , P. Ferraro1 , G. Biondi-Zoccai2 , G. Giordano1

 1 Operative Unit of Cardiovascular Interventions, Pineta Grande Clinic, Castelvolturno, and Operative Unit of Hemodynamics, S. Giuseppe Vesuviano, Italy; 2 Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy

Issue Number:
Heart, Lung and Vessels ; (in press): 313-314

Abstract

Introduction: The administration of iodinated contrast media in doses sufficient for diagnosis and procedural guidance, when coincident with renal insufficiency, presents a considerable risk of exacerbating and hastening renal failure. Carbon dioxide has been proposed in the past as an alternative, but only recently dedicated injection systems have become available. We aimed to review our ongoing experience with an automated carbon dioxide injector for peripheral diagnostic and interventional procedures.

Methods: Details on 21 patients undergoing peripheral procedures with carbon dioxide angiography were systematically collected. An automated injector enabling customized and repeated carbon dioxide injections was used in all cases, with iodinated contrast media used only as bailout.

Results: No major or minor complications occurred in these patients, either during the procedure or up to discharge. Comparison according to phase of the learning curve showed that with accruing experience operators relied progressively more on carbon dioxide only, as there was a significantly reduced need for additional iodinated contrast media injections per procedure (from 2.5±2.1 to 0.6±2.1 injections per patient, p=0.005). Accordingly, in the second phase of our learning curve, iodinated contrast media were avoided in 91% of cases in comparison to 20% of procedures performed in the beginning of our experience (p=0.002). Concomitantly, no significant change in the duration of the procedure occurred.

Conclusions: Carbon dioxide-based angiography using an automated injection system is feasible and safe in patients undergoing diagnostic or interventional procedures for infra-diaphragmatic conditions, especially for transcatheter renal sympathetic denervation

Automated CO2 Angiography – J.I.C.

Title :
Automated Carbon Dioxide Digital Angiography for Lower-Limb Arterial Disease Evaluation: Safety Assessment and Comparison With Standard Iodinated Contrast Media Angiography

Authors :
Filippo Scalise, MD1; Eugenio Novelli, PhD2; Carla Auguadro, MD1; Valentina Casali, MD1;Mariella Manfredi, MD1; Romano Zannoli, PhD, EngD3

Issue Number :
Volume 27 – Issue 1 – January, 2015 20-26

Abstract
Carbon dioxide (CO2) has been validated as a contrast agent in a large series of studies. A particular advantage of CO2 over iodinated contrast medium (ICM) is the absence of nephrotoxicity and allergic reactions. One of the limitations of CO2 angiography is the difficulty of CO2 manual injection due to its compressibility. The manual gas injection does not permit optimal control of the gas output. Development of an automated CO2 injector has overcome these problems. Aim. This study compares the feasibility, safety, and diagnostic accuracy of automated CO2 digital subtraction angiography (DSA) in comparison with ICM-DSA in the evaluation of critical limb ischemic (CLI) patients. Methods. We performed DSA with both CO2 and ICM on 40 consecutive CLI patients and directly compared the two techniques. Sixteen females and 24 males participated in the study (mean age, 71.7 years). We assessed the diagnostic accuracy of CO2 in identifying arterial stenosis in the lower limb, with ICM-DSA used as the gold standard. Results. The overall diagnostic accuracy of CO2-DSA was 96.9% (sensitivity, 99.0%; specificity, 96.1%; positive predictive value, 91.1%; negative predictive value, 99.6%). Tolerable minor symptoms occurred in 3 patients. No allergic reactions or significant decline in renal function were observed in patients receiving the CO2 injection. Conclusion. Carbon dioxide DSA is a valuable and safe alternative to traditional ICM-DSA for evaluating CLI patients. This modality should be considered as the standard choice for CLI patients undergoing angiographic evaluation who are known to have renal insufficiency or contrast allergy.