Total Iodine Contrast-Free Protocol in Complex Endovascular Aneurysm Repair

Abstract

Objectives:

Contrast-induced nephropathy is still a big issue related to using iodine contrast medium in patients with renal impairment undergoing complex endovascular aneurysm repair such as fenestrated or branched endovascular aneurysm repair (F/BEVAR). Although the use of carbon dioxide being well investigated in literature for standard EVAR, there are a few evidence about its use in F/BEVAR. The potential damage to kidneys is not only related to the procedure alone but also to the need to perform computed tomography angiography in the preoperative and postoperative period. With the aim to reduce the damage to renal function in patients with preexisting renal impairment, we report our experience of a total iodine contrast-free protocol in 6 patients with chronic kidney disease (stages from 3 to 5) who require a complex endovascular aneurysm repair due to an aneurysmatic disease of the thoracoabdominal aorta.

Materials and Methods:

Six consecutive patients with chronic kidney disease underwent F/BEVAR at our institution following a total iodine contrast-free protocol, from perioperative period to follow-up. These patients were preoperatively evaluated with duplex ultrasounds and plain-computed tomography scan to perform proper reconstruction with dedicated 3D software. All the procedures were carried on with CO₂ as contrast medium. During follow-up, every patient underwent plain-computed tomography scan at 1 month and then duplex ultrasound evaluations.

Results:

Technical success was achieved in all cases. There were no aneurysm or procedure-related complications related to the use of CO₂ in the perioperative period. At 6 months, in each case, the sac was stable and no endoleak were found. Serum creatinine and estimated glomerular filtration rate values were similar to preoperative ones both in the perioperative period and during follow-up.

Conclusions:

The total iodine contrast-free protocol showed its feasibility and safety to carry on complex endovascular procedures in patients affected by chronic kidney disease from stages 3 to 5 and concomitant aneurysmatic disease of the thoracoabdominal aorta. This protocol could also avoid further deteriorations of renal function that could lead those patients to hemodialysis. A large cohort of patient and an extended follow-up are required in the future to achieve more accurate data.

Clinical Impact

This study aims to evaluate an iodine-contrast-free protocol for patients with chronic kidney disease undergoing complex endovascular aortic repair, such as FEVAR or BEVAR. The use of this protocol may help preserve renal function and prevent further deterioration in patients at high risk for acute kidney injury or hemodialysis. Although the literature describes the role of CO₂ as a non-nephrotoxic contrast agent, there are no reported experiences involving both preoperative and postoperative evaluation without the use of iodine-based contrast media.