CO2 Angiography in the Standard and Complex Endovascular Repair of the Abdominal Aorta—A Narrative Review of the Literature

Figure 1. Schematic representation of the CO2 buoyancy effect and its impact on arterial visualization. CO2 places itself at the upper level of the aorta; therefore, vessels originating from the posterior wall (from clock time 3 to 9), as in this example of the left renal artery, will be difficult to detect; on the other hand, vessels originating from the anterior wall of the aorta (from clock time 9 to 3) will be easily detected, as in the right renal artery shown in this example.

Figure 2. Angiodroid automated injector (Angiodroid S.p.A., San Lazzaro di Savena, Italy).

Figure 3. Flowchart of the selection process. EVAR = endovascular aortic repair; F/BEVAR = fenestrated/branched EVAR.

Figure 4. Endovascular aortic repair (EVAR) conducted with exclusive use of CO2-DSA for a penetrating aortic ulcer treatment with supra-aortic fixation endograft. (A) Pre-operative CO2-DSA performed with the use of 6F 55 cm introducer sheath (red box in details) after the navigation of the main body endograft in the aortic neck based on pre-operative bone markers and acquired with visualization of both renal arteries; (B) intraoperative CO2-DSA with good visualization of both left (upper) and right (lower) internal iliac arteries; (C) final CO2-DSA showing good result of the procedure and sealing of the treated penetrating aortic ulcer, with filling of the lumbar arteries (red arrows) without sign of type-II endoleak.

Figure 5. (A) Juxtarenal abdominal aortic aneurysm planned with a four fenestrated endovascular aortic repair (FEVAR) custom-made device for renal arteries (RAs), the superior mesenteric artery (SMA), and celiac artery (CA). (B) Details of CO2-DSA of the left RA after stent graft deployment. (C) Details of CO2-DSA of the right RA after stent graft deployment. (D) Details of CO2-DSA of the fenestrated SMA and (E) after fenestration for the CA. (F) Final CO2-DSA showing complete exclusion of the aneurysm, patency of the endograft, and the target visceral vessels.