carbon dioxide angiography and intervention - slides
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CARBON DIOXIDEANGIOGRAPHY
ANDINTERVENTION
CARBON DIOXIDEANGIOGRAPHY
ANDINTERVENTION
Jim Caridi MDUniversity of Florida
Gainesville, FL
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WHYCO2 ?
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CO2 ADVANTAGES
1. Non-allergic 4. Low viscosity
2. Non - nephrotoxic 5. Inexpensive
3. Unlimited total 6. Minimal or no
volumes discomfort
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CO2 DISADVANTAGES
1. Requires unique delivery system
2. Invisible potential for undetected contamination
3. Currently not suggested in cerebral vessels
4. Bowel gas can interfere with abdominal images
5. Can be more labor intensive
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PERFORMING CO2
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Invisible
Buoyant Compressible
TO PERFORM CO2 ONEMUST
UNDERSTAND ITS UNIQUEPROPERTIES
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INVISIBLE? CONTAMINATION
1. CO2 cylinderRust, methane, H2O, particulate matter,
carbonic acid
2. Room air
diffusivity
malpositioned stopcock
inadequate flushing
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PREVENT CONTAMINATION
1. Use a disposable source of
medical grade CO2
2. Use a closed non-compressed
delivery system
3. Eliminate stopcocks
4. Glue connections
5. Flush system 2-3 times
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BUOYANT
CO2 doesnt mix with blood - it displaces it
CO2 rises to a non dependent position
Anterior images easily visualized
Posterior imaging depends upon displacement
of blood
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R
L
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CO2
- BUOYANCY
+
ANATOMY OR EXCESSIVE VOLUME
POTENTIAL TRAPPING
VAPOR LOCK
ISCHEMIA
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PREVENT TRAPPING
Prevent excessive volumes
Monitor with fluoroscopy
Wait between injections
Aspirate if necessary
** CHANGE THE PATIENTS POSITION**
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Excessive Volume = 1 large or multiple small injections
without delay
NEVER connect directly to a CO2 cylinder
Deliver known volumes - closed non-compressed system
Wait 1-2 min. between injections
Limit volumes to < 100 ccs / injection
Use stacking software program
PREVENT EXCESSIVE VOLUMES
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STACKING SOFTWARE
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EXPLOSIVE DELIVERY
Pain, N&V
Reflux - potential trapping, neurotoxicity
Vessel damage
INDETERMINATE VOLUMES
Can lead to accidental excessive volumes
COMPRESSIBLECOMPRESSIBLE
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PREVENT EXPLOSIVE
DELIVERY
Use a non-compressed
closed system
Purge catheter before
definitive injection
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NEUROTOXICITY
NITROUS OXIDE
ANESTHESIA
COPD
OTHER POTENTIAL CONCERNS
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Iodinated contrast allergy
INDICATIONS
Renal insufficiency
Arterial bleeding
High volume contrast procedures
Intervention
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CONTRAINDICATIONS
Supra-diaphragmatic arterial injections (intracranialCO2)
Use with nitrous oxide anesthesia
Known right to left shunts
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DELIVERYDELIVERY
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Non-compressed reservoir
Delivery syringe
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Non-compressed closed system
Non-compressed - for accurate volume
Hand injection - purge catheter to prevent explosive
delivery
One way valves - prevent reflux and necessity to
remove delivery syringe
Glued components - helps prevent air embolus
(Venturi effect)
DELIVERY
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IMAGING TECHNIQUES
1. Dose - in general 1.5 - 2 times I contrast
2. Radiopaque Catheter -
3. Selective injections / Nitroglycerine for poor flow
4. Image at 3-4 frames/sec using a 60 ms pulse width
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5. Monitor with fluoroscopy
6. Wait 1-2 minutes between injections
7. If the CO2 bolus is broken up use stacking software
8. Elevate the area of interest
IMAGING TECHNIQUES
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Low viscosity
Easier use of smaller catheters, microcatheters Can inject in-between catheter and wire
Detection of bleeding, AVF, collaterals
Portal vein visualization
Unlimited volume
Reflux
Ability to identify ostium or origin of vessel
INTERVENTION PRINCIPLES
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Tuohy Borst Fitting
Forcefully inject CO2
Use a large syringe
small syringe - CO2 will simply compress
wait 4-10 sec for CO2 to exit catheter
INTERVENTION
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INTERVENTION
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DETECTION OF BLEEDING
1. CO2 - low viscosity
2. Little or no capillary phase to obscure CO2
3. CO2 expands
4. CO2 is not diluted by blood
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VENOUS DX & TREATMENT
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VENOUS DX & TREATMENT
Slow steady injection of 15-30 cc (fluoroscope heart for
washout
CO2 is not diluted by blood and can opacify central
veins more readily from a peripheral approach
Venous PTA and stent placement
IVC filter placement
Translumbar/hepatic vein catheter placement
Ultra fine needle splenoportography
PICC placement
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ARTERIAL INTERVENTION Reflux - can opacify the entire vessel including ostium
for more precise stent placement
Can inject between guide cath and catheter or wire
and catheter to check placement withoutcompromising position for PTA and stenting
Can perform repeated injections without the fear ofrenal failure
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CO GUIDED TIPS
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CO2
GUIDED TIPS
Hepatic vein evaluation
Wedged hepatic venogramIntraparenchymal portal venogram
Entry site verificationPortal venogram
Parenchymal tract evaluation
Balloon and stent positioning
Post procedure portogram
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CONCLUSION
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CONCLUSION
CO2 angiography is safe when used appropriately
CO2 has unique properties as a contrast agent
It can be used alone or in addition to other contrast
agents
It is useful in both diagnosis and treatment