Safety of carbon dioxide digital subtraction angiography.

OBJECTIVE: Reports of fatality following carbon dioxide digital subtraction angiography (CO2-DSA) have raised concerns regarding its safety. This study reviews the safety of CO2-DSA. DESIGN: Single-institution retrospective review. SETTING: Tertiary care teaching hospital in Los Angeles, California. PATIENTS: A total of 951 patients who underwent 1007 CO2-DSA procedures during a 21-year period. MAIN OUTCOME MEASURES: Preprocedure and postprocedure creatinine values and periprocedural morbidity and mortality. RESULTS: A total of 632 arterial CO2-DSA were performed; 527 were aortograms with or without extremity runoff; 100, extremity alone; and 5, pulmonary. Venous CO2-DSA included 187 inferior vena cavagrams, 182 hepatic or visceral, 5 extremity venograms, and 1 superior vena cavagram. Associated endovascular procedures were performed in 499 cases; 162 were arterial interventions including 62 endovascular aneurysm repairs, 53 visceral or renal percutaneous angioplasty with/without stent, 41 extremity percutaneous angioplasty with or without a stent, and 4 cases of thrombolysis or embolization; 176 caval filters, 98 transjugular intrahepatic portosystemic shunts, 54 transjugular liver biopsies, and 9 other venous interventions. The mean preprocedure creatinine level was 2.1 mg/dL; postprocedure, 2.1 mg/dL (P = .56). There were a total of 61 (6.1%) procedural complications including 4 (0.4%) mortalities. Two were procedure-related complications: 1, suppurative pancreatitis following aortogram; and 2, hepatic bleed following failed transjugular intrahepatic portosystemic shunts. Two were attributable to patient disease; 1, metastatic adenocarcinoma; and 2, refractory, end-stage cardiomyopathy. CONCLUSION: Carbon dioxide digital subtraction angiography is a versatile technique that can be safely used for diagnostic and therapeutic endovascular procedures. Morbidity and mortality are acceptable with preservation of renal function. Thus, CO2-DSA is a safe alternative to iodinated contrast.

A method for serial selective arterial catheterization and digital subtraction angiography in rodents.

BACKGROUND AND PURPOSE: Imaging is a key element in the study of many rodent models of human diseases. The application of DSA has been limited in these studies in part because of a lack of a method that allows serial intra-arterial examinations to be performed during an extended period of time. It was our intent to develop and test a method for performing sequential arterial catheterizations and DSA in rats. MATERIALS AND METHODS: Using a transfemoral approach, we subjected 12 adult male Harvey rats to 3 sequential DSA examinations during a 6- to 8-week period. At each examination, 2 selective arterial catheterizations and a DSA were performed. Animals were monitored for ill effects, and images from the 3 examinations were compared for quality and the presence of any arterial injury. RESULTS: Ten of the 12 rats survived all 3 examinations. There were no adverse effects noted and no evidence of arterial injury from the examinations. CONCLUSIONS: With the technique described, it is possible to perform serial arterial catheterizations and DSA in rats. This technique will be useful as an adjunct in the use of rodents for the study of human diseases.

Perioperative imaging strategies for carotid endarterectomy. An analysis of morbidity and cost-effectiveness in symptomatic patients.

OBJECTIVE: To assess the cost-effectiveness of four diagnostic strategies for the preoperative evaluation of symptomatic patients who are potential candidates for carotid endarterectomy (ie, 70% to 99% stenosis): (1) duplex sonography (DS), (2) magnetic resonance angiography (MRA), (3) contrast angiography (CA), and (4) the combination of DS and MRA supplemented by CA for disparate results. METHODS: Cost-effectiveness analysis based largely on published clinical trial data. Sensitivities and specificities of noninvasive tests were estimated from 81 patients undergoing prospective evaluation with DS, MRA, and CA. OUTCOME MEASURE: Incremental cost per quality-adjusted year of life gained. RESULTS: For a hypothetical cohort of symptomatic patients undergoing evaluation for carotid endarterectomy, the combination of tests resulted in the greatest quality-adjusted life expectancy of the four options considered. After incorporating the costs of testing, surgery, and stroke, we found that neither the MRA nor the CA strategy was cost-effective. The combination of tests was more effective but more costly than DS, resulting in an additional cost of $22,400 per quality-adjusted year of life gained. For centers that do not have adequate MRA, CA resulted in an additional cost of $99,200 per quality-adjusted year of life saved compared with DS. CONCLUSIONS: Our results suggest that for the preoperative detection of a 70% to 99% carotid stenosis, the combination of DS and MRA, supplemented by CA for disparate results, is associated with the lowest long-term morbidity and mortality and has a favorable cost-effectiveness ratio. The combination of tests, or DS alone when MRA is not available, could potentially replace the current practice of using CA alone in the preoperative evaluation of patients with symptomatic carotid stenosis.