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The optimal operative protocol to accomplish CO2-EVAR resulting from a prospective interventional multicenter study

Vacirca, Andrea ; Faggioli, Gianluca ; Vaccarino, Roberta LU ; Dias, Nuno LU orcid ; Austermann, Martin ; Usai, Marco Virgilio ; Oberhuber, Alexander ; Schäfers, Johannes Frederik ; Bisdas, Theodosios and Patelis, Nikolaos , et al. (2023) In Journal of Vascular Surgery 77(5). p.1-1412
Abstract

Objectives: Carbon dioxide (CO2) angiography for endovascular aortic repair (CO2-EVAR) is used to treat abdominal aortic aneurysms (AAAs), especially in patients with chronic kidney disease or allergy to iodinated contrast medium (ICM). However, some technical issues regarding the visualization of the lowest renal artery (LoRA) and the best quality image through angiographies performed from pigtail or introducer sheath are still unsolved. The aim of this study was to analyze different steps of CO2-EVAR to create an operative standardized protocol. Methods: Patients undergoing CO2-EVAR were prospectively enrolled in five European centers from 2019 to 2021. CO2-EVAR was performed... (More)

Objectives: Carbon dioxide (CO2) angiography for endovascular aortic repair (CO2-EVAR) is used to treat abdominal aortic aneurysms (AAAs), especially in patients with chronic kidney disease or allergy to iodinated contrast medium (ICM). However, some technical issues regarding the visualization of the lowest renal artery (LoRA) and the best quality image through angiographies performed from pigtail or introducer sheath are still unsolved. The aim of this study was to analyze different steps of CO2-EVAR to create an operative standardized protocol. Methods: Patients undergoing CO2-EVAR were prospectively enrolled in five European centers from 2019 to 2021. CO2-EVAR was performed using an automated injector (pressure, 600 mmHg; volume, 100 cc); a small amount of ICM was injected in case of difficulty in LoRA visualization. LoRA visualization and image quality (1 = low, 2 = sufficient, 3 = good, 4 = excellent) were analyzed at different procedure steps: preoperative CO2 angiography from pigtail and femoral introducer sheath (first step), angiographies from pigtail at 0%, 50%, and 100% of proximal main body deployment (second step), contralateral hypogastric artery (CHA) visualization with CO2 injection from femoral introducer sheath (third step), and completion angiogram from pigtail and femoral introducer sheath (fourth step). Intraoperative and postoperative CO2-related adverse events were also evaluated. χ2 and Wilcoxon tests were used for statistical analysis. Results: In the considered period, 65 patients undergoing CO2-EVAR were enrolled (55/65 [84.5%] male; median age, 75 years [interquartile range (IQR), 11.5 years]). The median ICM injected was 17 cc (IQR, 51 cc); 19 (29.2%) of 65 procedures were performed with 0 cc ICM. Fifty-five (84.2%) of 65 patients underwent general anesthesia. In the first step, median image quality was significantly higher with CO2 injected from femoral introducer (pigtail, 2 [IQR, 3] vs introducer, 3 [IQR, 3]; P = .008). In the second step, LoRA was more frequently detected at 50% (93% vs 73.2%; P = .002) and 100% (94.1% vs 78.4%; P = .01) of proximal main body deployment compared with first angiography from pigtail; similarly, image quality was significantly higher at 50% (3 [IQR, 3] vs 2 [IQR, 3]; P ≤ .001) and 100% (4 [IQR, 3] vs 2 [IQR, 3]; P = .001) of proximal main body deployment. CHA was detected in 93% cases (third step). The mean image quality was significantly higher when final angiogram (fourth step) was performed from introducer (pigtail, 2.6 ± 1.1 vs introducer, 3.1 ± 0.9; P ≤ .001). The intraoperative (7.7%) and postoperative (12.5%) adverse events (pain, vomiting, diarrhea) were all transient and clinically mild. Conclusions: Preimplant CO2 angiography should be performed from femoral introducer sheath. Gas flow impediment created by proximal main body deployment can improve image quality and LoRA visualization with CO2. CHA can be satisfactorily visualized with CO2 alone. Completion CO2 angiogram should be performed from femoral introducer sheath. This operative protocol allows performance of CO2-EVAR with 0 cc or minimal ICM, with a low rate of mild temporary complications.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Abdominal aortic aneurysm, Carbon dioxide, CO-angiography, Endovascular aortic repair
in
Journal of Vascular Surgery
volume
77
issue
5
pages
1 - 1412
publisher
Mosby-Elsevier
external identifiers
  • pmid:36646335
  • scopus:85150831160
ISSN
0741-5214
DOI
10.1016/j.jvs.2023.01.013
language
English
LU publication?
yes
id
91083d6e-3aba-4725-9fd2-02f77a03e6e6
date added to LUP
2023-05-26 14:25:35
date last changed
2024-04-05 19:57:14
@article{91083d6e-3aba-4725-9fd2-02f77a03e6e6,
  abstract     = {{<p>Objectives: Carbon dioxide (CO<sub>2</sub>) angiography for endovascular aortic repair (CO<sub>2</sub>-EVAR) is used to treat abdominal aortic aneurysms (AAAs), especially in patients with chronic kidney disease or allergy to iodinated contrast medium (ICM). However, some technical issues regarding the visualization of the lowest renal artery (LoRA) and the best quality image through angiographies performed from pigtail or introducer sheath are still unsolved. The aim of this study was to analyze different steps of CO<sub>2</sub>-EVAR to create an operative standardized protocol. Methods: Patients undergoing CO<sub>2</sub>-EVAR were prospectively enrolled in five European centers from 2019 to 2021. CO<sub>2</sub>-EVAR was performed using an automated injector (pressure, 600 mmHg; volume, 100 cc); a small amount of ICM was injected in case of difficulty in LoRA visualization. LoRA visualization and image quality (1 = low, 2 = sufficient, 3 = good, 4 = excellent) were analyzed at different procedure steps: preoperative CO<sub>2</sub> angiography from pigtail and femoral introducer sheath (first step), angiographies from pigtail at 0%, 50%, and 100% of proximal main body deployment (second step), contralateral hypogastric artery (CHA) visualization with CO<sub>2</sub> injection from femoral introducer sheath (third step), and completion angiogram from pigtail and femoral introducer sheath (fourth step). Intraoperative and postoperative CO<sub>2</sub>-related adverse events were also evaluated. χ<sup>2</sup> and Wilcoxon tests were used for statistical analysis. Results: In the considered period, 65 patients undergoing CO<sub>2</sub>-EVAR were enrolled (55/65 [84.5%] male; median age, 75 years [interquartile range (IQR), 11.5 years]). The median ICM injected was 17 cc (IQR, 51 cc); 19 (29.2%) of 65 procedures were performed with 0 cc ICM. Fifty-five (84.2%) of 65 patients underwent general anesthesia. In the first step, median image quality was significantly higher with CO<sub>2</sub> injected from femoral introducer (pigtail, 2 [IQR, 3] vs introducer, 3 [IQR, 3]; P = .008). In the second step, LoRA was more frequently detected at 50% (93% vs 73.2%; P = .002) and 100% (94.1% vs 78.4%; P = .01) of proximal main body deployment compared with first angiography from pigtail; similarly, image quality was significantly higher at 50% (3 [IQR, 3] vs 2 [IQR, 3]; P ≤ .001) and 100% (4 [IQR, 3] vs 2 [IQR, 3]; P = .001) of proximal main body deployment. CHA was detected in 93% cases (third step). The mean image quality was significantly higher when final angiogram (fourth step) was performed from introducer (pigtail, 2.6 ± 1.1 vs introducer, 3.1 ± 0.9; P ≤ .001). The intraoperative (7.7%) and postoperative (12.5%) adverse events (pain, vomiting, diarrhea) were all transient and clinically mild. Conclusions: Preimplant CO<sub>2</sub> angiography should be performed from femoral introducer sheath. Gas flow impediment created by proximal main body deployment can improve image quality and LoRA visualization with CO<sub>2</sub>. CHA can be satisfactorily visualized with CO<sub>2</sub> alone. Completion CO<sub>2</sub> angiogram should be performed from femoral introducer sheath. This operative protocol allows performance of CO<sub>2</sub>-EVAR with 0 cc or minimal ICM, with a low rate of mild temporary complications.</p>}},
  author       = {{Vacirca, Andrea and Faggioli, Gianluca and Vaccarino, Roberta and Dias, Nuno and Austermann, Martin and Usai, Marco Virgilio and Oberhuber, Alexander and Schäfers, Johannes Frederik and Bisdas, Theodosios and Patelis, Nikolaos and Palermo, Sergio and Gargiulo, Mauro}},
  issn         = {{0741-5214}},
  keywords     = {{Abdominal aortic aneurysm; Carbon dioxide; CO-angiography; Endovascular aortic repair}},
  language     = {{eng}},
  number       = {{5}},
  pages        = {{1--1412}},
  publisher    = {{Mosby-Elsevier}},
  series       = {{Journal of Vascular Surgery}},
  title        = {{The optimal operative protocol to accomplish CO<sub>2</sub>-EVAR resulting from a prospective interventional multicenter study}},
  url          = {{http://dx.doi.org/10.1016/j.jvs.2023.01.013}},
  doi          = {{10.1016/j.jvs.2023.01.013}},
  volume       = {{77}},
  year         = {{2023}},
}