The use of carbon dioxide (CO₂) as a contrast agent in endovascular interventions represents a promising alternative for patients with contraindications to iodine-based contrast media. Despite its established application in international practice, CO₂ angiography remains underutilized in Russia. The objective of this study was to consolidate existing knowledge and international experience and present the first use of an automated carbon dioxide injector for endovascular procedures on lower limb arteries in Russia.

Indications for CO₂ angiography are not yet clearly defined; however, sterile medical-grade CO₂ can be used as a contrast agent in various anatomical cavities, including arteries below the diaphragm, veins, biliary ducts, urinary tracts, abscess cavities, and fistulas. For successful diagnostic and therapeutic endovascular procedures involving femoral and popliteal artery lesions, adherence to specific conditions is crucial. These include the availability of sterile medical-grade CO₂, angiographic systems capable of providing sufficient frame rates (at least 3 frames per second), the use of digital subtraction angiography (DSA), and ensuring immobilization of the area of interest.

The integration of an automated CO₂ injector and specialized software into angiographic systems enhances the safety, efficiency, and patient comfort during the procedure. CO₂ serves as the sole viable contrast agent for patients with contraindications to iodine-based agents, such as those with chronic kidney disease, diabetes mellitus, or renal transplants. Performing CO₂ angiography in these patients minimizes the risk of adverse effects on renal function while ensuring effective imaging for procedures like recanalization, balloon angioplasty, and stenting of peripheral arteries.

This study highlights the practical implementation of CO₂ angiography in Russia, emphasizing its role in expanding the scope of endovascular treatments and improving outcomes for high-risk patients.

Vladislav V. Derkach MBA, vascular surgeon,  the head of interventional cardiology and radiology department. Participant, speaker, lecturer and moderator at Russian and international conferences (Radial Course, TCT, LINC, CIRSE, CLIC, PCR, CID, etc.). Member of the Russian Society of Angiology and Vascular Surgery, the European Society of Cardiology, and the European Society of Phlebology.  Annually performed more than 1,500 operations to correct various diseases of the arteries and veins, acute myocardial infarction and coronary heart disease, complex heart rhythm disorders.

Key Achievement

In 2020, a groundbreaking method of automatic carbon dioxide (CO₂) angiography and endovascular interventions for patients with peripheral artery diseases was introduced into Russian healthcare practice. The first automated CO₂ injector in Russia, the Angiodroid system, was installed and successfully utilized at the Department of Interventional Radiology, Derkach V.V was headed.