Zero-Iodinated-Contrast CO2-Guided Atherectomy for Superficial Femoral Artery Chronic Total Occlusions in Advanced Chronic Kidney Disease

Background/Objectives: Patients with chronic kidney disease (CKD) who undergo complex femoropopliteal endovascular interventions are at heightened risk of contrast-associated acute kidney injury (CA-AKI). This study assessed technical feasibility, short-term creatinine-based renal outcomes, and clinical outcomes of a zero-iodinated-contrast, carbon dioxide (CO2)-guided atherectomy approach for chronic total occlusions (CTOs) of the superficial femoral artery (SFA). Materials and Methods: In this retrospective, single-center analysis, 25 non-dialysis patients with CKD underwent CO2-only angiography-guided atherectomy for SFA CTOs. Renal function, procedural characteristics, distal embolization, limb-related outcomes, and duplex ultrasound-defined patency were evaluated. Serum creatinine was measured at baseline and within 48 h after the procedure. Results: The mean age was 65.4 ± 9.8 years, and 36% of patients presented with chronic limb-threatening ischemia (CLTI). Baseline serum creatinine was 2.16 ± 0.44 mg/dL, and the estimated glomerular filtration rate (eGFR) was 29.5 ± 9.1 mL/min/1.73 m2; 56% of patients had Stage 4 CKD. Technical success was achieved in all procedures. Cumulative CO2-volume data were available for 24 patients, with a mean volume of 98.8 ± 37.6 mL, and the mean procedure duration was 38.2 ± 17.2 min. Distal embolization occurred in 20% of patients (5/25), including one event requiring catheter-directed thrombolysis; all embolic events were treated endovascularly, with near-complete recanalization in the thrombolysis case. Mean serum creatinine changed by −0.016 ± 0.086 mg/dL, and no creatinine-defined AKI was observed within the available 48-h assessment. No patient required initiation of dialysis. Follow-up outcomes were available for 24 of 25 patients (96%); one patient was lost to follow-up. Over a mean follow-up period of 26 months (with incompletely reconstructed surveillance), no duplex-defined restenosis, recurrent CTO, or target lesion revascularization (TLR) was documented among patients with available follow-up imaging; this is a descriptive observation within the available follow-up and does not establish universal or long-term freedom from restenosis. Conclusions: A zero-iodinated-contrast, CO2-guided atherectomy strategy appears technically feasible for SFA CTO revascularization in patients with advanced CKD and was associated with observed short-term creatinine stability within the available 48-h assessment in this small retrospective cohort. These preliminary observations require validation in larger, prospective, controlled studies.