A simple gas injector for carbon dioxide angiography

Image quality and safety of automated carbon dioxide digital subtraction angiography in femoropopliteal lesions: Results from a randomized single-center study

PURPOSE

To evaluate the image quality and the safety of automated carbon dioxide (CO₂) digital subtraction angiography (DSA).

MATERIALS AND METHODS

Fifty patients receiving DSA for femoropopliteal peripheral arterial disease (PAD) were enrolled in this single-center prospective study. All patients received iodinated contrast media (ICM) and CO₂ as a contrast agent in the same target lesion. As a primary endpoint, four raters independently evaluated the angiography images based on overall image quality, visibility of collaterals, and assessment of stenoses/occlusions. Inter-rater agreement was assessed using the intraclass correlation coefficient (ICC) and differences between the raters were evaluated using Friedmann's test. Secondary endpoints were procedure safety and patient pain assessment.

RESULTS

Inter-rater agreement between CO₂-DSA and ICM-DSA images was fair to excellent for overall image quality (ICC: 0.399-0.748), fair to excellent for the visibility of collaterals (ICC: 0.513-0.691), and poor to excellent for the assessment of stenoses/occlusions (ICC: -0.065-0.762). There were no significant differences between the raters. Two patients had a hematoma, one reported pain related to puncture, one became nauseous, and one vomited. No other adverse events were observed. Reported pain scores were significantly higher for CO₂-DSA vs. ICM-DSA (1.25 vs. 0625; p < 0.028).

CONCLUSION

CO2-DSA using automated injection system in combination with proprietary post-processing software is safe and comparable diagnostic test compared to ICM-DSA.

Physiology of Intraluminal Administration of Carbon Dioxide as a Contrast Medium

BACKGROUND

Carbon dioxide (CO2) exists in nature around us. In the middle of the 20th century, the intraluminal injection of CO2 demonstrated similar results to those of Digital Subtraction Angiography (DSA) with an iodinated contrast agent (ICA). Since then, the technology behind CO2 DSA has developed significantly.

OBJECTIVE

The aim of this study is to inform physicians about the unique properties of CO2 and its physiology after intraluminal injection.

METHODS

An extensive search for English literature on the properties of CO2 and the physiology of intraluminal administration was conducted using Pubmed.

RESULTS

There is sufficient literature on the properties of CO2 and the physiology of CO2 DSA. A review of this literature explains what happens to the human organism after the injection of CO2.

CONCLUSION

There is enough evidence that CO2 DSA is both effective, diagnostic and safe, but the properties of CO2 should be taken under consideration as complications occur, although rarely.

Comparison of intra-arterial digital subtraction angiography using carbon dioxide by 'home made' delivery system and conventional iodinated contrast media in the evaluation of peripheral arterial occlusive disease of the lower limbs

To prospectively compare the feasibility, safety and diagnostic role of carbon dioxide (CO(2)) digital subtraction angiography (DSA) using a 'home made' delivery system with iodinated contrast medium (ICM) DSA in the evaluation of peripheral arterial occlusive diseases (PAOD) of lower limbs. Twenty-one patients (27 limbs; all men; mean age, 47.6 years) who presented with PAOD of lower limbs underwent DSA using both intra-arterial CO(2) and ICM. Conventional ICM DSA was performed first and used as gold standard. Carbon dioxide was then injected by hand using a locally improvised home made plastic bag delivery system. Patient tolerance was assessed subjectively. Arteries from aortic bifurcation to the ankle were independently evaluated by two radiologists and graded for stenosis using a five-point scale. For each patient, the quality of CO(2) DSA images were compared with the corresponding images of ICM DSA and an overall grade of 'good', 'acceptable' or 'poor' was assigned. Cohen's kappa coefficient was used to determine inter-observer agreement. Carbon dioxide opacified 86.2% (188/195) of major arteries and depicted stenosis adequately in 84.5% (191/226) of arterial segments. A good or acceptable image quality of CO(2) DSA was obtained in over 95% of patients. Infrapopliteal arteries were inadequately visualized. Mild pain was seen in six (28.6%) patients with both contrast agents; one patient developed severe pain during CO(2) DSA. Inter-observer agreement was good (k > 0.75) at 70% of the segments. Administration of CO(2) into lower limb arteries is well tolerated. Carbon dioxide DSA using the locally improvised home made delivery system is a feasible and safe alternative to ICM DSA in the evaluation of PAOD. It provides adequate imaging of arteries of lower extremities except infrapopliteal segments.

The Current Status of the Use of Carbon Dioxide in Diagnostic and Interventional Angiographic Procedures

Since the first description of carbon dioxide (CO(2)) angiography the indications for using CO(2) have been changing and the applications of CO(2) angiography evolving. This review covers the contemporary role of CO(2) angiography. CO(2) angiography can be considered according to whether it is likely to be better, equivalent to or worse than conventional iodinated contrast medium (ICM). Areas where CO(2) angiography offers distinct advantages over ICM will be emphasized. The limitations to using CO(2) and specific caveats will be discussed. The basic physical properties of CO(2) and avoidance of the complications of gas angiography will be considered. CO(2) gas is cheap, non-allergenic, and is not nephrotoxic. Unfortunately it is not a panacea, angiographic quality is reduced, it is not tolerated by every patient, and it cannot be used in every location. It is important to be pragmatic and to use conventional contrast or alternative imaging rather than struggling with suboptimal CO(2) angiography.

Carbon dioxide angiography: a simple and safe system of delivery

Carbon dioxide (CO2) is an established alternate angiographic contrast agent, which can be delivered by pump or hand injection. We describe a simple, safe and inexpensive hand injection system that delivers a known volume of CO2 at atmospheric pressure and prevents contamination with room air.

CO(2) angiography

Iodinated contrast agents are routinely used in procedures to diagnose and treat peripheral vascular disease. Despite the development of low-osmolar contrast agents and premedication techniques, these agents are still associated with contrast-induced nephropathy and allergic reactions in some individuals. To overcome these problems, carbon dioxide angiography has been developed as an alternative to standard iodinated contrast angiography in certain patient populations. The technology of digital subtraction angiography has greatly improved the image quality of CO(2) angiography. Understanding the unique properties of CO(2), the techniques for its use, and its associated limitations and complications will allow interventional cardiologists to expand their treatments of atherosclerotic peripheral vascular disease.