Flat-detector computed tomographic СО₂ arteriohepaticography guided liver biopsy in patient with liver tumor and advanced chronic renal failure: a clinical case

INTRODUCTION: Carbon dioxide (СО₂) is a safe contrast agent for patients requiring endovascular and angiography-assisted procedures due to lack of renal toxicity and allergic potential. It is highly important in patients with renal failure and allergies to iodinated contrast agents.

OBJECTIVE: To demonstrate a clinical case of percutaneous biopsy guided with the flat-detector computed tomography (FDCT) CO₂ arteriohepaticography in the patient with suspected metastatic lesion of the liver, history of cervical squamous cell carcinoma and chronic kidney disease (CKD).

MATERIALS AND METHODS: A patient with squamous cell carcinoma of the cervix, due to concomitant kidney pathology (chronic tubulointerstitial nephritis, gouty nephropathy, CKD C4 according to the KDIGO classification) has contraindications for iodinated contrast, hence contrast enhanced computed tomography (CT) and regular FDCT angiography. A native CT study revealed a hypodence 17 mm diameter lesion in SVII of the liver. US and MRI data were ambiguous. The presence of a clear hypervascular rim in the arterial and venous phases of dynamic contrast enhancement could not rule out the metastasis. In order to clarify the nature of the lesion in the liver, multidisciplinary team suggested biopsy under digital subtraction angiography and FDCT arteriohepaticography using CO₂ as a contrast agent because of the risk of the haemorrage. For this purpose, using the Seldinger technique, through right femoral artery, by means of an Artis Zee angiographic unit (Siemens, Germany) catheterization and gas subtraction angiography of the common hepatic artery were performed. FDCT-CO₂-arteriohepaticography of the common hepatic artery was performed afterwards using the same installation and injecting 30 ml of carbon dioxide at the rate of 3 ml/sec (special «Angiodroid» (Italy) CO₂ injector was used) and a scanning delay of 3 sec (in 6sDCT Body mode).

RESULTS: Вy means of subtraction CO₂-arteriohepaticography and FDCT arteriohepaticography using CO₂ in SVII of the liver the solitary hypervascular 15 mm lesion was detected. In order to verify the lesion single-shot US and FDCT-guided biopsy was performed. It was followed by a control FDCT arteriohepaticography using _CO2 to exclude bleeding. Histopathology refuted metastasis.

CONCLUSION: CO₂ is a safe contrast agent in patients with renal failure and allergies to iodinated contrast agents. FDCT CO₂ arteriohepaticography is an effective alternative method, that allows safe visualization and bleeding control after interventions in patient with renal failure.

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