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Catheter-less angiography for endovascular aortic aneurysm repair: A new application of carbon dioxide as a contrast agent  Enrique Criado, MD, Loay Kabbani,

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Presentation on theme: "Catheter-less angiography for endovascular aortic aneurysm repair: A new application of carbon dioxide as a contrast agent  Enrique Criado, MD, Loay Kabbani,"— Presentation transcript:

1 Catheter-less angiography for endovascular aortic aneurysm repair: A new application of carbon dioxide as a contrast agent  Enrique Criado, MD, Loay Kabbani, MD, Kyung Cho, MD  Journal of Vascular Surgery  Volume 48, Issue 3, Pages (September 2008) DOI: /j.jvs Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

2 Fig 1 The carbon dioxide (CO2) delivery system. The system includes a 1500 cc plastic bag (pb) with a one-way stopcock and gas fitting (Angioflush 111 fluid collection bag, AngioDynamics, Inc., Queensbury, NY), three one-way check valves and an O-ring gas fitting (arrowhead), which connects the bag and the delivery system (AngioFlush 111 fluid management system, AngioDynamics, Inc), and a luer-lock syringe connected to the delivery port with a check-valve (white arrow). The delivery system is connected to the connecting tube (black arrow) of the CAPTOR hemostatic valve (hv) of the main body delivery system of Zenith Flex AAA Endovascular Graft (Cook Inc., Bloomington, Ind). Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

3 Fig 2 Deploying the first two covered stents of the main body. A, After advancing the main body delivery system just proximal to the left renal artery, digital subtraction angiographic (DSA) is obtained with the injection of 30-cc of carbon dioxide (CO2) through the connecting tube of the hemostatic valve (the patient's left side was elevated to 8°). There is excellent filling of the celiac (CA) and superior mesenteric (SMA) arteries and left renal artery (arrow). The level of the left renal artery is marked on the fluoroscopy monitor by a marker pencil. Right renal artery is absent from a nephrectomy. B, Using the landmark, the system is retracted until the four gold radiopaque markers of the proximal graft material is at least 2 mm from the renal artery. The first two covered stents are deployed by withdrawing the sheath, and repeat CO2 digital subtraction angiographic (DSA) demonstrates the position of the gold markers (longer arrow) inferior to the left renal artery (shorter arrow). Then deployment is proceeded until the contralateral limb is fully deployed. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

4 Fig 3 Deploying the iliac leg graft. After cannulation of the contralateral limb, the suprarenal stent is deployed and the contralateral guidewire is advanced into the thoracic aorta. The contralateral iliac leg that was prepped with saline solution and primed with carbon dioxide (CO2), is introduced into the external iliac artery. A, Digital subtraction angiographic (DSA) is performed in the right anterior oblique projection with the injection of 20-cc of CO2 through the connecting tube of the hemostatic valve. There is excellent filling of the common iliac (CI) and external iliac (EI) arteries, and the origin of the hypogastric artery (arrow). The level of the hypogastric artery is identified on the fluoroscopy monitor by a marker pencil. B, After deploying the iliac leg graft, repeat CO2 DSA confirmed the position of the graft (arrow) above the origin of the hypogastric artery. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

5 Fig 4 Deploying the ipsilateral iliac leg. After deploying the ipsilateral limb of the main body, the ipsilateral iliac leg graft that has been prepped with normal saline and primed with carbon dioxide (CO2), is introduced into the external iliac artery. A, Digital subtraction angiographic (DSA) is performed in the left anterior oblique projection with the injection of 20-cc of CO2 through the connecting tube of the hemostatic valve. There is excellent filling of the common and external iliac arteries and the origin of the hypogastric artery (arrow). B, After deployment of the iliac graft, repeat CO2 DSA confirmed the position of the iliac limb (arrow) seen above the hypogastric artery. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

6 Fig 5 Completion CO2 digital subtraction angiographic (DSA). After expansion of the molding balloon with dilute contrast along the aortic graft, a 5F cobra catheter is advanced from the left femoral sheath to the proximal end of the graft. A, DSA with the injection of 30-cc of CO2 confirmed the position of the main graft and patency of the renal artery (arrow). There is no endoleak from the proximal fixation site. B, After placing the catheter within the main body, repeat CO2 DSA is obtained. The graft and both iliac limbs are visualized. The middle colic artery of the superior mesenteric artery provides the primary collateral pathway to the excluded inferior mesenteric artery (arrow). There are no endoleaks or kinks. The renal and bilateral hypogastric arteries are filled by this injection. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

7 Fig 6 Sac perfusion after endograft placement. Intraprocedural digital subtraction angiography was performed in the left anterior oblique projection with the injection of 30-cc of carbon dioxide (CO2) into the main body. The main body and left iliac limb are filled with CO2. The aneurysm sac (arrow) is filled partially through left internal iliac-inferior mesenteric collateral channels. A CT scan one month after endograft placement showed no endoleak. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

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