Safety and Efficacy of Carbon Dioxide Angiography in the Endovascular Management of Critical Limb Ischemia Patients with Renal Insufficiency

Abstract

Background: This study aims to achieve angioplasty in CLTI patients with renal impairment
using CO2 angiography, to assess the clinical outcome with no risk of renal failure and to
assess the procedure of CO2 angiography, whether it can be standalone procedure.
Methods: From October 2017 to May 2019, a prospective clinical trial enrolled 35 patients
with CLTI associated with renal insufficiency. All were managed using automated CO2
angiography. The primary outcome was assessment of the safety and efficacy of CO2
angiography. The secondary outcome was freedom from renal events.
Results: No serious complications related to CO2 angiography occurred, while severe leg
pain occurred in 9 cases (29.7%).Image quality using CO2 angiography was good in 36
lesions (65.5%), accepted in 10 (18%) and poor in 9 (16.5%). We used Iodinated contrast
media (ICM) in 33 cases and did not use it in two case one of them due to allergy to iodine.
CIN occurred in five patients out of 35 in our study; two out of five with CIN required
dialysis while the others recovered to their baseline creatinine level preoperative. The two
patients who required dialysis, one of them passed away 1month postoperative due to septic
shock while the other required permanent dialysis and had below knee amputation. The only
two factors that were statistically significant in predicting the incidence of CIN in our study
preoperative creatinine level and amount of (ICM) (p value, 0.008 and 0.001 respectively).
There were three cases of mortality in our study (8.5%).
Conclusions: CO2 angiography is safe in the endovascular management of CLTI patients.
The diagnostic value of CO2 angiography is the most valuable in the femoropopliteal
segment and the least in the infrapopliteal vessels especially in the more distal segments due
to motion artefact caused by leg pain during injection. CO2 angiography is poor in showing
dissections during endovascular interventions; however, it allows excellent visualization of
stents and its struts. CO2 angiography may help to reduce the incidence of CIN by reducing
total volume of iodinated contrast during endovascular intervention.