Study Results
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Basic Information
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UNKNOWN
30 participants
OBSERVATIONAL
2021-01-01
2022-09-15
Brief Summary
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Recent literature experiences describe the use of automated CO2 angiography in EVAR.
One of the main issues of CO2 angiography is the inability to detect the origin of the lowest renal artery (proximal neck visualization) that was estimated up to 38%.
In these experiences, the CO2 automated angiography is usually performed by a 5F pigtail catheter placed at renal arteries level.
The aim of the study is to evaluate the efficacy of a new automated CO2 injection technique by a 5F introducer (single hole catheter) positioned at the distal level of the proximal neck in detecting both renal arteries in the first diagnostic and completion angiographies.
Detailed Description
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In the past few years, several studies pointed out the importance of reducing the amount of iodinated contrast medium injected and proposed carbon dioxide (CO2) as an alternative to partially or completely replace ICM, especially in patients with preoperative chronic renal impairment.
According with the literature, manual or automatic CO2 injection provides a good quality imaging of both proximal and distal sealing zone in standard EVAR procedures and, combined with fusion imaging, allows to perform juxta and pararenal abdominal aortic aneurysm repair with fenestrated endograft reducing the total amount of ICM required to the procedure.
The most relevant limit to the use of CO2 is the inability to identify the proximal landing zone and the lowest renal artery that occurs in a significant number of cases (38.7%).
This limit could be related to the physical property of CO2 because, differently from ICM, it is a gas that does not completely fill the aortic lumen but it floats in the anterior portion of the aneurysmatic sac and does not allow the detection of renal arteries with a posterior origin.
The automated CO2 injection is commonly performed using a pigtail catheter (5F/65mm length) placed at the renal arteries level.
The primary end point of the study is to identify an alternative and effective method of CO2 injection, using an automatic system through the digital Angiodroid injection system (Angiodroid Srl, San Lazzaro, Bologna) connected to a 5F introducer placed at the distal portion of infra-renal neck that allows the identification of the lowest renal artery.
This is a prospective, single center, observational, case-control study, in which each patient is the control of himself because during the procedure 2 angiographic CO2 techniques (angiography by pig tail vs 5 F introducer) are performed and compared.
All patients underwent a preoperative computed tomography angiography (CTA) within 3 months before the procedure. The images are analyzed using a dedicated software for vessel analysis (3Mensio TM, Vascular Imaging Bilthover, Netherlands) and the AAA volume is calculated using the same software by selecting points of the external aortic wall and internal aortic lumen from the lower renal artery to the aortic bifurcation.
The level of renal arteries and aortic bifurcation are evaluated on preoperative CTA reconstructions and matched with vertebral bone landmarks.
At the beginning of the procedure two CO2 DSA will be performed: the first one through the pigtail placed at the level of renal arteries and the second one through a 5F introducer placed at the end of the proximal sealing zone in order to identify the lowest renal artery and compare the quality of the images obtained.
The same way, at the end of the procedure after the endograft deployment, two CO2 DSA will be performed: the first one through the pigtail catheter placed at the level of renal arteries and the second one through the 5F introducer placed at the level of the contralateral iliac limb.
The investigators prospectively collect clinical and morphological preoperative, intraoperative and postoperative data as shown in the table above.
Clinical characteristics: age years, sex, hypertension (systolic blood pressure ≥140 or/and diastolic ≥90 mmHg, or specific therapy), dyslipidemia (total cholesterol ≥200 mg/dl or low density lipoprotein ≥120 mg/dl or specific therapy), diabetes mellitus (pre-diagnosed in therapy with oral hypoglycemic drugs or with insulin), current smoking, coronary artery disease (defined as a history of angina pectoris, myocardial infarction or coronary revascularization), chronic obstructive pulmonary disease (defined as chronic bronchitis or emphysema), chronic kidney disease (glomerular filtration rate \<60 ml/min), dialysis, pre and post-operative creatinine serum, ASA (American Society Anesthesiologic classification), medical therapy (antiplatelet types, anticoagulant therapy, statin therapy, anti-hypertensive medical therapy).
Morphological characteristics: aneurysm diameter, aneurysm volume, aneurysm neck features according to Chaickof classification, iliac axes features according to Chaickof classification, renal arteries number and clock position, hypogastric arteries patency, aortic carrefour diameter.
Intraoperative data: anesthesia (general or spinal), vascular access (surgical or percutaneous), endograft features (bi- or tri-modular, suprarenal fixation, proximal diameter of the endograft, left and right iliac limb diameter, embolization of the aneurysmatic sac, coils number, hypogastric embolization or coverage, other adjunctive maneuvers as iliac axes stenting), type and amount of contrast medium, fluoroscopy time, dose area product (DAP) (fluoroscopy DAP, DSA DAP and total DAP), renal arteries detection at the beginning of the procedure with CO2 DSA from 5F pigtail and 5F introducer, renal and hypogastric arteries and endoleaks detection at the end of the procedure with CO2 DSA from 5F pigtail and 5F introducer (as explained before).
Post-operative data: complications related to CO2 injection rate (nausea, vomit, abdominal pain, hypotension), endoleaks at the discharge, perioperative mortality, 30-days mortality, 30-days medical or surgical complications, 30-days reintervention rate, 30-days renal function.
Conditions
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Keywords
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Study Design
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CASE_CONTROL
PROSPECTIVE
Study Groups
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Population
The group includes all patients undergoing EVAR, each patient is considered as both case and control of himself as the two CO2 injection techniques, through the 5F pigtail and through the 5F introducer, are both used during the procedure.
Technique 1
It refers to CO2 digital subtraction angiographies performed at the beginning of the procedure through a 5F pigtail catheter placed at the level of renal arteries to identify the lowest renal artery.
Technique 2
It refers to CO2 digital subtraction angiographies performed at the beginning of the procedure through a 5F introducer placed at the end of the proximal sealing zone to identify the lowest renal artery.
Technique 3
It refers to CO2 digital subtraction angiographies performed at the end of the procedure through a 5F pigtail catheter through the pigtail catheter placed at the level of renal arteries.
Technique 4
It refers to CO2 digital subtraction angiographies performed at the end of the procedure through a 5F introducer placed at the level of the contralateral iliac limb.
Interventions
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Technique 1
It refers to CO2 digital subtraction angiographies performed at the beginning of the procedure through a 5F pigtail catheter placed at the level of renal arteries to identify the lowest renal artery.
Technique 2
It refers to CO2 digital subtraction angiographies performed at the beginning of the procedure through a 5F introducer placed at the end of the proximal sealing zone to identify the lowest renal artery.
Technique 3
It refers to CO2 digital subtraction angiographies performed at the end of the procedure through a 5F pigtail catheter through the pigtail catheter placed at the level of renal arteries.
Technique 4
It refers to CO2 digital subtraction angiographies performed at the end of the procedure through a 5F introducer placed at the level of the contralateral iliac limb.
Eligibility Criteria
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Inclusion Criteria
Exclusion Criteria
* Patients requiring advanced aortic repair (FEVAR, BEVAR)
* Urgent cases
18 Years
100 Years
ALL
No
Sponsors
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University of Bologna
OTHER
Responsible Party
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Enrico Gallitto
Principal Investigator
Principal Investigators
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Enrico Gallitto, MD, PhD
Role: PRINCIPAL_INVESTIGATOR
University of Bologna
Locations
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University of Bologna
Bologna, Emilia-Romagna, Italy
Countries
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Central Contacts
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Facility Contacts
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Enrico Gallitto, MD, PhD
Role: primary
References
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Mascoli C, Faggioli G, Gallitto E, Vento V, Pini R, Vacirca A, Indelicato G, Gargiulo M, Stella A. Standardization of a Carbon Dioxide Automated System for Endovascular Aortic Aneurysm Repair. Ann Vasc Surg. 2018 Aug;51:160-169. doi: 10.1016/j.avsg.2018.01.099. Epub 2018 Mar 6.
Gallitto E, Faggioli G, Vacirca A, Pini R, Mascoli C, Fenelli C, Logiacco A, Abualhin M, Gargiulo M. The benefit of combined carbon dioxide automated angiography and fusion imaging in preserving perioperative renal function in fenestrated endografting. J Vasc Surg. 2020 Dec;72(6):1906-1916. doi: 10.1016/j.jvs.2020.02.051. Epub 2020 Apr 8.
Mascoli C, Faggioli G, Gallitto E, Vento V, Indelicato G, Pini R, Vacirca A, Stella A, Gargiulo M. The Assessment of Carbon Dioxide Automated Angiography in Type II Endoleaks Detection: Comparison with Contrast-Enhanced Ultrasound. Contrast Media Mol Imaging. 2018 Mar 26;2018:7647165. doi: 10.1155/2018/7647165. eCollection 2018.
Vacirca A, Faggioli G, Mascoli C, Gallitto E, Pini R, Spath P, Logiacco A, Palermo S, Gargiulo M. CO2 Automated Angiography in Endovascular Aortic Repair Preserves Renal Function to a Greater Extent Compared with Iodinated Contrast Medium. Analysis of Technical and Anatomical Details. Ann Vasc Surg. 2022 Apr;81:79-88. doi: 10.1016/j.avsg.2021.10.039. Epub 2021 Nov 14.
Other Identifiers
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CO2 IT
Identifier Type: -
Identifier Source: org_study_id