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30-08-2018
Journal of Endovascular Therapy
TITLE
Automated Carbon Dioxide Angiography for the Evaluation and Endovascular Treatment of Diabetic Patients With Critical Limb Ischemia.
Authors:
Luis Mariano Palena, MD1, Larry J. Diaz-Sandoval, MD2, Alessandro Candeo, RT1, Cesare Brigato, DNP1, Enrico Sultato, DNP1, and Marco Manzi, MD1 1Interventional Radiology Unit and Foot & Ankle Clinic, Policlinico Abano Terme, Italy – 2Michigan State University and Metro Health Hospital, Wyoming, MI, USA
Issue Number:
Journal of Endovascular Therapy November 13, 2015
Abstract
Purpose: To test the safety, efficacy, and diagnostic accuracy of automated carbon dioxide (CO2) angiography (ACDA) for the evaluation of diabetic patients with critical limb ischemia (CLI) and baseline renal insufficiency and compare ACDA with iodinated contrast medium (ICM) during endovascular treatment.
Methods: From November 2014 to January 2015, 36 consecutive diabetic patients (mean age 74.8±5.8 years; 27 men) with stage ≥3 chronic kidney disease (CKD ≥3) and CLI underwent lower limb angiography with both CO2 and ICM followed by balloon angioplasty in a prospective single-center study. The primary outcome measure was the safety and efficacy of ACDA as the exclusive agent to guide angioplasty in this cohort. The secondary outcomes were the safety and diagnostic accuracy of ACDA injection as compared with ICM digital subtraction angiography (DSA) for invasive evaluation of these patients. Results: ACDA safely and effectively guided angioplasty in all patients without complications. Transcutaneous oxygen pressure improved from 11.8±6.3 to 58.4±7.6 mm Hg (p<0.001). There were no complications related to ACDA during diagnostic imaging and no significant changes in the estimated glomerular filtration rate from baseline to 24 hours (44.7±13.3 vs 47.0±0.8 mL/min/1.73 m2; nonsignificant). The diagnostic accuracy of CO2 was 89.8% (sensitivity 92.3%; specificity 75%; positive predictive value 95.5%; negative predictive value 63.1%). There was no statistically significant difference in the qualitative diagnostic accuracy between the media (p=0.197).
Conclusion: ACDA is an accurate, safe, and effective technique that can be utilized to guide endovascular interventions in diabetics with CLI and baseline CKD ≥3. Larger Multicenter randomized studies are needed to validate these results.
30-08-2018
Vascular Desease 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.
30-08-2018
Heart Lung Vessels
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
2015
JIC
TITLE
Automated Carbon Dioxide Digital Angiography for Lower-Limb Arterial Disease Evaluation: Safety Assessment and Comparison With Standard Iodinated Contrast Media Angiography
Author(s):
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.
2011
Mechanical Aspects of CO2 Angiography
TITLE
Mechanical Aspects of CO2 Angiography
Author(s):
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.
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