Department of Surgery, Section of Vascular Surgery, University of Michigan School of Medicine, Ann Arbor, MI 48109-5867, USA.
J Vasc Surg. 2012 Jun;55(6):1570-5. doi: 10.1016/j.jvs.2011.11.142. Epub 2012 Feb 16.
Renal dysfunction following endovascular abdominal aortic aneurysm repair (EVAR) remains a significant source of morbidity and mortality. We studied the use of carbon dioxide (CO(2)) as a non-nephrotoxic contrast agent for EVAR.
Recorded data from 114 consecutive patients who underwent EVAR with CO(2) as the contrast agent over 44 months were retrospectively analyzed. CO(2) was used exclusively in 72 patients and in an additional 42 patients iodinated contrast (IC) was given (mean, 37 mL). Renal and hypogastric artery localization and completion angiography were done with CO(2) in all patients, including additional arterial embolization in 16 cases. Preoperative National Kidney Foundation glomerular filtration rate (GFR) classification was normal in 16 patients, mildly decreased in 52, moderate to severely decreased in 44, and two patients were on dialysis.
All graft deployments were successful with no surgical conversions. CO(2) angiography identified 20 endoleaks (two type 1, 16 type 2, and two type 4) and three unintentionally covered arteries. Additional use of IC in 42 patients did not modify the procedure in any case. When compared with a cohort of patients who underwent EVAR using exclusively IC, the operative time was shorter with CO(2) (177 vs 194 minutes; P = .01); fluoroscopy time was less (21 vs 28 minutes; P = .002), and volume of IC was lower (37 vs 106 mL; P < .001). Postoperatively, there were two deaths, two instances of renal failure requiring dialysis, and no complications related to CO(2) use. Among patients with moderate to severely decreased GFR, those undergoing EVAR with IC had a 12.7% greater decrease in GFR compared with the CO(2) EVAR group (P = .004). At 1, 6, and 12-month follow-up, computed tomography angiography showed well-positioned endografts with the expected patent renal and hypogastric arteries in all patients and no difference in endoleak detection compared with the IC EVAR group. During follow-up, eight transluminal interventions and one open conversion were required, and no aneurysm-related deaths occurred.
CO(2)-guided EVAR is technically feasible and safe; it eliminates or reduces the need for IC use, may expedite the procedure, and avoids deterioration in renal function in patients with pre-existing renal insufficiency. A prospective trial comparing CO(2) with IC during EVAR is warranted.
血管内腹主动脉瘤修复术（EVAR）后肾功能障碍仍然是发病率和死亡率的重要来源。我们研究了二氧化碳（CO2）作为 EVAR 的非肾毒性对比剂的使用。
回顾性分析了 44 个月内 114 例连续接受 CO2 作为对比剂行 EVAR 的患者的记录数据。72 例患者单独使用 CO2，另外 42 例患者使用碘对比剂（IC）（平均 37mL）。所有患者均使用 CO2 进行肾和髂动脉定位和完成血管造影，16 例患者进行了额外的动脉栓塞。术前国立肾脏基金会肾小球滤过率（GFR）分类正常 16 例，轻度下降 52 例，中度至重度下降 44 例，2 例患者接受透析。
所有移植物均成功部署，无手术转换。CO2 血管造影发现 20 例内漏（2 型 1 例，16 型 2 例，4 型 2 例）和 3 例无意中覆盖的动脉。另外 42 例患者使用 IC 并未改变任何病例的手术过程。与单独使用 IC 行 EVAR 的患者队列相比，CO2 组的手术时间更短（177 比 194 分钟；P=.01）；透视时间更短（21 比 28 分钟；P=.002），IC 用量更少（37 比 106mL；P <.001）。术后有 2 例死亡，2 例肾衰竭需要透析，无与 CO2 使用相关的并发症。在中度至重度 GFR 下降的患者中，与 CO2-EVAR 组相比，IC-EVAR 组的 GFR 下降了 12.7%（P=.004）。在 1、6 和 12 个月的随访中，计算机断层血管造影显示所有患者的内置移植物位置良好，预期的肾和髂内动脉通畅，与 IC-EVAR 组相比，漏诊率无差异。在随访期间，需要进行 8 次经腔干预和 1 次开放转换，无动脉瘤相关死亡。
CO2 引导的 EVAR 技术上是可行和安全的；它可以消除或减少 IC 的使用需求，可能加快手术速度，并避免肾功能不全患者肾功能恶化。有必要进行一项比较 CO2 与 IC 在 EVAR 期间使用的前瞻性试验。
