Feasibility and safety of automated CO(2) angiography in peripheral arterial interventions

Carbon dioxide (CO(2)) gas is an established alternative to iodine contrast during angiography in patients with risk of postcontrast acute kidney injury and in those with history of iodine contrast allergy. Different CO(2) delivery systems during angiography are reported in literature, with automated delivery system being the latest. The aim of this study is to evaluate the safety, efficacy, and learning curve of an automated CO(2) injection system with controlled pressures in peripheral arterial interventions and also to study the patients’ tolerance to the system. From January 2018 to October 2019 peripheral arterial interventions were performed in 40 patients (median age-78 years, interquartile range: 69–84 years) using an automated CO(2) injection system with customized protocols, with conventional iodine contrast agent used only as a bailout option. The pain and tolerance during the CO(2) angiography were evaluated with a visual analog scale at the end of each procedure. The amount of CO(2), iodine contrast used, and radiation dose area product for the interventions were also systematically recorded for all procedures. These values were statistically compared in 2 groups, viz first 20 patients where a learning curve was expected vs the rest 20 patients. All procedures were successfully completed without complications. All patients tolerated the CO(2) angiography with a median total pain score of 3 (interquartile range: 3–4), with no statistical difference between the groups (P = .529). The 2 groups were statistically comparable in terms of comorbidities and the type of procedures performed (P = .807). The amount of iodine contrast agent used (24.60 ± 6.44 ml vs 32.70 ± 8.70 ml, P = .006) and the radiation dose area product associated were significantly lower in the second group (2160.74 ± 1181.52 μGym(2) vs 1531.62 ± 536.47 μGym(2), P = .043). Automated CO(2) angiography is technically feasible and safe for peripheral arterial interventions and is well tolerated by the patients. With the interventionalist becoming familiar with the technique, better diagnostic accuracy could be obtained using lower volumes of conventional iodine contrast agents and reduction of the radiation dose involved.