Carbon dioxide is a cost-effective contrast medium to guide revascularization of TASC A and TASC B femoropopliteal occlusive disease.
BACKGROUND
Iodine contrast medium (ICM) is considered gold standard in endovascular revascularization procedures. However, nephrotoxicity and hypersensitivity to ICM are causes that limit its indiscriminate use. Carbon dioxide (CO2) contrast angiography has been used as an alternative in patients with formal contraindication to ICM. However, no studies to the present date have compared in a randomized and prospective way, outcomes of revascularization procedures performed with either ICM or CO2 in patients eligible for use of both contrasts.


METHODS
Between April 2012 and April 2013, 35 patients with peripheral arterial disease with arterial lesions classified as Trans-Atlantic Inter-Society Consensus A or B (identified on preoperative angio computed tomography scan) and adequate runoff underwent femoropopliteal revascularization by endovascular technique in a prospective, randomized, and controlled study. Patients were randomized into 2 groups: CO2 group and ICM group, according to the contrast media selected of the procedure. We evaluated the following outcomes in both groups: feasibility of the procedures, complications, surgical outcomes (ankle-brachial index [ABI]), glomerular filtration rate using the Cockcroft-Gault formula, relationship between the volume of injected iodine and postoperative creatinine clearance, quality of the angiographic images obtained with CO2, costs of the endovascular materials, and finally, cost of contrast agents.


RESULTS
We were able to perform the proposed procedures in all patients treated in this series (ICM group and CO2). There were no CO2-related complications. No procedures required conversion to open surgery. Clinical results were satisfactory, with regression of ischemia and increased levels of ABI in both groups. Variations in creatinine clearance levels showed a numerical increase in the CO2 group and a decrease in ICM group, however, with no statistically significant difference between the delta clearance in each group. All CO2 arteriograms of the supragenicular arteries were graded as good or fair by both observers with high interobserver image quality concordance. There was no statistical difference between endovascular material costs between the groups, but the contrast cost was significantly lower in CO2 group (P < 0.001).


CONCLUSIONS
The use of CO2 in patients with no restriction for ICM is an alternative that does not limit the feasibility of the procedures. Similar outcomes were observed with CO2 when compared with the gold standard contrast (ICM) regarding quality of images produced, with no associated changes in creatinine clearance or hypersensitivity reactions and also allows a reduction in contrast-related costs in angioplasty procedures.
Hospital Israelita Albert Einstein, São Paulo, Brasil. Electronic address: cynthiamendes35@hotmail.com.
Cynthia
C
de Almeida Mendes
Hospital Israelita Albert Einstein, São Paulo, Brasil.
Alexandre
A
de Arruda Martins
Hospital Israelita Albert Einstein, São Paulo, Brasil.
Marcelo Passos
MP
Teivelis
Hospital Israelita Albert Einstein, São Paulo, Brasil.
Sergio
S
Kuzniec
Hospital Israelita Albert Einstein, São Paulo, Brasil.
Kenji
K
Nishinari
Hospital Israelita Albert Einstein, São Paulo, Brasil.
Mariana
M
Krutman
Hospital Israelita Albert Einstein, São Paulo, Brasil.
Helio
H
Halpern
Hospital Israelita Albert Einstein, São Paulo, Brasil.
Nelson
N
Wolosker
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D055109:Ankle Brachial Index; D001938:Brazil; D002245:Carbon Dioxide / Q000009:adverse effects / Q000191:economics*; D003251:Constriction, Pathologic; D003287:Contrast Media / Q000009:adverse effects / Q000191:economics*; D003362:Cost-Benefit Analysis; D057510:Endovascular Procedures / Q000009:adverse effects / Q000191:economics*; D005240:Feasibility Studies; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging* / Q000503:physiopathology; D005919:Glomerular Filtration Rate / Q000187:drug effects; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000191:economics* / Q000503:physiopathology / Q000628:therapy*; D011150:Popliteal Artery / Q000000981:diagnostic imaging* / Q000503:physiopathology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015641:Radiography, Interventional / Q000009:adverse effects / Q000191:economics*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D003287:Contrast Media; D002245:Carbon Dioxide