Chisci Emiliano, Ferrero Emanuele, Antonello Michele, Mezzetto Luca, Pulli Raffaele, Isernia Giacomo, Gargiulo Mauro, Pratesi Giovanni, Bertoglio Luca, Michelagnoli Stefano
Department of Surgery, Vascular and Endovascular Surgery Unit, Usl Toscana Centro, San Giovanni di Dio Hospital, Florence, Italy.
Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy.
Eur J Vasc Endovasc Surg. 2025 Mar;69(3):392-402. doi: 10.1016/j.ejvs.2024.11.011. Epub 2024 Nov 16.
Carbon dioxide (CO) angiography has emerged as a viable alternative to regular iodinated contrast medium (ICM) for guiding endovascular aneurysm repair (EVAR) procedures. This study aimed to evaluate the feasibility and safety of a standardised EVAR procedure using only CO angiography.
A prospective, multicentre, national study enrolled consecutive patients between January 2023 and January 2024 with asymptomatic abdominal aortic aneurysms measuring ≥ 55 mm and for whom a standard endovascular graft (instructions for use) was anatomically feasible. The study involved the use of an automatic CO injector to standardise intra-operative imaging. A strategy comprising five standardised steps was devised to visualise a target vessel (TV) that could not be seen during the first CO angiogram. The five steps were: (A) place the introducer closer to the TV; (B) tilt the table by 5 - 10° in the direction opposite to the TV; (C) selectively cannulate the TV; (D) cannulate the contralateral gate (only for repositionable devices); CO angiography was repeated in steps 1 - 2; and (E) use ICM.
Two hundred and ninety-three patients were enrolled (10 centres), with a median age of 78 (interquartile range [IQR] 72, 83) years; 256 (87.4%) were male. The overall procedure time, fluoroscopy time, and injected CO volume were 90 (IQR 65, 125) minutes, 15 (IQR 10, 22) minutes, and 600 (IQR 400, 800) mL, respectively. The 30 day mortality, complication, and re-intervention rates were 0.3% (n = 1), 6.8% (n = 20), and 2.4% (n = 7), respectively. CO related adverse events were rare (1%; n = 3) and minor. A zero iodine contrast EVAR procedure was feasible in 240 (patients 81.9%). The five standardised steps were used extensively: step A, 170 procedures (58.0%); step B, 109 procedures (37.2%); step C, 21 procedures (7.2%); step D, 14 procedures (4.8%); and step E, 53 procedures (18.1%), with a median volume of 20 (IQR 10, 35) mL. Significant predictors for ICM use were aneurysm diameter > 70 mm and a lowermost renal artery positioned between 3 and 9 o'clock.
This study demonstrated that the standardised zero iodine contrast EVAR protocol reported here is both safe and feasible and is applicable in 82% of consecutive non-selected patients. Limitations primarily arose from anatomical factors, and adjunctive standardised manoeuvres can effectively address these challenges in most cases.
二氧化碳（CO）血管造影已成为引导血管内动脉瘤修复（EVAR）手术的常规碘化造影剂（ICM）的一种可行替代方法。本研究旨在评估仅使用CO血管造影进行标准化EVAR手术的可行性和安全性。
一项前瞻性、多中心、全国性研究纳入了2023年1月至2024年1月期间连续入选的无症状腹主动脉瘤患者，这些患者的动脉瘤直径≥55mm，且标准血管内移植物（使用说明书）在解剖学上可行。该研究使用自动CO注射器来标准化术中成像。设计了一个包含五个标准化步骤的策略，以可视化在首次CO血管造影时看不到的目标血管（TV）。这五个步骤分别是：（A）将导管鞘放置得更靠近目标血管；（B）将手术台向与目标血管相反的方向倾斜5 - 10°；（C）选择性地插管目标血管；（D）插管对侧分支（仅适用于可重新定位的装置）；在步骤1 - 2中重复进行CO血管造影；（E）使用ICM。
共纳入293例患者（10个中心），中位年龄为78岁（四分位间距[IQR] 72, 83）；256例（87.4%）为男性。总体手术时间、透视时间和注入的CO量分别为90分钟（IQR 65, 125）、15分钟（IQR 10, 22）和600mL（IQR 400, 800）。30天死亡率、并发症发生率和再次干预率分别为0.3%（n = 1）、6.8%（n = 20）和2.4%（n = 7）。与CO相关的不良事件很少见（1%；n = 3）且为轻微事件。240例（81.9%的患者）可行零碘造影剂EVAR手术。五个标准化步骤被广泛应用：步骤A，170例手术（58.0%）；步骤B，109例手术（37.2%）；步骤C，21例手术（7.2%）；步骤D，14例手术（4.8%）；步骤E，53例手术（18.1%），中位用量为20mL（IQR 10, 35）。使用ICM的显著预测因素是动脉瘤直径>70mm和最低肾动脉位于3点至9点之间。
本研究表明，此处报告的标准化零碘造影剂EVAR方案既安全又可行，适用于82%的连续非选择性患者。局限性主要源于解剖因素，辅助标准化操作在大多数情况下可有效应对这些挑战。
