Safety and Efficacy of Hybrid Angiography in Chronic Lower Extremity Ischemia Patients at Risk of Contrast-Induced Acute Kidney Injury

Aim The aim of the study was to assess the feasibility and safety of hybrid angiography consisting of carbon dioxide (CO2) angiography supplemented by small doses of iodinated contrast medium (ICM) in the endovascular treatment of chronic limb threatening ischemia (CLTI) patients with pre-existing chronic kidney disease (CKD). Patients and Methods This prospective study comprised all non-dialysis-dependent CKD patients presenting for endovascular management of CLTI. All endovascular interventions were done using CO2 as a contrast medium whether alone or supplemented by ICM (hybrid angiography) to treat unilateral arterial steno-occlusive lesions of iliac, femoropopliteal, or BTK arteries. Study outcomes included feasibility of the device, technical success, and freedom from contrast-induced acute kidney injury (CI-AKI), renal replacement therapy, and CO2 angiography-related complications. Results A total of 206 CKD patients underwent endovascular intervention using CO2 only as a contrast medium (159 patients, 77.2%), or hybrid CO2-ICM angiography (47 patients, 22.8%). The overall technical success was 95.6%. Patients were followed up for a mean period of 17.9 +/- 4.6 months. The mean volumes of CO2, and ICM consumption were 200.7 +/- 95.1 mL, and 11.8 +/- 4.4 mL, respectively. The mean procedural, and fluoroscopy times were 95.6 +/- 12.5 and 49.5 +/- 10.8 minutes, respectively. BTK lesions were significantly associated with the need for hybrid angiography (P = <.0001). The mean pre- and postoperative serum creatinine levels were comparable (P = .08). Two patients (4.3%) showed transient manifestations of CI-AKI, but neither required renal replacement therapy. No statistically significant differences were encountered between the two study groups regarding procedure outcomes. Conclusion Hybrid CO2-ICM angiography is safe, feasible, effective, and a fairly simple alternative during endovascular interventions to treat chronic lower extremity ischemia. Using supplemental small volumes of ICM to overcome the suboptimal images generated by CO2 alone does not jeopardize the renal functions in CKD patients.