CO2 Angiography For Diagnosis And Intervention Syllabus

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9/16/2013

CO2 Angiography
Properties, History, Body’s response,
Dosage, and Indications

Kyung J. Cho, MD, FSIR
University of Michigan

Disclosure
None

CO2 Properties
•
•
•
•
•
•
•

Invisible gas
High solubility
Low viscosity
Buoyancy
Compressibility
Non-allergenic
Non-nephrotoxic

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Absorption of CO2 bubble in RA
after injection of 5 cc of CO2

Non-absorption of air bubble in
RA after injection of 5 cc of air

Injection of 30 cc of CO2 into L
external iliac artery via a 3F dilator

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CO2 injection
Endhole catheter vs. Pigtail catheter

CO2 Flow Dynamics
Buoyancy

300 inclination
CO2

Blood

Axial CT scan after intra-aortic
injections of CO2 or contrast medium

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Injection of 20 cc of CO2 into
proper hepatic artery via a 3Fr
microcatheter

1950-1970
CO2 as an intravenous contrast
CO2

LLD

Percent changes in blood pressure
following intracaval injections of ascending
doses of CO2 in swine
Supine

80
BP
60

% Change in SBP

40

CO2 ( cc/kg)

20

6.4
3.2

0
0

2

4

6

8

10

1.6
0.8

-20

0.4
0.2
-40

0.0

-60

-80
Time (min.)

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Percent changes in pulmonary arterial
pressure following intracaval injections of
ascending doses of CO2 in swine
Supine

40
MPAP

% Change in MPAP

30

20

CO2 (cc/kg)
6.4
3.2

10

1.6
0.8
0.4

0
0

2

4

6

8

0.2

10

0.0
-10

-20
Time (min.)

Percent changes in SaO2 following
intracaval injections of increasing doses of
CO2 in swine
Supine
10
O2 saturation

% change in oxygen saturation

8
6

CO2 (cc/kg)
0.0

4

0.2

2

0.4

0
-2

0.8
0

2

4

6

8

10

1.6
3.2

-4

6.4

-6
-8
-10
Time (min.)

Conclusions
• CO2 in doses of 0.2-1.6 cc/kg causes no
cardiopulmonary effects.
• Because diagnostic CO2 DSA increases PA
pressure, CO2 should be used cautiously in patients
with pulmonary hypertension.
• Blood pressure monitoring and capnography
provide the earliest sign of “vapor lock” in the
pulmonary artery from an inadvertent injection of
large volume of CO2 or air.

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Injection factors for CO2
angiography
•
•
•
•
•
•
•

Aortography
20 - 40 cc/sec
Celiac arteriography
15 - 20 cc/sec
Superior mesenteric
15 - 20 cc/sec
Renal arteriography
15 - 20 cc/sec
Iliac arteriography
15 - 20 cc/sec
Femoral arteriography 15 - 20 cc/sec
Inferior vena cavography 20 - 40 cc/sec

Indications
•
•
•
•
•
•

Contrast allergy
High risk patients for CIN
Arteriography below diaphragm
Venography (central veins, hepatic/portal vein, IVC)
Parenchymal injection (liver & spleen)
Intervention:
– Arterial intervention
– EVAR
– Venous intervention
– Hepatic-portal intervention

Conclusions
• CO2 is the only safe contrast agent in contrast
allergy and renal failure.
• Understanding properties of CO2 and development
of a facile catheterization technique with the use of
CO2 reflux and stacking are essential in obtaining a
successful CO2 angiogram.
• CO2 is preferable in many diagnostic arteriography
and endovascular interventions that often require
large amounts of contrast.

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9/27/2013

Carbon Dioxide Vascular
Imaging and Interventions

Daniel Simon, MD
Vascular Access Center of West Orange
West Orange, New Jersey

Carbon Dioxide Imaging
Angiography
Venography

CO2 Imaging - Advantages
Non nephrotoxic
No effect on GFR
Ideal for patients with renal Insuffciency
Competitive alternative for MRA/CTA

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Less Well Known Advantages
• Low viscosity agent
• Non allergic
• Relative unlimited dose limit

Disadvantages
•
•
•
•

Conspicuity
Patient discomfort
Unpredictable patient reactions
Unpredictable imaging quality

Carbon Dioxide Imaging

WHITE CONTRAST = CARBON DIOXIDE

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Carbon Dioxide

Iodine Based Contrast

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Carbon Dioxide Imaging
Subtracted Image

Aorta filled with CO2 unsubtracted image

Carbon Dioxide Imaging with
Interventions

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Renal Artery Stenosis PTA-Stent with CO2
PRE

POST

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Renal Transplant Assessment

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Carbon Dioxide Imaging
Lower Extremity

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Carbon Dioxide Lower Extremity
Angiography
Carbon Dioxide performs well in
occlusive disease

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Peripheral Interventions

SFA Occlusion

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Post Angioplasty and
Atherectomy

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Technique Matters
– Patient positioning
– Breath holding
– Motion
– Bowel gas
– Injection rate

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Manage Your Expectations
• Approach as a LOW contrast study rather
than a NO contrast study
• Pain resolves.
• When you see nothing its usually because
there is nothing there.

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10/1/2013

CO2: Applications

Hector Ferral, MD
NorthShore University HealthSystem
Interventional Radiology

Disclosure

• Consultant for Terumo

CO2: Applications
• TIPS procedures
• Aneurysm repair
• Borderline Kidney Function

• Dialysis access interventions
• Allergy to Contrast

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CO2:Basics
• Do not load your syringe directly from
a source (CO2 tank)
• Always use a closed delivery system
• CO2mmander system

• Keep record of injection volumes
• Analyze your runs carefully
• Understand CO2 distribution after injection
• Avoid “vapor-lock”

CO2MMANDER

TIPS procedures
• We use CO2 for all our TIPS procedures
• CO2 portogram is critical for the portal
vein localization stage of the procedure

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CO2 Portogram in TIPS

CO2 Portogram in TIPS

TIPS procedures
• AP and oblique views
• Excellent to localize the portal vein

• Wedge injection
• Wedged catheter or balloon catheter
• Gentle injection of 15-20 cc
• Careful in patients with ascites

• Intraparenchymal injection

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ANEURYSM REPAIR

Case Presentation
• 78 year old man with severe atherosclerotic
disease, chronic renal failure with a stable
serum creatinine at 2.5 mg/dL and a large
iliac artery aneurysm
• Needs aneurysm repair but it is desirable to
avoid iodinated contrast

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CO2 arteriogram and embolization

Aneurysm repair

Aneurysm repair
•
•
•
•

Iliac aneurysm coiling with CO2
AAA stent-graft using CO2 & IVUS
Total contrast used: 30 cc
Renal function unchanged

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DIALYSIS ACCESS INTERVENTION

Case Presentation
• 68 year old woman with ESRD
• On hemodialysis via an AV fistula
• Allergic to iodinated contrast
•
•
•
•

Refractory to pre-medication
Ongoing problems with her AV fistula
Bleeding post-dialysis
Requires 3 month-surveys

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CO2 Fistulogram

CO2 Fistulogram

Dialysis access intervention
• This patient’s procedures are
completed whenever necessary without
the use of contrast medium
• No further allergic reactions

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Final comments
• CO2: Applications in the angio-suite
•
•
•
•

Safe
Reliable
Reproducible
Cheap (save on contrast and drugs)

• Excellent problem-solving tool

Thank you

8

CARBON DIOXIDE
DIGITAL SUBTRACTION

ANGIOGRAPHY
&
INTERVENTION
Jim Caridi
University of Florida
jimcaridi@gmail.com

1

DISCLOSURES
Consultant and investor:
AngioAdvancements LLC

2

DELIVERY OF
INTRAVASCULAR CO2 IS
CURRENTLY
CONSIDERED OFF LABEL
BY THE FDA
3

1

CO2 ADVANTAGES
•
•
•
•

Non-allergic
Non-nephrotoxic (unlimited volumes)
Rapidly absorbed (20 - 30X O2)
Low viscosity (1/400 iodinated contrast)
•
•
•
•

Easier to use with microcatheters
Can inject in-between catheter and wire
Detection of bleeding, AVF
Portal vein visualization

• Central reflux
•

Ability to identify vessel (ostium) central to catheter tip

• Cost (1cc = .005)

4

CO2 DISADVANTAGES
1. Requires unique delivery system
2. Invisible – concern for undetected contamination
3. Cerebral vessels should be avoided
4. Bowel gas can interfere with abdominal images
5. Potentially more labor intensive

5

PROCEDURES
•
•
•
•
•
•
•
•
•

Renal insufficiency / allergy
High volume contrast procedures
Arterial and Venous Dx
Detection of Acute hemorrhage / fistula
IVC filters
EVAR
TIPS
Portal vein intervention
Interventional oncology

6

2

CO2 CAVEATS
• Contamination
• Excessive volumes
• Compressive delivery
• Pulmonary HTN

7

CONTAMINATION
1. CO2 cylinder
Rust, methane, H2O, particulate matter,
carbonic acid
2. Room air
diffusivity
malpositioned stopcock
inadequate flushing
8

PREVENT CONTAMINATION
1. Use a disposable source of
medical grade CO2
2. Use a closed delivery system
3. Eliminate 3-way stopcocks
4. Secure connections
5. Flush system
9

3

Plastic Bag Delivery System
Hawkins, Caridi, and Kerns. AJR 165: 1995:1487-1489

AngioFill Bag Collection System and Angioflush 11.
AngioDynamics

10

FLACCID CO2 RECEPTACLE

DELIVERY SYRINGE
11

CO2 ANGIOGRAPHY
TECHNIQUE

4

MERIT MEDICAL CUSTOM WASTE
BAG AND CONTRAST DELIVERY SET

13

MERITMEDICAL CUSTOM WASTE
BAG AND CONTRAST DELIVERY SET

Flaccid reservoir

One way valves
Clamp

Catheter

Delivery syringe
15

5

Adjustment knob
Activation button
PSI Gauge
CO2 Cartridge
Luer lock

16

Medical Grade
CO2 cannister
10,000 cc’s

Activation button
17

ANGIASSIST:
CO2, chemoembolization, embolics, thrombolytics, contrast

One way valve

One way valve
Reservoir

Delivery
Proprietary valve
18

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ADVANTAGES
• Pre-assembeled
• Compact
• User friendly cannot be connected
inappropriately
• CO2 cannot go directly to patient
• One purge
• No explosive delivery
20

Small hole in drape

7

Extension tubing

More CO2

8

DELIVERY SYSTEM
• Non-compressed - for accurate volume and prevent
explosive delivery
• Closed system – to prevent contamination

• One way valves - prevent reflux and necessity to
remove delivery syringe
• Glued components - helps prevent air contamination
• Hand injection - purge catheter first to prevent
explosive delivery
25

CARBON DIOXIDE
DIGITAL SUBTRACTION
ANGIOGRAPHY
• CO2 angiography is safe when used appropriately
• The delivery system is simple
• CO2 has unique properties as a contrast agent
• It is a useful tool in both diagnosis and
intervention alone or as an adjunct with I contrast

26

THANK YOU

27

9



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