Cardiovasc Interv and Ther DOI 10.1007/s12928-013-0218-4
CASE REPORT
Total bowel ischemia after carbon dioxide angiography in a patient with inferior mesenteric artery occlusion Atsushi Mizuno • Yutaro Nishi • Koichiro Niwa
Received: 20 August 2013 / Accepted: 8 October 2013 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2013
Abstract A 70-year-old man with a history of hypertension and chronic renal failure experienced claudication in his left leg. He was treated by endovascular stenting in his left leg. We used CO2 angiography to prevent contrastinduced nephropathy. After the procedure, livedo vasculitis and lactic acidosis developed. We diagnosed the patient with CO2-induced ischemic colitis, after which we changed his position and administered conservative therapy. Contrast-enhanced computed tomography showed total bowel ischemia and total occlusion at the ostium of the inferior mesenteric artery. This rare complication after CO2 angiography might be related to the atherosclerotic occlusion of the inferior mesenteric artery. Keywords CO2 Bowel ischemia Common trunk Mesenteric artery
Introduction A 70-year-old man with a history of hypertension and chronic renal failure experienced claudication in his left leg 2 months prior to admission. His ankle brachial pressure index was lower on the left side than on the right side (0.70 versus 1.03). Ultrasound revealed narrowing of the common iliac artery and distal superficial femoral artery. We scheduled endovascular therapy. His serum creatinine level was 1.45 mg/dL (estimated Glomerular filtration rate, 38.5 mL min-1 9 1.73 m-2). We performed CO2
A. Mizuno (&) Y. Nishi K. Niwa Department of Cardiology, Cardiovascular Center, St. Luke’s International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, Japan e-mail: [email protected]
angiography-guided endovascular therapy via the right femoral artery. We put a 6-French long sheath (SheathLess PVÒ, Asahi Intecc; Nagoya, Japan) from the right femoral artery and crossed a 0.014-inch wire (Cruise; Asahi Intecc, Tokyo, Japan). After performing intravascular ultrasound, the superficial femoral artery lesion was treated with a nitinol self-expanding stent (Zilver, 6.0 9 40 mm; Cook, USA) and a self-expanding stent (E-Luminexx, 8.0 9 120 mm; Bard, Murray Hill, NJ, USA) was deployed in the left common iliac artery (Fig. 1a–d). Approximately 500 mL of CO2 was used to visualize the left leg via the left common iliac artery during the procedure, which lasted approximately 90 min. Injection of CO2 for diagnosis and intervention included 50 mL injections for iliac lesions and 20 mL injections by a hand syringe for the superior femoral artery. No iodinated contrast media was used. During the procedure, the patient experienced abdominal distension, but no pain. After the procedure, we noted that the lower part of the body (especially the front side) and the lower legs developed a reddish coloration (Fig. 2a, b). The patient did not experience any pain; therefore, he was kept under observation in the general cardiac ward. Mild abdominal discomfort persisted, and diarrhea occurred early the next morning. Several hours later, he developed hematochezia. His abdomen was soft, with slight rebound tenderness. We performed contrast-enhanced computed tomography emergently, which showed total bowel ischemia and no significant infarction (Fig. 2d, e). The intestines were not supplied by the inferior branch of the mesenteric artery (Fig. 3a–c). We diagnosed the patient with total bowel ischemic colitis resulting from the CO2-induced vapor lock phenomenon. He was transferred to the intensive care unit and his body position was changed to allow
123
A. Mizuno et al. Fig. 1 a CO2 angiography showing stenosis in the left iliac artery; b Balloon dilatation after deploying a self-expanding stent; c CO2 angiography showing focal stenosis in the superficial femoral artery; d CO2 angiography shows no residual stenosis in the superficial femoral artery after stenting
removal of CO2 from the mesenteric artery. The red coloration of his abdomen faded slightly the next day (Fig. 2c). His serum creatinine and blood creatine kinase enzyme levels peaked after 24 h (3.89 mg/dL and 1572 IU/L, respectively). Complete blood count showed an elevated white blood cell count of 19.4 9 103/lL with no eosinophils. His lactic acid level increased to 4.2 mmol/L and peaked within 24 h. Abdominal rebound tenderness resolved completely, but mild abdominal discomfort persisted for an additional 5 days. An abdominal ultrasound and computed tomography showed recovery from the edematous change of his bowel in 2 weeks. We discharged him in 21 days.
Discussion This is a rare case of CO2 angiography-induced total bowel ischemia. There were several reports on this syndrome, but in this patient, longer hospitalization was needed because of total bowel ischemia.
123
CO2 angiography The first use of an intravascular CO2 injection for diagnostic purposes via the peripheral vein was reported in the 1950s [1]. As a result of the pioneering efforts of Irwin Hawkins, intra-arterial CO2 gas first gained widespread acceptance as an alternative negative contrast agent during his procedure in the 1980s [2, 3]. A recent contemporary review of all diagnostic procedures (angiography, computed tomographic scans, etc.) that use iodinated contrast reported a respective complication and mortality rate of 25 and 7.8 % in patients who develop contrast-induced nephropathy [4]. A contrast agent is not preferably used, especially in patients with chronic kidney disease; CO2 angiography is an optional procedure used to avoid contrast-induced nephropathy. Previous reports show the safety of CO2 digital subtraction angiography in a guidedprocedure in approximately 500 patients with chronic kidney disease, with a few complications [5]. The boluses should be generally limited to 60 mL, with a 2-min interval between injections. If an excess amount of CO2 is injected
Total bowel ischemia caused by CO2 angiography
Fig. 2 a, b Diffuse mottling of his abdomen and lower legs, which is compatible with livedo reticularis; c Mottling of his abdomen almost disappeared the next day; d, e Contrast-enhanced computed
tomography (d sagittal and e axial) shows total bowel ischemia with pronounced bowel wall thickening
Fig. 3 a–c Three-dimensional reconstruction of the abdominal artery by contrast-enhanced computed tomography (a anterior view, b left side view, and c right side view). No inferior mesenteric artery is seen
branching from the abdominal aorta. Instead, co-lateral arteries supplying the area usually supplied by the inferior mesenteric artery are seen from the superior mesenteric artery (blue vessel)
or the time between each injection is inadequate, the CO2 will not be clear, resulting in ischemia. Because CO2 is less dense than blood, it could be trapped in nondependent structures as observed in our case. In our case, we administered several CO2 injections to visualize all the
arteries in the leg (superficial femoral artery, popliteal artery, and below-knee arteries) and ad hoc endovascular therapy. Patient movement during CO2 angiography impedes image quality and necessitates repeat angiography. Nevertheless, a total of 500 mL of CO2 is too large for
123
A. Mizuno et al.
peripheral intervention alone, and might be one of the causes of this complication. The total amount of CO2 injection should be carefully considered.
confirmed inferior mesenteric artery occlusion before the procedure by performing magnetic resonance angiography or Doppler ultrasound.
Bowel ischemia Conclusion Bowel ischemia is a rare complication, but there are a few reports on this syndrome after CO2 angiography. One case resulted in death and in the other case, kidney function worsened, similar to that observed in contrast-induced nephropathy [6–8]. According to previous reports, with the patient in the supine position, the anterior position of the celiac, superior mesenteric, and inferior mesenteric arteries leads to preferential filling of these vessels with CO2 during injection of CO2 into the abdominal aorta. In addition, during selective injection of the iliac vessels, reflux of CO2 may lead to filling of the superior mesenteric artery [7, 9]. In our case, we injected CO2 gas from the left common iliac artery; therefore, its reflux might have caused filling of the mesenteric arteries. Reflux to the mesenteric arteries must be carefully examined in every angiogram. When a large interface is present between the blood and CO2, the accumulated CO2 normally dissolves very quickly and is eliminated by the lungs. However, accumulated CO2 could be trapped in nondependent (against gravity) vessels such as the mesenteric arteries, causing a ‘‘vapor lock’’ phenomenon in the vessel. In addition, the pressure of the gas may prevent collateral flow from entering the affected vascular distribution, thereby compromising tissue perfusion. In previous reports, no effective therapy besides changing body position was known. We changed the patient’s position to allow rapid redistribution of the trapped gas. One previous report showed that only a 3-day hospitalization period was needed after bowel ischemia, but the patient in our case needed 3 weeks. We believe that this prolonged period was because of total bowel ischemia that was not limited to the superior mesenteric artery. Atherosclerotic occlusion of the inferior mesenteric artery In this patient, no inferior mesenteric artery was noted, and the distal colon was supplied by the superior mesenteric artery. Occlusion of the inferior mesenteric artery is not rare, and mesenteric ischemia can develop even in asymptomatic patients with mesenteric artery stenosis or occlusion [10, 11]. We thought that this anomaly might have been the cause of the bowel ischemia. This anatomical variation affects not only the superior mesenteric artery but also the inferior mesenteric artery, which resulted in total bowel ischemia. Furthermore, we might have
123
To our knowledge, this is the first report on total bowel ischemia caused by CO2 angiography, especially in patients with inferior mesenteric artery occlusion. We should consider serious complications such as bowel ischemia, when performing CO2 angiography-guided endovascular therapy. Knowledge of anatomic variation could be important to prevent a severe and poor prognosis. Finally, reflux of CO2 should be carefully prevented during injection. Conflict of interest
We do not have any conflicts of interest.
References 1. Durant TM, Stauffer HM, Oppenheimer MJ, Paul RE Jr. The safety of intravascular carbon dioxide and its use for roentgenologic visualization of intracardiac structures. Ann Intern Med. 1957;47:191–201. 2. Hawkins IF. Carbon dioxide digital subtraction arteriography. AJR Am J Roentgenol. 1982;139:19–24. 3. Higashimori A, Yokoi Y. Stent implantation for chronic total occlusion in the iliac artery using intravascular ultrasound-guided carbon dioxide angiography without iodinated contrast medium. Cardiovasc Interv Ther. 2013;28:415–8. 4. From AM, Bartholmai BJ, Williams AW, Cha SS, McDonald FS. Mortality associated with nephropathy after radiographic contrast exposure. Mayo Clin Proc. 2008;83:1095–100. 5. Moos JM. Safety of carbon dioxide digital subtraction angiography. Arch Surg. 2011;146:1428. 6. Rundback JH, Shah PM, Wong J, Babu SC, Rozenblit G, Poplausky MR. Livedo reticularis, rhabdomyolysis, massive intestinal infarction, and death after carbon dioxide arteriography. J Vasc Surg. 1997;26:337–40. 7. Spinosa DJ, Matsumoto AH, Angle JF, Hagspiel KD, Hooper TN. Transient mesenteric ischemia: a complication of carbon dioxide angiography. J Vasc Interv Radiol. 1998;9:561–4. 8. Johnson PL, Neperud J, Arnold J, Thomas J. Livedo reticularis and bowel ischemia after carbon dioxide arteriography in a patient with CREST syndrome. J Vasc Interv Radiol. 2011;22:395–9. 9. Caridi JG, Hawkins IF. CO2 digital subtraction angiography: potential complications and Their prevention. J Vasc Interv Radiol. 1997;8:383–91. 10. Hashidomi H, Saito S. Spontaneous isolated superior mesenteric artery dissection treated under intravascular ultrasound guidance. Cardiovasc Interv Ther. 2011;26:269–73. 11. Thomas JH, Blake K, Pierce GE, Hermreck AS, Seigel E. The clinical course of asymptomatic mesenteric arterial stenosis. J Vasc Surg. 1998;27:840–4.
CASE REPORT
Total bowel ischemia after carbon dioxide angiography in a patient with inferior mesenteric artery occlusion Atsushi Mizuno • Yutaro Nishi • Koichiro Niwa
Received: 20 August 2013 / Accepted: 8 October 2013 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2013
Abstract A 70-year-old man with a history of hypertension and chronic renal failure experienced claudication in his left leg. He was treated by endovascular stenting in his left leg. We used CO2 angiography to prevent contrastinduced nephropathy. After the procedure, livedo vasculitis and lactic acidosis developed. We diagnosed the patient with CO2-induced ischemic colitis, after which we changed his position and administered conservative therapy. Contrast-enhanced computed tomography showed total bowel ischemia and total occlusion at the ostium of the inferior mesenteric artery. This rare complication after CO2 angiography might be related to the atherosclerotic occlusion of the inferior mesenteric artery. Keywords CO2 Bowel ischemia Common trunk Mesenteric artery
Introduction A 70-year-old man with a history of hypertension and chronic renal failure experienced claudication in his left leg 2 months prior to admission. His ankle brachial pressure index was lower on the left side than on the right side (0.70 versus 1.03). Ultrasound revealed narrowing of the common iliac artery and distal superficial femoral artery. We scheduled endovascular therapy. His serum creatinine level was 1.45 mg/dL (estimated Glomerular filtration rate, 38.5 mL min-1 9 1.73 m-2). We performed CO2
A. Mizuno (&) Y. Nishi K. Niwa Department of Cardiology, Cardiovascular Center, St. Luke’s International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, Japan e-mail: [email protected]
angiography-guided endovascular therapy via the right femoral artery. We put a 6-French long sheath (SheathLess PVÒ, Asahi Intecc; Nagoya, Japan) from the right femoral artery and crossed a 0.014-inch wire (Cruise; Asahi Intecc, Tokyo, Japan). After performing intravascular ultrasound, the superficial femoral artery lesion was treated with a nitinol self-expanding stent (Zilver, 6.0 9 40 mm; Cook, USA) and a self-expanding stent (E-Luminexx, 8.0 9 120 mm; Bard, Murray Hill, NJ, USA) was deployed in the left common iliac artery (Fig. 1a–d). Approximately 500 mL of CO2 was used to visualize the left leg via the left common iliac artery during the procedure, which lasted approximately 90 min. Injection of CO2 for diagnosis and intervention included 50 mL injections for iliac lesions and 20 mL injections by a hand syringe for the superior femoral artery. No iodinated contrast media was used. During the procedure, the patient experienced abdominal distension, but no pain. After the procedure, we noted that the lower part of the body (especially the front side) and the lower legs developed a reddish coloration (Fig. 2a, b). The patient did not experience any pain; therefore, he was kept under observation in the general cardiac ward. Mild abdominal discomfort persisted, and diarrhea occurred early the next morning. Several hours later, he developed hematochezia. His abdomen was soft, with slight rebound tenderness. We performed contrast-enhanced computed tomography emergently, which showed total bowel ischemia and no significant infarction (Fig. 2d, e). The intestines were not supplied by the inferior branch of the mesenteric artery (Fig. 3a–c). We diagnosed the patient with total bowel ischemic colitis resulting from the CO2-induced vapor lock phenomenon. He was transferred to the intensive care unit and his body position was changed to allow
123
A. Mizuno et al. Fig. 1 a CO2 angiography showing stenosis in the left iliac artery; b Balloon dilatation after deploying a self-expanding stent; c CO2 angiography showing focal stenosis in the superficial femoral artery; d CO2 angiography shows no residual stenosis in the superficial femoral artery after stenting
removal of CO2 from the mesenteric artery. The red coloration of his abdomen faded slightly the next day (Fig. 2c). His serum creatinine and blood creatine kinase enzyme levels peaked after 24 h (3.89 mg/dL and 1572 IU/L, respectively). Complete blood count showed an elevated white blood cell count of 19.4 9 103/lL with no eosinophils. His lactic acid level increased to 4.2 mmol/L and peaked within 24 h. Abdominal rebound tenderness resolved completely, but mild abdominal discomfort persisted for an additional 5 days. An abdominal ultrasound and computed tomography showed recovery from the edematous change of his bowel in 2 weeks. We discharged him in 21 days.
Discussion This is a rare case of CO2 angiography-induced total bowel ischemia. There were several reports on this syndrome, but in this patient, longer hospitalization was needed because of total bowel ischemia.
123
CO2 angiography The first use of an intravascular CO2 injection for diagnostic purposes via the peripheral vein was reported in the 1950s [1]. As a result of the pioneering efforts of Irwin Hawkins, intra-arterial CO2 gas first gained widespread acceptance as an alternative negative contrast agent during his procedure in the 1980s [2, 3]. A recent contemporary review of all diagnostic procedures (angiography, computed tomographic scans, etc.) that use iodinated contrast reported a respective complication and mortality rate of 25 and 7.8 % in patients who develop contrast-induced nephropathy [4]. A contrast agent is not preferably used, especially in patients with chronic kidney disease; CO2 angiography is an optional procedure used to avoid contrast-induced nephropathy. Previous reports show the safety of CO2 digital subtraction angiography in a guidedprocedure in approximately 500 patients with chronic kidney disease, with a few complications [5]. The boluses should be generally limited to 60 mL, with a 2-min interval between injections. If an excess amount of CO2 is injected
Total bowel ischemia caused by CO2 angiography
Fig. 2 a, b Diffuse mottling of his abdomen and lower legs, which is compatible with livedo reticularis; c Mottling of his abdomen almost disappeared the next day; d, e Contrast-enhanced computed
tomography (d sagittal and e axial) shows total bowel ischemia with pronounced bowel wall thickening
Fig. 3 a–c Three-dimensional reconstruction of the abdominal artery by contrast-enhanced computed tomography (a anterior view, b left side view, and c right side view). No inferior mesenteric artery is seen
branching from the abdominal aorta. Instead, co-lateral arteries supplying the area usually supplied by the inferior mesenteric artery are seen from the superior mesenteric artery (blue vessel)
or the time between each injection is inadequate, the CO2 will not be clear, resulting in ischemia. Because CO2 is less dense than blood, it could be trapped in nondependent structures as observed in our case. In our case, we administered several CO2 injections to visualize all the
arteries in the leg (superficial femoral artery, popliteal artery, and below-knee arteries) and ad hoc endovascular therapy. Patient movement during CO2 angiography impedes image quality and necessitates repeat angiography. Nevertheless, a total of 500 mL of CO2 is too large for
123
A. Mizuno et al.
peripheral intervention alone, and might be one of the causes of this complication. The total amount of CO2 injection should be carefully considered.
confirmed inferior mesenteric artery occlusion before the procedure by performing magnetic resonance angiography or Doppler ultrasound.
Bowel ischemia Conclusion Bowel ischemia is a rare complication, but there are a few reports on this syndrome after CO2 angiography. One case resulted in death and in the other case, kidney function worsened, similar to that observed in contrast-induced nephropathy [6–8]. According to previous reports, with the patient in the supine position, the anterior position of the celiac, superior mesenteric, and inferior mesenteric arteries leads to preferential filling of these vessels with CO2 during injection of CO2 into the abdominal aorta. In addition, during selective injection of the iliac vessels, reflux of CO2 may lead to filling of the superior mesenteric artery [7, 9]. In our case, we injected CO2 gas from the left common iliac artery; therefore, its reflux might have caused filling of the mesenteric arteries. Reflux to the mesenteric arteries must be carefully examined in every angiogram. When a large interface is present between the blood and CO2, the accumulated CO2 normally dissolves very quickly and is eliminated by the lungs. However, accumulated CO2 could be trapped in nondependent (against gravity) vessels such as the mesenteric arteries, causing a ‘‘vapor lock’’ phenomenon in the vessel. In addition, the pressure of the gas may prevent collateral flow from entering the affected vascular distribution, thereby compromising tissue perfusion. In previous reports, no effective therapy besides changing body position was known. We changed the patient’s position to allow rapid redistribution of the trapped gas. One previous report showed that only a 3-day hospitalization period was needed after bowel ischemia, but the patient in our case needed 3 weeks. We believe that this prolonged period was because of total bowel ischemia that was not limited to the superior mesenteric artery. Atherosclerotic occlusion of the inferior mesenteric artery In this patient, no inferior mesenteric artery was noted, and the distal colon was supplied by the superior mesenteric artery. Occlusion of the inferior mesenteric artery is not rare, and mesenteric ischemia can develop even in asymptomatic patients with mesenteric artery stenosis or occlusion [10, 11]. We thought that this anomaly might have been the cause of the bowel ischemia. This anatomical variation affects not only the superior mesenteric artery but also the inferior mesenteric artery, which resulted in total bowel ischemia. Furthermore, we might have
123
To our knowledge, this is the first report on total bowel ischemia caused by CO2 angiography, especially in patients with inferior mesenteric artery occlusion. We should consider serious complications such as bowel ischemia, when performing CO2 angiography-guided endovascular therapy. Knowledge of anatomic variation could be important to prevent a severe and poor prognosis. Finally, reflux of CO2 should be carefully prevented during injection. Conflict of interest
We do not have any conflicts of interest.
References 1. Durant TM, Stauffer HM, Oppenheimer MJ, Paul RE Jr. The safety of intravascular carbon dioxide and its use for roentgenologic visualization of intracardiac structures. Ann Intern Med. 1957;47:191–201. 2. Hawkins IF. Carbon dioxide digital subtraction arteriography. AJR Am J Roentgenol. 1982;139:19–24. 3. Higashimori A, Yokoi Y. Stent implantation for chronic total occlusion in the iliac artery using intravascular ultrasound-guided carbon dioxide angiography without iodinated contrast medium. Cardiovasc Interv Ther. 2013;28:415–8. 4. From AM, Bartholmai BJ, Williams AW, Cha SS, McDonald FS. Mortality associated with nephropathy after radiographic contrast exposure. Mayo Clin Proc. 2008;83:1095–100. 5. Moos JM. Safety of carbon dioxide digital subtraction angiography. Arch Surg. 2011;146:1428. 6. Rundback JH, Shah PM, Wong J, Babu SC, Rozenblit G, Poplausky MR. Livedo reticularis, rhabdomyolysis, massive intestinal infarction, and death after carbon dioxide arteriography. J Vasc Surg. 1997;26:337–40. 7. Spinosa DJ, Matsumoto AH, Angle JF, Hagspiel KD, Hooper TN. Transient mesenteric ischemia: a complication of carbon dioxide angiography. J Vasc Interv Radiol. 1998;9:561–4. 8. Johnson PL, Neperud J, Arnold J, Thomas J. Livedo reticularis and bowel ischemia after carbon dioxide arteriography in a patient with CREST syndrome. J Vasc Interv Radiol. 2011;22:395–9. 9. Caridi JG, Hawkins IF. CO2 digital subtraction angiography: potential complications and Their prevention. J Vasc Interv Radiol. 1997;8:383–91. 10. Hashidomi H, Saito S. Spontaneous isolated superior mesenteric artery dissection treated under intravascular ultrasound guidance. Cardiovasc Interv Ther. 2011;26:269–73. 11. Thomas JH, Blake K, Pierce GE, Hermreck AS, Seigel E. The clinical course of asymptomatic mesenteric arterial stenosis. J Vasc Surg. 1998;27:840–4.
