OBJECTIVE: The objective of this study was to investigate whether the use of carbon dioxide (CO(2)) angiography decreases the intraoperative use of iodine contrast medium (ICM), thereby decreasing the risk of developing postoperative renal damage in patients undergoing iliac branch device (IBD) implantation. METHODS: Patients undergoing IBD implantation at a single tertiary center between May 2013 and August 2019 were screened for inclusion in the study. A cohort of patients in whom an intraoperative imaging protocol using predominantly CO(2) was compared with a control group in whom ICM was used (CO(2) and ICM groups). Fusion imaging was used in both groups. Retrospective review of the medical charts and all imaging was performed. Variables were expressed as median with interquartile range (IQR) or absolute number and percentage. Wilcoxon-Mann-Whitney and chi(2) tests were used to compare continuous and categorical variables, respectively. P values of <0 .05 were considered statistically significant. RESULTS: Twenty-three patients were included in the CO(2) group and 21 in the ICM group without significant differences in patient characteristics between the groups. Intraoperative iodine exposure was lower in the CO(2) group than in the ICM group (8.2 g [IQR, 7.1-10.9 g) vs 15.8 g (IQR 7.6-21 g); P = 0.015, respectively). There were no differences in technical success, clinical success, fluoroscopy time, and dose-area product in the 2 groups. There were no adverse events that could be related to the intraoperative use of CO(2.) There was no difference in postoperative survival nor renal function assessment between the groups despite the higher number of accessory renal arteries embolized in the CO(2) group (P = 0.221). CONCLUSIONS: Reduction of intraoperative ICM exposure during IBD implantation is feasible through the predominant use of CO(2) automated angiography. This can be done safely without affecting the technical success or radiation exposure. The immediate postoperative renal damage was low when a modern intraoperative imaging protocol with ICM was used and was not significantly reduced by the use of CO(2). Further and larger studies are needed to investigate the long-term effects. CLINICAL IMPACT: This study aimed to investigate how to minimize intraoperative risk during iliac branched repair exploring the intraoperative use of automated carbon dioxide angiography in order to decrease the use of contrast media protecting renal function and thereby potentially impacting long-term survival.