SLR - May 2017 - Amanda L. Crowell
Reference: Stegemann E, Tegtmeier C, Bimpong-Buta NY, Sansone R, Uhlenbruch M, Richter A, Stegemann B, Roden M, Westenfeld R, Kelm M, Heiss C. Carbondioxide-Aided Angiography Decreases Contrast Volume and Preserves Kidney Function in Peripheral Vascular Interventions. Angiology. 2016 Oct;67(9):875–81.
Reviewed By: Amanda L. Crowell, DPM
Residency Program: Temple University Hospital, Philadelphia, PA
Podiatric Relevance: Many patients evaluated by foot and ankle surgeons present with peripheral vascular disease. Vascular surgeons or interventional cardiologists may then perform an angiogram, which is most commonly completed with an iodinated contrast medium and allows for simultaneous diagnosis and intervention in the form of balloon angioplasty and arterial stenting. However, the use of this contrast medium might be contraindicated in patients with specific allergies to iodinated contrast or those with chronic kidney disease. There is an alternative option for these patients—carbon dioxide angiography. Carbon dioxide may be used as the sole imaging modality or to supplement and reduce the volume of iodinated contrast medium required in a traditional angiogram. Foot and ankle surgeons should be familiar with this emerging technique and become familiar with specialists in their area who perform it for appropriate referral when needed.
Methods: The authors performed a retrospective review of 154 patients over a 13-month period who received traditional angiography and 33 patients who underwent a carbon dioxide angiography with supplemental iodinated contrast and four patients who received carbon dioxide as the sole contrast agent. They evaluated walking distance and ankle-brachial index measurements both pre- and postoperatively. They also compared intervention success rates, amount of contrast injected, irradiation time and serum creatinine at one and two days postoperatively.
Results: There were 29 cases of contrast-induced nephrotoxicity in the traditional group versus two in the carbon dioxide group. The amount of iodinated contrast used in the traditional group was 113 ± 76 mL as opposed to only 34 ± 41 mL in the carbon dioxide group. There was a 96 percent success rate in the traditional group and a 100 percent success rate in the carbon dioxide group. ABIs in those patients who received traditional angiography improved from 0.59 ± 0.24 to 0.70 ± 0.25. The carbon dioxide group saw improvement from 0.66 ± 0.28 to 0.89 ± 0.26.
Conclusions: The authors concluded that carbon dioxide angiography is a viable alternative but may be most useful in situations where image accuracy is not critical or when supplementation with iodinated contrast would not be absolutely contraindicated. Although some continue to criticize carbon dioxide angiography for its inferior image quality, improvements in digital subtraction angiography software and techniques have greatly improved visualization in recent years. As more interventionalists become trained in the technique and technology continues to improve, it may become more readily available across all centers.