Carbon dioxide as standard of care for zero contrast interventions: when, why and how?

BACKGROUND: Traditional contrast media containing iodine remain the gold standard for vessel visualization during endovascular procedures. On the other hand, their use has several side effects and implications and may cause contrast medium-induced nephropathy. Carbon dioxide (CO2) angiography is an old alternative technique used only for critical patients in order to prevent kidney damages or allergic reactions. Zero contrast procedure: The availability of automated CO2 injectors has led to a spread of the use of CO2 angiography, giving an option for zero contrast interventions, preserving patient renal function and saving costs for hospital facility. Taking advantage of the properties of CO2 gas, it is possible to improve the performance of some complex procedures such as atherectomy and the detection of type II endoleaks after EVARs. However, a learning curve is needed to get good imaging, and learn about the qualities and limitations of the technique. CONCLUSIONS: The use of automatic delivery systems for CO2 angiography appears to be a good choice for the use of CO2 as first imaging option. The standardization of injection protocols as well as the extensive use of this technique could lead to significant benefits both for the patient's prospects and health facilities.