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Taste of Boston
Taste of Boston

International Plenary

IP10 - Carbon dioxide angiography in EVAR is associated to less renal deterioration than carbon dioxide+iodinated contrast:a propensity-matched analysis from a multicenter prospective zero-iodine EVAR study.

Wednesday, June 10, 2026
2:21 PM - 2:26 PM ET
Location: Hynes CC, Third Level, Room 306
Objectives: Iodinated contrast media (ICM) has been implied as a contributor to renal deterioration following endovascular aneurysm repair (EVAR), particularly in patients with preexisting kidney dysfunction. A primary aim of the Multicentre Prospective Zero Iodine Contrast EVAR Study was to determine whether a carbon dioxide (CO₂)–only angiographic strategy provides superior renal protection compared with combined CO₂+ICM imaging at mid-term follow-up

Methods: A prospective multicentre cohort of 293 consecutive patients undergoing elective EVAR was enrolled across 10 high-volume centres. Intraoperative CO₂ angiography was standardized using an automated injector system. Overall, 82% (n=240) of patients underwent EVAR guided exclusively by CO₂, whereas 18%(n=53) received combined CO₂+ICM imaging. A propensity score-matched cohort was generated (53 CO₂-only vs 53 CO₂+ICM) using optimal matching, achieving excellent covariate balance (mean absolute standardized difference 0.0417). The primary endpoint was progression of chronic kidney disease (CKD) stage, defined as a permanent increase of ≥1 CKD class compared with baseline. Secondary endpoints included survival, reintervention, and aneurysm sac shrinkage.

Results: Among 293 patients undergoing EVAR, progression by ≥1 CKD stage occurred in 24 (8.2%). In multivariable analysis of the overall cohort, CO₂-only angiography and baseline CKD stage 1–2 were independently associated with a lower risk of renal deterioration (OR, 0.18 and 0.01, respectively; both P < .01). In the propensity score–matched analysis, CO₂-only angiography remained independently protective against CKD progression (OR, 0.116; 95% CI, 0.02–0.49; P < .01). Higher preoperative eGFR was also associated with a lower risk of CKD progression (OR per 1-unit increase, 0.927; 95% CI, 0.88–0.96; P = .0004), whereas baseline CKD stage 3–5 was a strong predictor of renal deterioration (OR, 164; P = .016). Freedom from CKD progression at 25 months was significantly higher with CO₂-only compared with ICM (91% vs 64%; log-rank P = .013; Figure 1). No significant differences were observed between the CO₂-only and CO₂+ICM groups in overall survival (89.79% vs 80.7%; P = .127) or aneurysm sac shrinkage (48.9% vs 46.5%; P = .676). Detailed outcomes are reported in Table I.

Conclusions: In this multicentre prospective cohort of EVAR patients, CO₂-only angiography was independently associated with a significantly lower risk of CKD stage progression compared with CO₂ + ICM–based strategies. The risk was greatest in patients with pre-existing renal dysfunction, underscoring the need to adopt ICM-sparing or ICM-free strategies in this subgroup whenever feasible. Overall, these findings support CO₂-only angiography as an effective renal-protective approach during EVAR and warrant confirmation in randomized prospective trials