Purpose: To present a new combination of imaging techniques that helps reduce the use of iodinated contrast during endovascular aneurysm repair (EVAR) procedures in patients with renal insufficiency. Technique: Relevant anatomical structures are marked in the preprocedure computed tomography (CT) angiogram. A 3D-3D image fusion between the preprocedure CT and an intraprocedure cone-beam CT is performed in order to overlay anatomical information on live fluoroscopy. Verification of the correct overlay matching (or adjustment if necessary) is based on carbon dioxide (CO2) digital subtraction angiograms (DSA) instead of iodine DSA. The stent-graft is placed and deployed based on the overlaid information. Correct device placement is finally verified with conventional contrast angiography. Conclusion: The combination of 3D image fusion of a preoperative CT with live fluoroscopy and CO2 DSA verification is feasible and sufficient for guidance of abdominal EVAR. This method minimizes the use of iodinated contrast media, protecting residual function in the setting of preexisting renal insufficiency.
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