Accuracy and safety of CO2 digital subtraction angiography during endovascular treatment of symptomatic peripheral artery occlusive disease. A prospective study on Egyptian patients

Purpose: To study the efficacy, safety and clinical outcome of carbon dioxide DSA during angioplasty procedures for patients with predominant femoropopliteal segment occlusive lesions, aiming to reduce possible allergic reactions and potential nephrotoxicity. Materials and methods: The study included eighteen Egyptian patients in a prospective manner, with evidence of predominant femoropopliteal arterial occlusive disease by Duplex study. All the selected patients had borderline renal functions with serum creatinine levels between 1.5 mg/dL and 2 mg/dL. Every patient was scheduled for a percutaneous endovascular therapy during which CO2 DSA and small volume injections of ICM DSA of the diseased segment and distal arterial tree were done. We analyzed our results emphasizing the technical success, CO2 DSA related complications, allergic reactions and intolerance. We also correlated the amount of contrast injected with the serum creatinine levels as well as the degree of opacification of the diseased segment. Results: We were able to achieve technical success in 88% of our cases except in two patients who had TASC D lesions. The average fluoroscopy time in our study was about 100 min. There were no CO2 related complications or allergic reactions. Five patients were intolerant to CO2 injection related pains and repeated injections were performed with smaller volumes. The injected mean volume of CO2 was 76.1 mL while the mean volume of ICM used per patient was 24 mL. Most patients showed non-significant rise of serum creatinine levels at both samples. Moreover, the results of the “Good” score & the “Fair” score for the CO2 DSA image quality plotted by the interobserver agreement was about 40% & 33% respectively from the total number of patients included in the study. Conclusion: CO2 DSA is a non-nephrotoxic alternative to traditional ICM DSA that could be safely used and well tolerated during endovascular management of lower extremity symptomatic arterial disease. When selectively delivered to the femoropopliteal segment, CO2 provides superior quality images that would cancel or markedly reduce the ICM volume required for prompt visualization and decision making during the revascularization procedure.