Alma Mater Studiorum Bologna University. S.Orsola-Malpighi, Bologna, Italy Vascular Surgery. CO 2 angiography for. EVAR procedure. E.

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1 Alma Mater Studiorum Bologna University S.Orsola-Malpighi, Bologna, Italy Vascular Surgery CO 2 angiography for EVAR procedure E. Gallitto

2 CO 2 in aortic abdominal procedures Why How Limits Tips and Tricks Alma Mater Studiorum University of Bologna

3 CO 2 in aortic abdominal procedures Why Alma Mater Studiorum University of Bologna

4 Renal Issues Renal impairment is an independent predictor of mortality after OR and EVAR Sailer A et al. Eur Radiol Contrast induced nephropathy in EVAR ranged between 2%-16% Greenberg RK et al. J Vasc Surg 2004 Chao A et al. J Vasc Surg 2007 Alma Mater Studiorum University of Bologna

5 A systematic review & meta-analysis indicates underreporting renal dysfunction following EVAR 1-year renal function deterioration 18% To discuss Measures that should be implemented to mitigate or minimize this effect on renal function Karthikesalingam A, Kidney Interventional Advance, 2015

6 Carbon dioxide (CO 2 ) Non-nephrotoxic Non-allergenic gas Several studies have proposed the use of the carbon dioxide (CO 2 ) as an alternative contrast media for EVAR

7 N Author Year Journal Title 1 Chao A et al 2007 J Vasc Surg 2 Criado E et al 2008 J Vasc Surg 3 Manual injection Criado E et al 2012 J Vasc Surg Not optimal control of the gas output 4 Huang SG et al 2013 Ann Vasc Surg 5 Sueyoshi E et al 2015 J Vasc Surg Carbon dioxide digital subtraction angiography-assisted endovascular aortic aneurysm repair in the azotemic patient. Catheter-less angiography for endovascular aortic aneurysm repair: a new application of carbon dioxide as a contrast agent. Endovascular aortic aneurysm repair with carbon dioxide-guided angiography in patients with renal insufficiency. A prospective study of carbon dioxide digital subtraction versus standard contrast arteriography in the detection of endoleaks in endovascular abdominal aortic aneurysm repairs. The use of CO 2 in EVAR procedure has not been standardised jet Carbon dioxide digital subtraction angiography as an option for detection of endoleaks in endovascular abdominal aortic aneurysm repair procedure. 6 De Almeida Mendes C et al 2017 Ann Vasc Surg Carbon Dioxide as Contrast Medium to Guide Endovascular Aortic Aneurysm Repair. 7 De Angelis C et al 2017 Int J Cardiovasc Imaging. Carbon dioxide (CO2) angiography as an option for endovascular abdominal aortic aneurysm repair (EVAR) in patients with chronic kidney disease (CKD).

8 CO 2 in aortic abdominal procedures Why How Alma Mater Studiorum University of Bologna

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10 Automated injection system Angiodroid carbon dioxide angiography system

11 Injection parameters

12 Co2 line 10F sheet Iodinated Line diagnostic pigtail

13 Iodinated Line CO 2 Pig tail

14 @ diagnostic angiography Origin of the lowest RA Iodinated contrast media CO2

15 @ completion angiography Patency of the lowest RA CO 2 Iodinated contrast media

16 @ completion angiography -Patency of the HA -Type II endoleaks CO 2 CO 2

17 Methods Consecutive patients undergoing EVAR for AAA between August and December 2016 All procedures performed with automated CO 2 injection and controlled with traditional iodinate contrast medium (ICM) angiography

18 Hybrid Room

19 Endpoints 1. Visualization of renal and hypogastric arteries Osteo renal artery 2. Detection of endoleaks 3. Safety of CO 2 standardized Aneurysm automated injection

20 Results CO 2 Diagnostic Angiography N % 1 Patient 31 Lowest renal artery (RA) visualization Lowest RA not visualised Hypogastric artery visualization

21 * * * RA visualization * ** VS RA not visualised

22 Bi/Tri-Dimensional morphological pre-operative characteristics RA mean No RA mean p * AAA diameter (mm) 55.1 (6.4) 58.7 (10.8) 0.09 AAA Total Volume (mm 3 ) (61.9) (107.9) 0.09 AAA Lumen Volume (mm 3 ) 57.0 (10,2) 95.9 (25.2) 0.03 Distance RA- Aortic Biforcation (mm) (13,2) (14,1) 0.98 Distance RA - Right Hypogastric artery (mm) (22.3) (17,6) 0.29 Distance LRA - Left Hypogastric artery (mm) (27.9) (14.3) 0.11 Distance LRA - 10F sheet apex (mm) (22,5) (17,8) 0.53 * T-student Test

23 Results CO 2 Completion Angiography N % Patient 31 Lowest renal artery (RA) visualization Bilateral RA visualization Hypogastric artery visualization Endoleak I/III 0 - Endoleak II 10 32

24 Endoleak type II CO 2 VS ICM CO2 ICM ELII 10-32% 2-6%

25 Endoleak type II ID PATIENT CO 2 ICM CEUS Tot : Detected : Undetected

26 Endoleak type II ID PATIENT CO 2 A ICA CEUS ELII detection 17 CEUS 18 and ICM showed a poor agreement (Cohen's K:0.4) 21 CEUS and CO 2 showed a substantial agreement (Cohen's K:0.7) Tot

27 Results 3 CO2 adverse event 3 patients severe hypotension during the procedure or immediately afterwards 2 patients of them had also nausea and vomiting just before the onset of the hypotension All the symptoms solved spontaneously

28 CO2 automated system for EVAR Conclusion Safe Excellent hypogastric artery visualization Excellent type II endoleak detection Renal arteries visualization to be improved

29 CO 2 in aortic abdominal procedures Why How Limits Tips and Tricks Alma Mater Studiorum University of Bologna

30 # 1 CO 2 and Air have similar radiopacity Artefacts in the final image

31 # 1 CO 2 and Air have similar radiopacity Artefacts in the final image

32 # 2 Visualization of the Renal arteries Vessel section CO 2 FLOATS = CO 2 = blood CO 2 FILLS SUPERFICIAL VESSELS IF RENAL ARTERY IS IN A POSTERIOR POSITION FROM SAGITTAL PLANE POINT OF VIEW IT WILL BE DIFFICULT TO COMPLETELY FILL IT WITH CO 2 LATERAL TILTING OF PATIENT

33 Renal Artery Orientation Anterior Posterior

34 ? CO2

35 ?? CO2 in the anterior portion of the Aneurysm

36 Preoperative Bone Marks Evaluation Renal Arteries T12 Carrefour Hypogastric L5

37 L1

38 L1

39 L1 Avoid the first procedural Aortography

40 Few ml of Iodinated Contrast to visualize the lower renal artery

41 Fusion Imaging & Vessel Navigator CO 2 angiography

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44 Pig tail First Stent of the Endograft Open

45 Accurate Endograft Deployment at the juxta-renal Aorta

46 Summary CO 2 angiography for EVAR safe & effective Patient Selection AAA volume RA orientation Patient Preparation Diet, Carbon Pre-operative Planning Vertebral Bone Mark / Vessel Navigator/ Repositionable Endograft Standardized protocols with automated system Pressure / Volume ml