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Feasibility and safety of using carbon dioxide exclusively in regular endovascular aortic aneurysm repair : results of a multicentre, prospective, zero iodine contrast endovascular aneurysm repair study

Selected in ESVS Journal by Hortense Chalret du Rieu

This study evaluates the use of CO2 angiography for standardised EVAR without iodine contrast. Conducted across multiple centres, it enrolled 293 patients with asymptomatic abdominal aortic aneurysms (≥ 55 mm). The results show that the zero-iodine contrast protocol is both safe and feasible, applicable to 82 % of patients, and demonstrates high procedural success.
 

References:

Authors: Emiliano Chiscia, Emanuele Ferrerob, Michele Antonelloc, Luca Mezzettod, Raffaele Pullie, Giacomo Iserniaf, Mauro Gargiulog, Giovanni Pratesih,∙Luca Bertoglioi,∙Stefano Michelagnolia, the Zero Iodine Contrast EVAR Collaborative Study Group.

Reference: Eur J Vasc Endovasc Surg . 2024 Nov 16:S1078-5884(24)00967-5

DOI: 10.1016/j.ejvs.2024.11.011

Read the abstract

Objective:

The objective was to evaluate the feasibility and safety of a standardised EVAR procedure using only CO2 angiography.

Study:

This prospective, multicentre, national study enrolled consecutive patients between January 2023 and January 2024. 

Population:

293 patients enrolled with asymptomatic abdominal aortic aneurysms measuring ≥ 55 mm and for whom a standard endovascular graft (instructions for use) was anatomically feasible. 

Endpoint: 

Procedural technical success, clinical success at 30 days, 25 and zero iodine contrast EVAR procedure feasibility.

Outcomes and conclusion:

Feasibility and safety of using carbon dioxide exclusively in regular endovascular aortic aneurysm repair : results of a multicentre, prospective, zero iodine contrast endovascular aneurysm repair study
Clock face positions of the lowermost renal artery in the standardised zero iodine contrast EVAR group and the ICM group. Source: ESVS Journal

The standardised zero iodine contrast EVAR protocol reported here is both safe and feasible, and is applicable in 82 % of consecutive non-selected patients. 

Comments:

This multicentre, prospective study is the largest to date evaluating the feasibility and safety of endovascular aortic aneurysm repair (EVAR) using only CO2 angiography. While literature reports a median feasibility rate of 24 % (IQR 17-42), this study achieved an impressive 82 %, thanks to a standardized protocol, meticulous procedural planning, and advanced imaging techniques.

Key findings include:

  • Improved procedural efficiency – potential reduction in operative and fluoroscopy time.
  • Imaging challenges – CO2 angiography requires expertise, post-processing techniques, and standardized protocols.
  • Clinical benefits – CO2 is non-toxic, widely available, cost-effective, and avoids renal complications associated with contrast agents.
  • Low 30-day mortality (0.3 %) – comparable or superior to previous studies.
  • Minor adverse events – mild gastrointestinal symptoms in a small percentage of patients.

CO2 injection automation (e.g., Angiodroid SpA, INSPECT 3005R) improves precision and reliability, making it a viable alternative for iodine-free EVAR. Future research should explore its role in complex cases and assess emerging imaging technologies such as 3D fusion imaging, intravascular ultrasound, and fiber-optic RealShape technology.

Study limitations:

While this study represents the largest cohort to date evaluating iodine-free EVAR, some limitations should be acknowledged:

  • Selection bias – The study population may not fully represent all EVAR patients.
  • Unaccounted variables – Certain factors that could have influenced outcomes were not analyzed.
  • No direct comparison – The study did not include a control group using iodine contrast for a direct outcome comparison.

Further research is needed to validate these findings in a randomized setting and assess long-term outcomes.

 

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Hortense Chalret

Hortense Chalret du Rieu