Endovascular aortic aneurysm repair with carbon dioxide-guided angiography in patients with renal insufficiency Enrique Criado, MD, Gilbert R. Upchurch,

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Presentation transcript:

Endovascular aortic aneurysm repair with carbon dioxide-guided angiography in patients with renal insufficiency Enrique Criado, MD, Gilbert R. Upchurch, MD, Kate Young, MSRS, John E. Rectenwald, MD, Dawn M. Coleman, MD, Jonathon L. Eliason, MD, Guillermo A. Escobar, MD Journal of Vascular Surgery Volume 55, Issue 6, Pages 1570-1575 (June 2012) DOI: 10.1016/j.jvs.2011.11.142 Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 1 Under fluoroscopic guidance, the main body of the endograft delivery sheath is advanced into the aorta, and the proximal stent is placed at the estimated level of the renal arteries. From the contralateral side, the tip of a 5-F angled glide catheter is placed at the same aortic level to initiate the angiographic procedure. Note that this patient had a pre-existing left renal artery stent. Journal of Vascular Surgery 2012 55, 1570-1575DOI: (10.1016/j.jvs.2011.11.142) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 2 With digital subtraction technique in carbon dioxide (CO2) settings, using a 60-mL syringe, 40 mL of CO2 are injected by hand in approximately 2 seconds through the angled glide catheter and an aortogram is obtained. Note the clear opacification of the renal arteries, which serve for guidance in the deployment of the main body of the endograft. During this sequence, the aortic bifurcation is also visualized. Journal of Vascular Surgery 2012 55, 1570-1575DOI: (10.1016/j.jvs.2011.11.142) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 3 Following deployment of the main body of the endograft, the contralateral docking limb is retrogradely cannulated, and the left hypogastric artery is localized by obtaining a pelvic angiogram in the right anterior oblique projection, injecting 30 mL of carbon dioxide (CO2) retrogradely through the left femoral sheath. Note the angiographic detail offered by CO2 depicting a stenosis of the origin of the left hypogastric artery. Journal of Vascular Surgery 2012 55, 1570-1575DOI: (10.1016/j.jvs.2011.11.142) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 4 Following deployment of the contralateral limb of the endograft, a pelvic angiogram is obtained in the left anterior oblique projection, and a 30-mL injection of carbon dioxide (CO2) through the right femoral sheath is placed after removal of the main-body delivery system. Alternatively, CO2 may be injected through the side port of the ipsilateral limb delivery sheath, advanced into the external iliac artery, saving a sheath exchange step. Note that this pelvic angiogram is shown without subtraction, still providing excellent anatomical detail of the iliac bifurcation and the internal iliac artery branches. Journal of Vascular Surgery 2012 55, 1570-1575DOI: (10.1016/j.jvs.2011.11.142) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 5 The completion angiogram is done with the angled glide catheter in the perirenal aorta. The fluoroscopic sequence is held to allow late opacification of lumbars and inferior mesenteric artery. It is important to bear in mind that carbon dioxide (CO2) opacifies the arterial branches much faster than iodinated contrast (IC). Note that this angiogram depicts the renal arteries, the superior mesenteric artery with all its branches, and several lumbar arteries seen without opacification of the aneurysmal sac. Both hypogastric arteries are patent in the image. Journal of Vascular Surgery 2012 55, 1570-1575DOI: (10.1016/j.jvs.2011.11.142) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 6 An additional oblique projection shows all the visceral vessels, a stenosis in the left renal stent, and retrograde opacification of the inferior mesenteric artery via the left colic and superior hemorrhoidal arteries, but without passage of carbon dioxide (CO2) into the aneurysmal sac. The postoperative computerized tomography (CT) scan confirmed the absence of endoleaks in this patient. Journal of Vascular Surgery 2012 55, 1570-1575DOI: (10.1016/j.jvs.2011.11.142) Copyright © 2012 Society for Vascular Surgery Terms and Conditions