Arteriography in chronic renal failure: a case for carbon dioxide

Carbon dioxide angiography during peripheral angioplasty procedures significantly reduces the risk of contrast-induced nephropathy in patients with chronic kidney disease

BACKGROUND

Iodinated contrast media are amongst the most frequently prescribed medications, however, their use is not without complications. With contrast-induced nephropathy constituting a major concern, alternative non-iodine based approaches have been explored such as carbon dioxide angiography. The purpose of this study is to report the incidence of contrast-induced nephropathy following carbon dioxide angiography in patients with impaired renal function that underwent peripheral angioplasty compared with a historical cohort of patients that underwent angioplasty with use of solely iodine contrast medium. The historical cohort of patients treated with iodinated contrast was used as control. Baseline demographics and renal function tests were recorded. Primary outcome was incidence of contrast-induced nephropathy within 48-72 h post intervention. Receiver-Operating-Characteristic curve analysis was used to correlate the volume of iodinated contrast with the risk of contrast-induced nephropathy.

RESULTS

Carbon Dioxide was used as an alternative to iodinated contrast media in patients with impaired renal function (eGFR<60mls/min/1.73 m2) undergoing peripheral angioplasty procedures. Fifty, consecutive patients (baseline eGFR = 38.6 ± 13.2mls/min/1.73 m2) were included in a prospective clinical audit. These were matched (1:2) with a historical cohort of patients (baseline eGFR = 43.3 ± 12.2mls/min/1.73 m2) treated with Iodinated contrast media. The incidence of contrast-induced nephropathy was 14% (n = 7/50) in case of carbon dioxide vs. 29% (n = 29/100) in the matched cohort group (p = 0.045). Receiver-Operating-Characteristic analysis showed that use of >25mls of contrast was 94.4% (95% CI:81-99%) sensitive in predicting contrast-induced nephropathy.

CONCLUSION

Carbon dioxide imaging during peripheral angioplasty procedures protects against contrast-induced nephropathy. Use of >25mls of iodinated contrast media in high-risk patients is a predictor of contrast-induced nephropathy.

Contrast induced-acute kidney injury following peripheral angiography with carbon dioxide versus iodinated contrast media: A meta-analysis and systematic review of current literature

OBJECTIVE

We conducted a meta-analysis to compare the incidence of acute kidney injury (AKI) with carbon dioxide (CO₂ ) versus iodinated contrast media (ICM).

BACKGROUND

Contrast induced-acute kidney injury (CI-AKI) is a known complication following endovascular procedures with ICM. CO₂ has been employed as an alternative imaging medium as it is nontoxic to the kidneys.

METHODS

Search of indexed databases was performed and 1,732 references were retrieved. Eight studies (7 observational, 1 Randomized Controlled Trial) formed the meta-analysis. Primary outcome was AKI. Fixed effect model was used when possible in addition to analysis of publication bias.

RESULTS

In this meta-analysis, 677 patients underwent 754 peripheral angiographic procedures. Compared with ICM, CO₂ was associated with a decreased incidence of AKI (4.3% vs. 11.1%; OR 0.465, 95% CI: 0.218-0.992; P = 0.048). Subgroup analysis of four studies that included granular data for patients with chronic kidney disease (CKD) did not demonstrate a decreased incidence of AKI with CO₂ (4.1% vs. 10.0%; OR 0.449, 95% CI: 0.165-1.221, P = 0.117). Patients undergoing CO₂ angiography experienced a higher number of nonrenal events including limb/abdominal pain (11 vs. 0; P = 0.001) and nausea/vomiting (9 vs. 1; P = 0.006).

CONCLUSIONS

In comparison to ICM, CO₂ use is associated with a modestly reduced rate of AKI with more frequent adverse nonrenal events. In studies that use CO₂ as the primary imaging agent, the average incidence of AKI remained high at 6.2%-supporting the concept that factors other than renal toxicity from ICM may contribute to renal impairment following peripheral angiography. © 2017 Wiley Periodicals, Inc.

Contrast alternatives for iodinated contrast allergy and renal dysfunction: options and limitations

Diagnostic angiography and vascular interventions make routine use of iodinated contrast material (ICM). Patients with renal disease or contrast allergy pose limitations on the use of ICM. In such cases, alternative contrast media may be used to carry out the procedure. Current alternatives include carbon dioxide, gadolinium, and dilute ICM. Each of these alternatives has its own unique features and limitations. In the present review article, the current alternatives to ICM are explored, with a focus on the applications and restrictions of each.

Safety and utility of uterine artery embolization with CO2 and a gadolinium-based contrast medium

The authors evaluated the safety and clinical outcomes of uterine artery embolization (UAE) without the use of conventional iodinated contrast media for symptomatic uterine leiomyomata. Patients underwent UAE with use of CO(2) gas and a gadolinium-based contrast medium. The safety and feasibility of the technique were assessed. Patients were followed up at 24 hours, 1 month, and 6 months after UAE and yearly thereafter. UAE without iodinated contrast medium was attempted in eight patients (mean age, 42.7 years +/- 4.1), and bilateral UAE was successful in all patients. The mean fluoroscopy time was 14.9 minutes. The mean amount of gadolinium-based contrast medium used was 30.6 mL or 0.181 mmol/kg. No major complications were noted. The mean improvement in the symptom severity score was 53.8. The mean reduction in leiomyoma volume was 42%. To date, no repeat interventions have been performed. UAE with CO(2) and a gadolinium-based contrast medium is a viable treatment option for patients with a severe allergy to iodinated contrast media or renal insufficiency.

Prevention of perioperative acute renal failure: what works?

Perioperative acute renal failure (ARF) is associated with increased morbidity and mortality. Patients undergoing cardiac, vascular and major abdominal surgery and those with pre-operative renal insufficiency are at increased risk for developing post-operative ARF. The aetiologies of perioperative ARF are multi-factorial. However, pre-renal azotaemia and ischaemic acute tubular necrosis (ATN) are the predominant causes. Preventive strategies involve identifying patients at risk, optimizing intravascular volume as well as renal function with perioperative haemodynamic monitoring, and avoiding nephrotoxins. Various pharmacological agents have been used to optimize renal perfusion and tubular function. Unfortunately, none has been shown to be effective in randomized placebo-controlled trials. In this chapter, we discuss the prophylactic use of fluids, vasoactive drugs, diuretics and other agents, as well as modification of surgical techniques to reduce the incidence of perioperative ARF.

Neurotoxicity of angiographic carbon dioxide in the cerebral vasculature

RATIONALE AND OBJECTIVES

This study was undertaken to resolve conflicting evidence about the neurotoxicity of carbon dioxide gas as an angiographic contrast medium within the cerebral vasculature.

MATERIALS AND METHODS

Single intracarotid injections or five consecutive intracarotid injections, at 2-minute intervals, of carbon dioxide, iopromide or saline, were given to 32 rabbits under clinically relevant conditions. Extravasation of Evans blue and Tc-pertechnetate was used to determine blood-brain barrier damage at 30 minutes or 6 hours after injection. At 6 hours after multiple injections, brains were removed for histologic examination.

RESULTS

A single intracarotid injection of carbon dioxide caused minimal blood-brain barrier breakdown, whereas multiple injections caused significant breakdown that was still present at 6 hours after the injections. All carbon dioxide-injected brains that underwent histologic examination showed evidence of irreversible brain damage in the injected hemisphere.

CONCLUSIONS

The study confirms the neurotoxicity of carbon dioxide within the cerebral vasculature and its unsuitability for clinical use in cerebral angiography.

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.

Lower-extremity peripheral arterial disease among patients with end-stage renal disease

Peripheral arterial occlusive disease (PAOD) accounts for significant morbidity and mortality among end-stage renal disease (ESRD) patients but has not been as extensively studied as other kinds of atherosclerotic disease in this population. The current epidemiology and management of PAOD in ESRD patients is here reviewed and target areas for future research are identified. The prevalence of PAOD appears to be much higher among ESRD patients than in the general population. Risk factors for disease among ESRD patients are not well understood but probably include both conventional and dialysis or uremia-associated risk factors. Standard diagnostic techniques used to identify PAOD in the general population may not be as helpful in ESRD patients because many of these tests are inaccurate in the settings of vascular calcification and small-vessel disease. Despite the fact that this is a common disease in ESRD patients, most of these patients are not screened for PAOD. Interventions that have proven effective in the prevention and treatment of PAOD in the general population, such as smoking cessation, preventive foot care, and exercise, have not been systematically applied to ESRD patients. Furthermore, the optimal management of ischemic ulceration and gangrene in ESRD patients is quite controversial, and better algorithms for the prevention and management of PAOD in ESRD patients are needed. In conclusion, PAOD is common in ESRD patients. Future research should identify risk factors for disease in this population, and efforts should be made to develop strategies for the effective prevention and management of limb ischemia in this population.