Review
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Feb 26, 2020; 12(2): 76-90
Published online Feb 26, 2020. doi: 10.4330/wjc.v12.i2.76
Carbon dioxide-angiography for patients with peripheral arterial disease at risk of contrast-induced nephropathy
Amol Gupta, Akinsansoye K Dosekun, Vinod Kumar
Amol Gupta, Vinod Kumar, Department of Cardiology, Heart, Vascular and Leg Center, Bakersfield, CA 93309, United States
Akinsansoye K Dosekun, Department of Nephrology, University of Texas, Houston, TX 77030, United States
Author contributions: Gupta A contributed to the conception and design of the work, literature search, data analysis for the work, and drafting the manuscript; Dosekun AK contributed to the critical revision of the manuscript; Kumar V contributed to the conception and design of the work and critically revised the manuscript.
Conflict-of-interest statement: The authors have no conflicts of interest to declare in relation to this manuscript.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Amol Gupta, MD, Research Associate, Clinical Researcher, Department of Cardiology, Heart, Vascular and Leg Center, 5020 Commerce Drive, Bakersfield, CA 93309, United States. amol@vippllc.com
Received: August 25, 2019
Peer-review started: August 25, 2019
First decision: September 28, 2019
Revised: January 3, 2020
Accepted: January 13, 2020
Article in press: January 13, 2020
Published online: February 26, 2020
Processing time: 185 Days and 11.6 Hours
Abstract

Patients with peripheral arterial disease (PAD) and critical limb ischemia are at risk for limb amputation and require urgent management to restore blood flow. Patients with PAD often have several comorbidities, including chronic kidney disease, diabetes mellitus, and hypertension. Diagnostic and interventional angiography using iodinated contrast agents provides excellent image resolution but can be associated with contrast-induced nephropathy (CIN). The use of carbon dioxide (CO2) as a contrast agent reduces the volume of iodine contrast required for angiography and reduces the incidence of CIN. However, CO2 angiography has been underutilized due to concerns regarding safety and image quality. Modern CO2 delivery systems with advanced digital subtraction angiography techniques and hybrid angiography have improved imaging accuracy and reduced the incidence of CIN. Awareness of the need for optimal imaging conditions, contraindications, and potential complications have improved the safety of CO2 angiography. This review aims to highlight current technological advances in the delivery of CO2 in vascular angiography for patients with PAD and critical limb ischemia, which result in limb preservation while preventing kidney damage.

Keywords: Endovascular procedures; Angiography; Digital subtraction; Chronic kidney disease; Peripheral artery disease; Carbon dioxide

Core tip: Patients with peripheral arterial disease and critical limb ischemia require diagnostic and interventional angiography; however, iodinated contrast agents can be associated with contrast-induced nephropathy. Carbon dioxide angiography represents a safe and effective alternative to the use of iodinated contrast medium. This updated review provides readers with a comprehensive analysis of the current technological advances in the delivery and imaging of carbon dioxide for vascular angiography and its diagnostic value, with limitations and challenges being addressed.