2D-Perfusion Angiography Using Carbon Dioxide (CO2): A Feasible Tool to Monitor Immediate Treatment Response to Endovascular Therapy of Peripheral Arterial Disease?

Cornelia L A Dewald,Bernhard C Meyer,Sabine K Maschke,Frank K Wacker,Timo C Meine,Jan B Hinrichs,Lena S Becker

doi:10.1007/s00270-020-02722-z

Cornelia L A Dewald, Bernhard C Meyer + Show 5 more

Open Access

https://doi.org/10.1007/s00270-020-02722-z

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Abstract

PurposePatients with peripheral arterial disease (PAD) or critical limb ischemia (CLI) require revascularization. Traditionally, endovascular therapy (EVT) is performed with iodinated contrast agent (ICM), which can provoke potential deterioration in renal function. CO2 is a safe negative contrast agent to guide vascular procedures, but interpretation of CO2 angiography is challenging. Changes in blood flow following iodine-aided EVT are assessable with 2D-perfusion angiography (2D-PA). The aim of this study was to evaluate 2D-PA as a tool to monitor blood flow changes during CO2-aided EVT.Material and Methods2D-PA was performed before and after ten EVTs (nine stents; one endoprosthesis; 10/2012–02/2020) in nine patients (six men; 65 ± 10y) with Fontaine stage IIb (n = 8) and IV (n = 1). A reference ROI (ROIINFLOW) was placed in the artery before the targeted obstruction and a target ROI (ROIOUTFLOW) distally. Corresponding ROIs were used pre- and post-EVT. Time to peak (TTP), peak density (PD) and area under the curve (AUC) were computed. The reference/target ROI ratios (TTPOUTFLOW/TTPINFLOW; PDOUTFLOW/PDINFLOW; AUCOUTFLOW/AUCINFLOW) were calculated.Results2D-PA was technically feasible in all cases. A significant increase of 82% in PDOUTFLOW/PDINFLOW (0.44 ± 0.4 to 0.8 ± 0.63; p = 0.002) and of 132% in AUCOUTFLOW/AUCINFLOW (0.34 ± 0.22 to 0.79 ± 0.59; p = 0.002) was seen. A trend for a decrease in TTPOUTFLOW/TTPINFLOW was observed (− 24%; 5.57 ± 3.66 s–4.25 ± 1.64 s; p = 0.6).ConclusionThe presented 2D-PA technique facilitates the assessment of arterial flow in CO2-aided EVTs and has the potential to simplify the assessment of immediate treatment response.

Highlights

Peripheral arterial disease (PAD) is a major public health problem with rising prevalence and considerable socioeconomic impact [1,2,3]
Changes in blood flow following iodine-aided endovascular therapy (EVT) are assessable with 2D-perfusion angiography (2D-PA)
The presented 2D-PA technique facilitates the assessment of arterial flow in CO2-aided EVTs and has the potential to simplify the assessment of immediate treatment response

Summary

Introduction

Peripheral arterial disease (PAD) is a major public health problem with rising prevalence and considerable socioeconomic impact [1,2,3]. Coexisting renal, diabetic, vascular and other chronic comorbidities are common in patients with PAD, which can complicate disease management [2, 7, 8]. Carbon dioxide (CO2) has long been acknowledged as a safe intravascular, negative contrast agent to guide vascular procedures in patients with chronic kidney disease (CKD), hypersensitivities to iodinated contrast agent (ICM) or hyperthyroidism [1, 4, 9,10,11]. The unsteady image quality in this infrequently used technique can limit the interpretation of contrast flow changes following EVT. This might negatively affect EVT with CO2, as the angiographic endpoint in EVT depends on the visual comparison of blood flow before and after revascularization

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