Carbon Dioxide Digital Subtraction Angiography: Everything You Need to Know and More

In 1971, during a routine celiac axis injection, 70 cc of room air was inadvertently injected into a patient instead of iodinated contrast. Fortunately, there were no ill effects, and despite the use of cut film at the time, Dr. Hawkins visualized the celiac axis and its branches as a negative image. Because of this incident, in combination with his previous knowledge of carbon dioxide (CO2) in venous imaging, he began to study the intra-arterial use of CO2 in animals. After the safe and successful use in animals, he applied the same principles to humans. As technology continued to improve, CO2 evolved into a viable vascular imaging agent. Although used initially for renal failure and iodinated contrast allergy, the many unique properties of CO2 yielded multiple advantages, which are now used in a multitude of scenarios alone or in combination with traditional contrast. Despite somewhat awkward delivery devices in the past, it has now been used with great success in both adults and children for more than 3 decades with only limited reportable complications. Its safe use in children has been described, and when performed in this age group, the same principles apply as for adults. This article describes the history and technique of CO2 angiography for vascular procedures.