Safety and Effectiveness of Carbon Dioxide Angiography for Endovascular Aneurysm Repair: Systematic Review and Meta-analysis.

OBJECTIVE: Endovascular aortic aneurysm repair (EVAR) traditionally relies on iodinated contrast media (ICM), which can be problematic in patients with renal insufficiency or iodine allergy. Carbon dioxide (CO2) has emerged as a valuable alternative to mitigate these risks. This systematic review with meta-analysis aims to evaluate the safety and effectiveness of CO2 angiography in EVAR. METHODS: A literature search was conducted using PubMed, Cochrane Library, Scopus and ISI databases to identify studies published up to May 2026 that assessed CO2 angiography use in EVAR. The primary endpoint of safety was acute kidney injury (AKI) occurrence. Effectiveness was evaluated based on technical success rates. The incidence of acute kidney injury was pooled using a random-effects meta-analysis, with sources of heterogeneity explored via meta-regression. RESULTS: Eight studies involving 1699 patients were included, with 581 undergoing EVAR with CO2 angiography and 1118 receiving ICM. There was no statistical difference regarding AKI between the EVAR cohort assessed with CO2 angiography and the ICM angiography cohort, with an overall AKI risk ratio of 0.65 (95% CI: 0.27-1.56) (I2=0%). CO2 angiography is associated with longer procedural times and higher radiation exposure in some studies. The intraoperative endoleak detection rate was similar or slightly higher in the CO2 group. No significant differences in mortality rates were observed between the groups. CONCLUSIONS: CO2 angiography shows comparable safety and effectiveness to ICM in EVAR procedures. However, risk-reduction of AKI was not statistically different between ICM and CO2.