CARBON DIOXIDE Angiography and Intervention - Slides

7/31/2019 CARBON DIOXIDE Angiography and Intervention - Slides

1/74

1

CARBON DIOXIDEANGIOGRAPHY

ANDINTERVENTION

CARBON DIOXIDEANGIOGRAPHY

ANDINTERVENTION

Jim Caridi MDUniversity of Florida

Gainesville, FL


2/74

2

WHYCO2 ?


3/74

3

CO2 ADVANTAGES

1. Non-allergic 4. Low viscosity

2. Non - nephrotoxic 5. Inexpensive

3. Unlimited total 6. Minimal or no

volumes discomfort


4/74

4

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


5/74

5

PERFORMING CO2


6/74

6

Invisible

Buoyant Compressible

TO PERFORM CO2 ONEMUST

UNDERSTAND ITS UNIQUEPROPERTIES


7/74

7

INVISIBLE? CONTAMINATION

1. CO2 cylinderRust, methane, H2O, particulate matter,

carbonic acid

2. Room air

diffusivity

malpositioned stopcock

inadequate flushing


8/74

8

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


9/74

9

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


10/74

10


11/74

11

R

L

R

L


12/74

12


13/74

13


14/74

14


15/74


16/74

16


17/74

17


18/74

18

CO2

- BUOYANCY

+

ANATOMY OR EXCESSIVE VOLUME

POTENTIAL TRAPPING

VAPOR LOCK

ISCHEMIA


19/74

19

PREVENT TRAPPING

Prevent excessive volumes

Monitor with fluoroscopy

Wait between injections

Aspirate if necessary

** CHANGE THE PATIENTS POSITION**


20/74

20

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


21/74

21

STACKING SOFTWARE


22/74

22


23/74

23

EXPLOSIVE DELIVERY

Pain, N&V

Reflux - potential trapping, neurotoxicity

Vessel damage

INDETERMINATE VOLUMES

Can lead to accidental excessive volumes

COMPRESSIBLECOMPRESSIBLE


24/74

24

PREVENT EXPLOSIVE

DELIVERY

Use a non-compressed

closed system

Purge catheter before

definitive injection


25/74

25

NEUROTOXICITY

NITROUS OXIDE

ANESTHESIA

COPD

OTHER POTENTIAL CONCERNS


26/74

26

Iodinated contrast allergy

INDICATIONS

Renal insufficiency

Arterial bleeding

High volume contrast procedures

Intervention


27/74

27

CONTRAINDICATIONS

Supra-diaphragmatic arterial injections (intracranialCO2)

Use with nitrous oxide anesthesia

Known right to left shunts


28/74

28

DELIVERYDELIVERY


29/74

29

Non-compressed reservoir

Delivery syringe


30/74

30


31/74

31

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


32/74

32

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


33/74

33

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


34/74

34


35/74

35

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


36/74

36

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


37/74

37

INTERVENTION


38/74

38

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


39/74

39CONTRAST CO2


40/74

40


41/74

41


42/74

42


43/74

43


44/74

44


45/74

45


46/74

46


47/74

47

VENOUS DX & TREATMENT


48/74

48

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


49/74

49


50/74

50


51/74

51


52/74

52


53/74

53


54/74

54


55/74

55


56/74

56


57/74

57


58/74

58

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


59/74

59


60/74

60


61/74

61


62/74

62


63/74

63


64/74

64


65/74

65


66/74

66

CO GUIDED TIPS


67/74

67

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


68/74

68


69/74

69


70/74

70


71/74

71


72/74

72

CONCLUSION


73/74

73


74/74

74

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

CARBON DIOXIDE Angiography and Intervention - Slides

Documents

Transcript of CARBON DIOXIDE Angiography and Intervention - Slides