CO2 Angiography For Diagnosis And Intervention Syllabus

2013-10-01

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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

None

Disclosure

CO2 Properties

•Invisible gas

•High solubility

•Low viscosity

•Buoyancy

•Compressibility

•Non-allergenic

•Non-nephrotoxic

9/16/2013

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

9/16/2013

CO2 injection

Endhole catheter vs. Pigtail catheter

CO2

Blood

CO2 Flow Dynamics

300 inclination

Buoyancy

Axial CT scan after intra-aortic

injections of CO2 or contrast medium

9/16/2013

Injection of 20 cc of CO2 into

proper hepatic artery via a 3Fr

microcatheter

LLD

1950-1970

CO2 as an intravenous contrast

CO2

Percent changes in blood pressure

following intracaval injections of ascending

doses of CO2 in swine

-80

-60

-40

-20

0 2 4 6 8 10

Time (min.)

% Change in SBP

6.4

3.2

1.6

0.8

0.4

0.2

0.0

Supine

CO2 ( cc/kg)

9/16/2013

Percent changes in pulmonary arterial

pressure following intracaval injections of

ascending doses of CO2 in swine

-20

-10

0 2 4 6 8 10

Time (min.)

% Change in MPAP

6.4

3.2

1.6

0.8

0.4

0.2

0.0

Supine

MPAP

CO2 (cc/kg)

Percent changes in SaO2 following

intracaval injections of increasing doses of

CO2 in swine

-10

-8

-6

-4

-2

0246810

Time (min.)

% change in oxygen saturation

0.0

0.2

0.4

0.8

1.6

3.2

6.4

Supine

O2 saturation

CO2 (cc/kg)

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.

9/16/2013

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.

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

9/27/2013

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

9/27/2013

Carbon Dioxide Iodine Based Contrast

9/27/2013

Carbon Dioxide Imaging

Subtracted Image Aorta filled with CO2 -

unsubtracted image

Carbon Dioxide Imaging with

Interventions

9/27/2013

Renal Artery Stenosis PTA-Stent with CO2

PRE POST

9/27/2013

Renal Transplant Assessment

9/27/2013

Carbon Dioxide Imaging

Lower Extremity

9/27/2013

Carbon Dioxide Lower Extremity

Angiography

Carbon Dioxide performs well in

occlusive disease

9/27/2013

Peripheral Interventions

SFA Occlusion

9/27/2013

Post Angioplasty and

Atherectomy

9/27/2013

Technique Matters

–Patient positioning

–Breath holding

–Motion

–Bowel gas

–Injection rate

9/27/2013

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.

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

10/1/2013

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

10/1/2013

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

10/1/2013

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

10/1/2013

CO2 arteriogram and embolization

Aneurysm repair

•Iliac aneurysm coiling with CO2

•AAA stent-graft using CO2 & IVUS

•Total contrast used: 30 cc

•Renal function unchanged

10/1/2013

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

10/1/2013

CO2 Fistulogram

Dialysis access intervention

•This patient’s procedures are

completed whenever necessary without

the use of contrast medium

•No further allergic reactions

10/1/2013

Final comments

•CO2: Applications in the angio-suite

•Safe

•Reliable

•Reproducible

•Cheap (save on contrast and drugs)

•Excellent problem-solving tool

Thank you

1 1

CARBON DIOXIDE

DIGITAL SUBTRACTION

ANGIOGRAPHY

INTERVENTION

Jim Caridi

University of Florida

jimcaridi@gmail.com

DISCLOSURES

Consultant and investor:

AngioAdvancements LLC

DELIVERY OF

INTRAVASCULAR CO2 IS

CURRENTLY

CONSIDERED OFF LABEL

BY THE FDA

•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)

CO2 ADVANTAGES

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

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

CO2 CAVEATS

•Contamination

•Excessive volumes

•Compressive delivery

•Pulmonary HTN

CONTAMINATION

1. CO2 cylinder

Rust, methane, H2O, particulate matter,

carbonic acid

2. Room air

diffusivity

malpositioned stopcock

inadequate flushing

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

Plastic Bag Delivery System

Hawkins, Caridi, and Kerns. AJR 165: 1995:1487-1489

AngioFill Bag Collection System and Angioflush 11.

AngioDynamics

FLACCID CO2 RECEPTACLE

DELIVERY SYRINGE

CO2 ANGIOGRAPHY

TECHNIQUE

MERIT MEDICAL CUSTOM WASTE

BAG AND CONTRAST DELIVERY SET

MERITMEDICAL CUSTOM WASTE

BAG AND CONTRAST DELIVERY SET

Flaccid reservoir

Clamp

Delivery syringe

Catheter

One way valves

Adjustment knob

Activation button

PSI Gauge

CO2 Cartridge

Luer lock

Medical Grade

CO2 cannister

10,000 cc’s

Activation button

ANGIASSIST:

One way valve

CO2, chemoembolization, embolics, thrombolytics, contrast

Proprietary valve

One way valve

Reservoir Delivery

ADVANTAGES

•Pre-assembeled

•Compact

•User friendly cannot be connected

inappropriately

•CO2 cannot go directly to patient

•One purge

•No explosive delivery

Small hole in drape

Extension tubing

More CO2

• 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

DELIVERY SYSTEM

•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

CARBON DIOXIDE

DIGITAL SUBTRACTION

ANGIOGRAPHY

THANK YOU

CO2 Angiography For Diagnosis And Intervention Syllabus

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