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Feasibility and impact of carbon dioxide angiography on acute kidney injury following endovascular interventions in patients with peripheral artery disease and renal impairment

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Abstract

Background

Post-contrast acute kidney injury (AKI) is a dreaded complication of endovascular revascularization using iodinated contrast medium in patients with peripheral artery disease and concomitant chronic kidney disease (CKD). This study sought to evaluate the incidence of AKI in patients with peripheral artery disease and CKD undergoing endovascular revascularization and using carbon dioxide (CO2) as contrast medium.

Methods and Results

From 04/2015 to 07/2018, all consecutive peripheral artery disease patients with CKD stage ≥ 3 referred for endovascular revascularization of symptomatic peripheral artery disease were prospectively included. During endovascular revascularization, CO2 as contrast medium was manually injected and iodinated contrast medium was additionally used when needed. The reference group consisted of 211 cardiovascular risk factor-matched patients undergoing endovascular revascularization with iodinated contrast medium only. CO2-guided endovascular revascularization was performed in 102 patients, thereof 16 (15.7%) patients exclusively with CO2. Baseline CKD stage ≥ 4 and iodinated contrast medium volume > 50 ml were disproportionally associated with post-procedural post-contrast AKI. At CKD stage 4 the odds ratio for post-contrast AKI was 13.2 (95% CI 1.489–117.004; p = 0.02) for iodinated contrast medium volume 51-100 ml and 37.7 (95% CI 3.927–362.234; p = 0.002) for iodinated contrast medium volume > 100 ml. The corresponding values at CKD stage 5 were 23.7 (95% CI 2.666–210.583; p = 0.005) and 28.3 (95% CI 3.289–243.252; p = 0.002), respectively. Radiation (dose area product) was significantly higher in the CO2-endovascular revascularization group (6.025 ± 6.926 cGy*cm2 vs. 4.281 ± 4.722 cGy*cm2, p = 0.009).

Conclusion

CO2 is an applicable and safe alternative to iodinated contrast medium for endovascular revascularization in peripheral artery disease patients with concomitant CKD. Patients with CKD stage 4 or 5, being at highest risk for post-contrast AKI, should primarily be treated by CO2-guided endovascular revascularization.

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References

  1. Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, Norman PE, Sampson UK, Williams LJ, Mensah GA, Criqui MH (2013) Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 382:1329–1340

    Article  Google Scholar 

  2. Malyar N, Fürstenberg T, Wellmann J, Meyborg M, Lüders F, Gebauer K, Bunzemeier H, Roeder N, Reinecke H (2013) Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population-based analysis. Eur Heart J 34:2706–2714

    Article  Google Scholar 

  3. Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I, ESC Scientific Document Group (2018) 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries Endorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 39:763–816

    Article  Google Scholar 

  4. Lawall H, Huppert P, Espinola-Klein C, Rümenapf G (2016) The diagnosis and treatment of peripheral arterial vascular disease. Dtsch Arztebl Int 113:729–736

    PubMed  PubMed Central  Google Scholar 

  5. Setacci C, de Donato G, Teraa M, Moll FL, Ricco JB, Becker F, Robert-Ebadi H, Cao P, Eckstein HH, De Rango P, Diehm N, Schmidli J, Dick F, Davies AH, Lepäntalo M, Apelqvist J (2011) Chapter IV: treatment of critical limb ischaemia. Eur J Vasc Endovasc Surg 42(Suppl 2):S43–S59

    Article  Google Scholar 

  6. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, TASC II Working Group, Bell K, Caporusso J, Durand-Zaleski I, Komori K, Lammer J, Liapis C, Novo S, Razavi M, Robbs J, Schaper N, Shigematsu H, Sapoval M, White C, White J, Clement D, Creager M, Jaff M, Mohler E 3rd, Rutherford RB, Sheehan P, Sillesen H, Rosenfield K (2007) Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg 33(Suppl 1):S1–75

    Article  Google Scholar 

  7. McCullough PA, Choi JP, Feghali GA, Schussler JM, Stoler RM, Vallabahn RC, Mehta A (2016) Contrast-induced acute kidney injury. J Am Coll Cardiol 68:1465–1473

    Article  Google Scholar 

  8. Lüders F, Bunzemeier H, Engelbertz C, Malyar NM, Meyborg M, Roeder N, Berger K, Reinecke H (2016) CKD and acute and long-term outcome of patients with peripheral artery disease and critical limb ischemia. Clin J Am Soc Nephrol 11:216–222

    Article  Google Scholar 

  9. Parfrey PS, Griffiths SM, Barrett BJ, Paul MD, Genge M, Withers J, Farid N, McManamon PJ (1989) Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. A prospective controlled study. N Engl J Med 320:143–149

    Article  CAS  Google Scholar 

  10. van der Molen AJ, Reimer P, Dekkers IA, Bongartz G, Bellin MF, Bertolotto M, Clement O, Heinz-Peer G, Stacul F, Webb JAW, Thomsen HS (2018) Post-contrast acute kidney injury—part 1: definition, clinical features, incidence, role of contrast medium and risk factors: Recommendations for updated ESUR Contrast Medium Safety Committee guidelines. Eur Radiol 28:2845–2855

    Article  Google Scholar 

  11. Gurm HS, Dixon SR, Smith DE, Share D, Lalonde T, Greenbaum A, Moscucci M, BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) Registry (2011) Renal function-based contrast dosing to define safe limits of radiographic contrast media in patients undergoing percutaneous coronary interventions. J Am Coll Cardiol 58:907–914

    Article  Google Scholar 

  12. Prasad A, Ortiz-Lopez C, Khan A, Levin D, Kaye DM (2016) Acute kidney injury following peripheral angiography and endovascular therapy: a systematic review of the literature. Catheter Cardiovasc Interv 88:264–273

    Article  Google Scholar 

  13. Prasad A, Hughston H, Michalek J, Trevino A, Gupta K, Martinez JP, Hoang DT, Wu PB, Banerjee S, Masoomi R (2019) Acute kidney injury in patients undergoing endovascular therapy for critical limb ischemia. Catheter Cardiovasc Interv 94:636–641

    Article  Google Scholar 

  14. Waybill MM, Waybill PN (2001) Contrast media-induced nephrotoxicity: identification of patients at risk and algorithms for prevention. J Vasc Interv Radiol 12:3–9

    Article  CAS  Google Scholar 

  15. Lüders F, Malyar N, Meyborg M, Gebauer K, Brand E, Reinecke H (2012) Impact of peripheral arterial occlusive disease on the development of contrast medium-induced acute kidney injury. Nephron Clin Pract 122:38–43

    Article  Google Scholar 

  16. Moos JM, Ham SW, Han SM, Lew WK, Hua HT, Hood DB, Rowe VL, Weaver FA (2011) Safety of carbon dioxide digital subtraction angiography. Arch Surg 146:1428–1432

    Article  Google Scholar 

  17. Khwaja A (2012) KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract 120:c179–184

    Google Scholar 

  18. Deutsche Gesellschaft für Angiologie—Gesellschaft für Gefäßmedizin (2016) S3-Leitlinie PAVK—Diagnostik, Therapie und Nachsorge der peripheren arteriellen Verschlusskrankheit. Vasa 45(Suppl 95):1–96

    Google Scholar 

  19. Schulte KL, Amendt K, Hoffmann U, Tiefenbacher C, Weiss T, Mudra H, Hardung D, Nikol S (2012) Curriculum for interventional therapy for arterial diseases. Clinical competence for execution of catheter-based interventions on the arteries of the extremities, on the pelvic, visceral and renal arteries, on the extracranial arteries supplying the brain, and on dialysis shunts. Vasa 41:463–476

    Article  Google Scholar 

  20. Latus J, Schwenger V, Schlieper G, Reinecke H, Hoyer J, Persson PB, Remppis BA, Mahfoud F (2020) Contrast medium-induced acute kidney injury—consensus paper of the working group “Heart and Kidney” of the German Cardiac Society and the German Society of Nephrology. Kardiologe. https://doi.org/10.1007/s12181-020-00411-2

    Article  Google Scholar 

  21. Fujihara M, Kawasaki D, Shintani Y, Fukunaga M, Nakama T, Koshida R, Higashimori A, Yokoi Y (2015) CO2 Angiography Registry Investigators (2015) Endovascular therapy by CO2 angiography to prevent contrast-induced nephropathy in patients with chronic kidney disease: a prospective multicenter trial of CO2 angiography registry. Catheter Cardiovasc Interv 85:870–877

    Article  Google Scholar 

  22. Ghumman SS, Weinerman J, Khan A, Cheema MS, Garcia M, Levin D, Suri R, Prasad A (2017) Contrast induced-acute kidney injury following peripheral angiography with carbon dioxide versus iodinated contrast media: a meta-analysis and systematic review of current literature. Catheter Cardiovasc Interv 90:437–448

    Article  Google Scholar 

  23. Morsey H, Aslam M, Standfield N (2003) Patients with critical ischemia of the lower limb are at risk of developing kidney dysfunction. Am J Surg 185:360–363

    Article  Google Scholar 

  24. Arora P, Davari-Farid S, Pourafkari L, Gupta A, Dosluoglu HH, Nader ND (2015) The effect of acute kidney injury after revascularization on the development of chronic kidney disease and mortality in patients with chronic limb ischemia. J Vasc Surg 61:720–727

    Article  Google Scholar 

  25. Goldenberg I, Chonchol M, Guetta V (2009) Reversible acute kidney injury following contrast exposure and the risk of long-term mortality. Am J Nephrol 29:136–144

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Cardiology I, Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Münster, Germany

    Tim Jakobi, Matthias Meyborg, Eva Freisinger, Katrin Gebauer, Jacqueline Stella, Christiane Engelbertz, Holger Reinecke & Nasser M. Malyar

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  1. Tim Jakobi
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  2. Matthias Meyborg
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  3. Eva Freisinger
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  7. Holger Reinecke
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  8. Nasser M. Malyar
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Contributions

TJ, MM, NM designed the study; MM, HR, NM performed the revascularization procedures; TJ, NM, CE, EF performed the statistical analysis; TJ wrote the manuscript in consultation with NM; all authors contributed to the interpretation of the results, provided critical feedback and helped shape the research, analysis and manuscript.

Corresponding author

Correspondence to Nasser M. Malyar.

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Conflict of interest

TJ and MM have no conflicts of interest; EF reports grants from Bayer and Pfizer outside the submitted work; KG reports travel support from Sanofi, personal fees from Bayer and NovoNordisk, and has been on the advisory board of Amgen, all outside the submitted work; JS reports travel support from Daiichi Sankyo outside the submitted work; CE reports travel support from Bayer Vital outside the submitted work; HR reports personal fees from Bristol Myers Squibb, Daiichii Sankyo, DiaPlan, MedUpdate, NeoVasc, and Pfizer, all outside the submitted work. He acted as a consultant for NovoNordisk, Pluristem, and Pfizer. He took part in the conduction of multicentre trials of Bard, Bayer, Biotronik, Novartis, and Pluristem; NM reports personal fees from Bayer Vital, Bard, Cordis and Medtronic, all outside the frame of the submitted work.

Ethics approval

The study protocol was approved by the ethical committee of the Westfälische-Wilhelms-University of Muenster.

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Informed consent was obtained from all patients before inclusion in the study.

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Jakobi, T., Meyborg, M., Freisinger, E. et al. Feasibility and impact of carbon dioxide angiography on acute kidney injury following endovascular interventions in patients with peripheral artery disease and renal impairment. J Nephrol 34, 811–820 (2021). https://doi.org/10.1007/s40620-020-00909-8

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  • DOI: https://doi.org/10.1007/s40620-020-00909-8

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