Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Vascular Surgery Unit, IRCCS, University Hospital Policlinico Sant'Orsola, Bologna, Italy.
J Vasc Surg. 2023 May;77(5):1405-1412.e1. doi: 10.1016/j.jvs.2023.01.013. Epub 2023 Jan 13.
Carbon dioxide (CO) angiography for endovascular aortic repair (CO-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-EVAR to create an operative standardized protocol.
Patients undergoing CO-EVAR were prospectively enrolled in five European centers from 2019 to 2021. CO-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 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 injection from femoral introducer sheath (third step), and completion angiogram from pigtail and femoral introducer sheath (fourth step). Intraoperative and postoperative CO-related adverse events were also evaluated. χ and Wilcoxon tests were used for statistical analysis.
In the considered period, 65 patients undergoing CO-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 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.
Preimplant CO 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. CHA can be satisfactorily visualized with CO alone. Completion CO angiogram should be performed from femoral introducer sheath. This operative protocol allows performance of CO-EVAR with 0 cc or minimal ICM, with a low rate of mild temporary complications.
二氧化碳（CO）血管造影术用于治疗腹主动脉瘤（AAA），特别是在慢性肾脏病或对碘造影剂（ICM）过敏的患者中。然而，在使用猪尾或引入鞘进行血管造影时，关于肾下动脉（LoRA）的可视化和最佳质量图像的一些技术问题仍未得到解决。本研究旨在分析 CO-EVAR 的不同步骤，以创建一个手术标准化方案。
2019 年至 2021 年，五个欧洲中心前瞻性纳入接受 CO-EVAR 的患者。使用自动注射器进行 CO-EVAR（压力，600mmHg；体积，100cc）；在 LoRA 可视化困难的情况下，少量注入 ICM。分析术前从猪尾和股动脉引入鞘进行 CO 血管造影（第一步）、从猪尾进行 0%、50%和 100%近端主体放置的血管造影（第二步）、从股动脉引入鞘进行对侧髂内动脉（CHA）可视化（第三步）和从猪尾和股动脉引入鞘进行完成血管造影（第四步）的不同步骤的 LoRA 可视化和图像质量（1=低，2=足够，3=良好，4=优秀）。还评估了术中与术后与 CO 相关的不良事件。使用 χ 和 Wilcoxon 检验进行统计分析。
在考虑期间，共纳入 65 例接受 CO-EVAR 的患者（55/65 [84.5%]男性；中位年龄，75 岁[四分位距（IQR），11.5 岁]）。中位 ICM 注射量为 17cc（IQR，51cc）；65 例中有 19 例（29.2%）未注射 ICM。55 例（84.2%）患者接受全身麻醉。在第一步中，从股动脉引入鞘中注入 CO 时，中位图像质量明显更高（猪尾，2[IQR，3] vs 引入鞘，3[IQR，3]；P=0.008）。在第二步中，与首次从猪尾进行的血管造影相比，在近端主体放置的 50%（93% vs 73.2%；P=0.002）和 100%（94.1% vs 78.4%；P=0.01）时更频繁地检测到 LoRA；同样，在近端主体放置的 50%（3[IQR，3] vs 2[IQR，3]；P≤0.001）和 100%（4[IQR，3] vs 2[IQR，3]；P=0.001）时，图像质量明显更高。在 93%的病例中（第三步）检测到 CHA。当从引入鞘进行最终血管造影（第四步）时，平均图像质量明显更高（猪尾，2.6±1.1 vs 引入鞘，3.1±0.9；P≤0.001）。术中（7.7%）和术后（12.5%）的不良事件（疼痛、呕吐、腹泻）均为短暂的，临床症状较轻。
应从股动脉引入鞘进行植入前 CO 血管造影。近端主体放置造成的气体流动阻碍可以提高 CO 的图像质量和 LoRA 可视化效果。单独使用 CO 可以满意地显示 CHA。应从股动脉引入鞘进行完成的 CO 血管造影。该手术方案允许使用 0cc 或最小 ICM 进行 CO-EVAR，且轻度短暂性并发症发生率低。
