Feasibility and Safety of Exclusively Using Carbon Dioxide in Regular Endovascular Aortic Aneurysm Repair: Results of a Multicentre, Prospective, Zero Iodine Contrast Endovascular Aneurysm Repair Study

Emiliano Chisci; Emanuele Ferrero; Michele Antonello; Luca Mezzetto; Raffaele Pulli; Giacomo Isernia; Mauro Gargiulo; Giovanni Pratesi; Domenico Angiletta; Luca Bertoglio; Sara Simongini; Simone Panci; Tommaso Lazzarotto; Lorenza Chiera; Michelangelo Ferri; Andrea Gaggiano; Simona Marrocco; Elda Chiara Colacchio; Michele Piazza; Franco Grego; Lorenzo Grosso; Gian Franco Veraldi; Aaron Thomas Fargion; Roberto Falso; Gioele Simonte; Gianbattista Parlani; Massimo Lenti; Enrico Gallitto; Chiara Mascoli; Caterina Melani; Sergio Zacà; Lucia Di Stefano; Stefano Bonardelli; Apollonia Verrengia; Stefano Michelagnoli; Zero Iodine Contrast EVAR Collaborative Study Group

doi:10.1016/j.ejvs.2024.11.011

Feasibility and Safety of Exclusively Using Carbon Dioxide in Regular Endovascular Aortic Aneurysm Repair: Results of a Multicentre, Prospective, Zero Iodine Contrast Endovascular Aneurysm Repair Study

Eur J Vasc Endovasc Surg. 2024 Nov 16:S1078-5884(24)00967-5. doi: 10.1016/j.ejvs.2024.11.011. Online ahead of print.

Authors

Emiliano Chisci¹, Emanuele Ferrero², Michele Antonello³, Luca Mezzetto⁴, Raffaele Pulli⁵, Giacomo Isernia⁶, Mauro Gargiulo⁷, Giovanni Pratesi⁸, Domenico Angiletta⁹, Luca Bertoglio¹⁰, Sara Simongini¹¹, Simone Panci¹¹, Tommaso Lazzarotto¹¹, Lorenza Chiera², Michelangelo Ferri², Andrea Gaggiano², Simona Marrocco³, Elda Chiara Colacchio³, Michele Piazza³, Franco Grego³, Lorenzo Grosso⁴, Gian Franco Veraldi⁴, Aaron Thomas Fargion⁵, Roberto Falso⁵, Gioele Simonte⁶, Gianbattista Parlani⁶, Massimo Lenti⁶, Enrico Gallitto⁷, Chiara Mascoli¹², Caterina Melani⁸, Sergio Zacà⁹, Lucia Di Stefano⁹, Stefano Bonardelli¹⁰, Apollonia Verrengia¹², Stefano Michelagnoli¹¹; Zero Iodine Contrast EVAR Collaborative Study Group

Affiliations

¹ Department of Surgery, Vascular and Endovascular Surgery Unit, Usl Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy. Electronic address: e.chisci@gmail.com.
² Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy.
³ Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy.
⁴ Department of Vascular Surgery, University and Hospital Trust of Verona, University of Verona -School of Medicine, Verona, Italy.
⁵ Section of Vascular Surgery, Department of Excellence of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
⁶ Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy.
⁷ Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy.
⁸ Clinic of Vascular and Vascular Surgery, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy.
⁹ Vascular and Endovascular Surgery, Department of Emergency and Organs Transplantation, "Aldo Moro" University of Bari School of Medicine, Bari, Italy.
¹⁰ Division of Vascular Surgery, Department of Experimental and Clinical Sciences, University of Brescia School of Medicine, Spedali Civili di Brescia, Brescia, Italy.
¹¹ Department of Surgery, Vascular and Endovascular Surgery Unit, Usl Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy.
¹² Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy.

PMID: 39557380
DOI: 10.1016/j.ejvs.2024.11.011

Abstract

Objective: Carbon dioxide (CO₂) 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 CO₂ angiography.

Methods: 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 standard endovascular graft (instructions for use) was anatomically feasible. The study involved the use of an automatic CO₂ 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 CO₂ angiography. 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); CO₂ angiography was repeated in steps 1 - 2; and (E) use ICM.

Results: A total of 293 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 CO₂ 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. CO₂ related adverse events were rare (1%) 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 position of the lowermost renal artery between 3 and 9 o'clock.

Conclusion: This study demonstrated that the standardised zero iodine contrast EVAR protocol reported here is both safe and feasible and is applicable to 82% of consecutive non-selected patients. Limitations primarily arose from anatomical factors, and adjunctive standardised manoeuvres can effectively address these challenges in most cases.

Keywords: CO(2) angiography; EVAR; Multicentre; Prospective.