Carbon dioxide digital subtraction angiography-assisted endovascular aortic aneurysm repair in the azotemic patient

J Vasc Surg. 2007 Mar;45(3):451-8; discussion 458-60. doi: 10.1016/j.jvs.2006.11.017. Epub 2007 Jan 24.


Objective: This report analyzes the safety and efficacy of carbon dioxide digital subtraction angiography (CO(2)-DSA) for EVAR in a group of patients with renal insufficiency compared with a concurrent group of patients with normal renal function undergoing EVAR with iodinated contrast angiography (ICA).

Methods: Between 2003 and 2005, 100 consecutive patients who underwent EVAR using ICA, CO(2)-DSA, or both were retrospectively reviewed, and preoperative, intraoperative, postoperative, and follow-up variables were collected. Patients were divided into two groups depending on renal function and contrast used. Group I comprised patients with normal renal function in whom ICA was used exclusively, and group II patients had a serum creatinine >or=1.5 mg/dL, and CO(2)-DSA was used preferentially and supplemented with ICA, when necessary. The two groups were compared for the outcomes of successful graft placement, renal function, endoleak type, and frequency, and the need for graft revision. Comparisons were made using chi(2) analysis, Student t test, and the Fisher exact test.

Results: A total of 84 EVARs were performed in group I and 16 in group II. Patient demographics and risk factors were similar between groups with the exception of serum creatinine, which was significantly increased in group II (1.8 mg/dL vs 1.0 mg/dL P < .0005). All 100 endografts were successfully implanted. Patients in group II had longer fluoroscopy times, longer operative times, and increased radiation exposure, and 13 of 16 patients required supplemental ICA. Mean iodinated contrast use was 27 mL for group II vs 148 mL in group I (P < .0005). Mean postoperative serum creatinine was unchanged from baseline, and 30-day morbidity was similar for both groups. No patient required dialysis. No patients died. Perioperatively, and at 1 and 6 months, the endoleak type and incidence and need for endograft revision was no different between groups.

Conclusions: CO(2)-DSA is safe, can be used to guide EVAR, and provides outcomes similar to ICA-guided EVAR. CO2-DSA protects renal function in the azotemic patient by lessening the need for iodinated contrast and associated nephrotoxicity, but with the tradeoff of longer fluoroscopy and operating room times and increased radiation exposure.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Angiography, Digital Subtraction / instrumentation
  • Angiography, Digital Subtraction / methods*
  • Angioplasty, Balloon*
  • Aortic Aneurysm / complications
  • Aortic Aneurysm / diagnostic imaging*
  • Aortic Aneurysm / surgery
  • Aortic Aneurysm / therapy
  • Azotemia / blood
  • Azotemia / complications*
  • Blood Vessel Prosthesis Implantation*
  • California
  • Carbon Dioxide* / adverse effects
  • Cohort Studies
  • Contrast Media* / adverse effects
  • Creatine / blood
  • Female
  • Follow-Up Studies
  • Humans
  • Hydrocarbons, Iodinated / adverse effects
  • Kidney Function Tests
  • Male
  • Middle Aged
  • Prosthesis Failure
  • Radiography, Interventional / methods*
  • Reoperation
  • Retrospective Studies
  • Severity of Illness Index
  • Time Factors
  • Treatment Outcome


  • Contrast Media
  • Hydrocarbons, Iodinated
  • Carbon Dioxide
  • Creatine