Diagnostic Accuracy and Renal Safety of Carbon Dioxide Angiography in Lower Limb Angiography: A Systematic Review and Meta-Analysis

Background/Objectives: Iodinated contrast media (ICM) used in lower limb angiography carry risks of contrast-induced nephropathy (CIN) and allergic reactions, particularly in patients with peripheral arterial disease (PAD) and renal dysfunction. Carbon dioxide (CO2) angiography offers a potential non-nephrotoxic alternative. The purpose of this study was to evaluate the diagnostic accuracy and renal safety of CO2 angiography compared with ICM in patients undergoing lower limb angiography for PAD.

Methods

A systematic search of PubMed, Scopus, and Web of Science was performed from inception to 4 September 2025. Studies comparing CO2 angiography with ICM in adult PAD patients were included. Risk of bias was assessed with QUADAS-2 for diagnostic accuracy studies and RoB 2 for randomised trials, and the methodological quality of comparative observational studies with the Newcastle–Ottawa Scale. Pooled sensitivity, specificity, adverse events, CIN, contrast volume, serum creatinine, and estimated glomerular filtration rate (eGFR) were analysed using random-effects models.