A Pilot Study of Endovascular Repair for Ruptured Aortic Aneurysms With the Use of Carbon Dioxide Angiography Alone

Introduction: Endovascular aortic repair (EVAR) of a ruptured abdominal aortic aneurysm (rAAA) has become a common approach. Hemorrhagic shock associated with the use of iodinated contrast medium (ICM) increases the risk of acute kidney injury (AKI). Theoretically, eliminating ICM from EVAR can decrease that risk. The aim of this pilot study was to analyze the feasibility and safety of emergent EVAR performed with the exclusive use of carbon dioxide (CO 2 ) for a rAAA. Methods: Since 2021, all consecutive rAAAs with hemorrhagic shock and suitable anatomical criteria for a standard endograft have been treated by EVAR with the exclusive use of CO 2 using an automated CO 2 injector (Angiodroid SpA, San Lazzaro di Savena, Italy). Results: Eight percutaneous EVARs were performed under local anesthesia. Median age was 78 (interquartile range [IQR]=6) years, 5 patients were male. The technical success was 100%, the 30-day mortality was 25% (n=2), the median amount of administered CO 2 was 400 (IQR=60) ml. The median change in serum creatinine level between admission, post-operative and 30-day values was an increase of 0.14 mg/dL and a decrease of 0.11 mg/dL, respectively. Post-operative AKI occurred in the two patients who died. All 6 surviving patients showed sac shrinkage >5 mm, and no reinterventions at a median follow-up of 10 months. Conclusions: Endovascular repair of rAAA with the exclusive use of CO 2 as contrast agent is technically feasible and safe. Further studies are needed to determine whether CO 2 increases survival rate and limits the progression of renal dysfunction after endovascular repair of rAAA. Clinical Impact The recorded rate of post-operative AKI after endovascular repair of rAAA performed with the use of CO 2 found in this pilot study was significantly lower than the one reported in the literature with the use of ICM. Our hyphotesis is that the use of CO 2 during rEVAR might increase survival rate and limits the progression of renal dysfunction.