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Carbon Dioxide Enhanced Angiography Protects Renal Function Without Losing Interventional Efficacy During Tibial Interventions
Candice R. Chipman, MD, Jonathan A. Higgins, MBBS, Rachel H. Choe, MS, Ryan A. Abdul-Haqq, MS, Kevin E. Todd, Jr., BS, Christian A. Maurer, BS, Jung H. Kim, MPH, Sadaf S. Ahanchi, MD, David J. Dexter, Jr., MD, Jean M. Panneton, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
OBJECTIVE: Analyze the impact of CO2 enhanced angiography compared to conventional contrast angiography on interventional outcomes and renal function.METHODS: We retrospectively reviewed tibial interventions in patients with lower-limb ischemia between 2008 and 2010. Patients were divided into a CO2 enhanced group and traditional contrast group.
RESULTS: We reviewed 463 tibial interventions (87% critical limb ischemia, 13% claudication) with complete laboratory data. Patients were
subdivided into stage of chronic kidney disease (CKD): CKD1=86, CKD2=131, CKD3=110, CKD4=32, CKD5=103. The data was divided into 56 interventions with CO2 enhanced imaging and 407 interventions with traditional Iodixanol contrast imaging. After exclusion of dialysis
patients, mean contrast volume for the CO2 enhanced group was 31mL ± 31 versus 104mL ± 65 for the Iodixanol group, p=<0.001.
Mean age of the entire cohort was 70 with 58% male. There was a statistically higher proportion of renal insufficiency (RI) in the CO2 enhanced group (48.2%) versus the Iodixanol group (9.2%), p=0.02. Other demographics and risk factors were not significant between the 2 groups.
All dialysis patients, n=103, were removed for renal function analysis. The CO2 enhanced group versus the Iodixanol group had a higher mean preoperative creatinine (pre-Cr) 1.7 versus 1.1, p<0.001 and a higher mean postoperative creatinine (post-Cr) 1.7 versus 1.2, p=0.04. However, when comparing mean change in Cr (ΔCr) and mean change in estimated glomerular filtration rate (ΔeGFR), there was no significant difference: with the entire cohort having a mean decrease in creatinine of 0.02 and a mean increase in the eGFR of 10.
Average follow up for the entire cohort was 18 months ± 15. Kaplan-Meier curves at 12 and 36 months showed no significant difference between the Iodixanol group versus CO2 enhanced group for primary patency (66%, 55% versus 75%, 47%; p=0.39), primary assisted patency (85%, 76% versus 89%, 61%; p=0.65), secondary patency (95%, 92% versus 95%, 91%; p=0.69), limb salvage (85%, 78% versus 97%, 85%; p=0.11) or reintervention rate (28% versus 21%, p=0.34).
CONCLUSION: Our results dispute the perception that CO2 enhanced imaging protects renal function at the expense of image quality and ultimately primary outcomes in the tibial territory. CO2 enhanced
angiography reduced the total contrast load and renal insult, without
compromising outcomes, supporting the broader application of CO2
enhanced imaging during endovascular tibial interventions.
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