1
|
Patel RJ, Lee AM, Hallsten J, Lane JS, Barleben AR, Malas MB. Use of surgical augmented intelligence maps can reduce radiation and improve safety in the endovascular treatment of complex aortic aneurysms. J Vasc Surg 2023; 77:982-990.e2. [PMID: 36581011 DOI: 10.1016/j.jvs.2022.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The introduction of endovascular procedures has revolutionized the management of complex aortic aneurysms. Although repair has traditionally required longer operative times and increased radiation exposure compared with simple endovascular aneurysm repair, the recent introduction of three-dimensional technology has become an invaluable operative adjunct. Surgical augmented intelligence (AI) is a rapidly evolving tool initiated at our institution in June 2019. In our study, we sought to determine whether this technology improved patient and operator safety. METHODS A retrospective review of patients who had undergone endovascular repair of complex aortic aneurysms (pararenal, juxtarenal, or thoracoabdominal), type B dissection, or infrarenal (endoleak, coil placement, or renal angiography with or without intervention) at a tertiary care center from August 2015 to November 2021 was performed. Patients were stratified according to the findings from intelligent maps, which are patient-specific AI tools used in the operating room in conjunction with real-time fluoroscopic images. The primary outcomes included operative time, radiation exposure, fluoroscopy time, and contrast use. The secondary outcomes included 30-day postoperative complications and long-term follow-up. Linear regression models were used to evaluate the association between AI use and the main outcomes. RESULTS During the 6-year period, 116 patients were included in the present study, with no significant differences in the baseline characteristics. Of the 116 patients, 76 (65.5%) had undergone procedures using AI and 40 (34.5%) had undergone procedures without AI software. The intraoperative outcomes revealed a significant decrease in radiation exposure (AI group, 1955 mGy; vs non-AI group, 3755 mGy; P = .004), a significant decrease in the fluoroscopy time (AI group, 55.6 minutes; vs non-AI group, 86.9 minutes; P = .007), a decrease in the operative time (AI group, 255 minutes; vs non-AI group, 284 minutes; P = .294), and a significant decrease in contrast use (AI group, 123 mL; vs non-AI group, 199 mL; P < .0001). No differences were found in the 30-day and long-term outcomes. CONCLUSIONS The results from the present study have demonstrated that the use of AI technology combined with intraoperative imaging can significantly facilitate complex endovascular aneurysm repair by decreasing the operative time, radiation exposure, fluoroscopy time, and contrast use. Overall, evolving technology such as AI has improved radiation safety for both the patient and the entire operating room team.
Collapse
Affiliation(s)
- Rohini J Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Arielle M Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - John Hallsten
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - John S Lane
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Andrew R Barleben
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA.
| |
Collapse
|
2
|
Modarai B, Haulon S, Ainsbury E, Böckler D, Vano-Carruana E, Dawson J, Farber M, Van Herzeele I, Hertault A, van Herwaarden J, Patel A, Wanhainen A, Weiss S, Esvs Guidelines Committee, Bastos Gonçalves F, Björck M, Chakfé N, de Borst GJ, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kakkos SK, Koncar IB, Kolh P, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Document Reviewers, Bacher K, Brountzos E, Fanelli F, Fidalgo Domingos LA, Gargiulo M, Mani K, Mastracci TM, Maurel B, Morgan RA, Schneider P. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Radiation Safety. Eur J Vasc Endovasc Surg 2023; 65:171-222. [PMID: 36130680 DOI: 10.1016/j.ejvs.2022.09.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/15/2022] [Indexed: 01/24/2023]
|
3
|
Illuminati G, Nardi P, Fresilli D, Sorrenti S, Lauro A, Pizzardi G, Ruggeri M, Ulisse S, Cantisani V, D'Andrea V. Fully Ultrasound-Assisted Endovascular Aneurysm Repair (EVAR): preliminary report. Ann Vasc Surg 2022; 84:55-60. [PMID: 35257913 DOI: 10.1016/j.avsg.2022.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/09/2022] [Accepted: 02/13/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reducing fluoroscopy times and iodine contrast administration during endovascular exclusion (EVAR) of infrarenal aortic aneurysms (AAA) remains a challenge. The purpose of this study was to evaluate the preliminary results of a fully ultrasound-assisted EVAR without iodine contrast administration. METHODS Twentyseven consecutive patients, underwent an elective IVUS-assisted EVAR with final CEUS control of correct aneurysm exclusion. In no case intraprocedural injection of iodine contrast medium was performed. The primary study's endpoints were the overall duration of the procedure, duration of fluoroscopy, cumulative radiation dose, the length of intraoperative CEUS control and the comparison of findings between intraoperative CEUS and CT-scan at one month. RESULTS Mean duration of the procedure was 130 ± 35 minutes. Overall duration of fluoroscopy was 22 ± 18 minutes. Mean radiation dose was 66 mGy (range, 24 - 82). The mean length of CEUS final control was 8 ± 2 minutes. No type I or type III endoleak was detected either at CEUS or at angio-CT scan at one month from EVAR. CEUS revealed a type II endoleak in 6 patients (22%) , compared to 9 type II endoleaks (33%) detected at angio-CT scan one month after the procedure (p = 0.5). CONCLUSIONS Fully ultrasound (IVUS and CEUS) -assisted EVAR is safe, feasible and reliable, completely eliminating the need for iodine contrast medium and reducing the radiation exposure for both patients and surgeons.
Collapse
Affiliation(s)
| | | | | | | | | | - Giulia Pizzardi
- The Unit of Vascular Surgery, "San Camillo De Lellis" Hospital, Rieti, Italy
| | - Massimo Ruggeri
- The Unit of Vascular Surgery, "San Camillo De Lellis" Hospital, Rieti, Italy
| | | | - Vito Cantisani
- Radiology, the University of Rome "La Sapienza" , Rome, Italy
| | | |
Collapse
|
4
|
Efthymiou FO, Metaxas VI, Dimitroukas CP, Kakkos SK, Panayiotakis GS. KERMA-AREA PRODUCT, ENTRANCE SURFACE DOSE AND EFFECTIVE DOSE IN ABDOMINAL ENDOVASCULAR ANEURYSM REPAIR. RADIATION PROTECTION DOSIMETRY 2021; 194:121-134. [PMID: 34227656 DOI: 10.1093/rpd/ncab082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/15/2021] [Accepted: 05/09/2021] [Indexed: 06/13/2023]
Abstract
This study aims to evaluate patient radiation dose during fluoroscopically guided endovascular aneurysm repair (EVAR) procedures. Fluoroscopy time (FT) and kerma-area product (KAP) were recorded from 87 patients that underwent EVAR procedures with a mobile C-arm fluoroscopy system. Effective dose (ED) and organs' doses were calculated utilising appropriate conversion coefficients based on the recorded KAP values. Entrance surface dose (ESD) was calculated based on KAP values and technical parameters. The mean FT was 22.7 min (range 6.4-76.8 min), resulting in a mean KAP of 36.6 Gy cm2 (range 2.0-167.8 Gy cm2), a mean ED of 6.2 mSv (range 0.3-28.5 mSv) and a mean ESD of 458 mGy (range 26-2098 mGy). The corresponding median values were 17.4 min, 25.6 Gy cm2, 4.4 mSv and 320 mGy. The threshold of 2 Gy for skin erythema was exceeded in two procedures for a focus-to-skin distance (FSD) of 40 cm and six procedures when an FSD of 30 cm was considered. The highest doses absorbed by the adrenals, kidneys, spleen and pancreas and ranged between 3.7 and 313.3 mGy (average 66.8 mGy), 3.3 and 285.1 mGy (average 60.8 mGy), 1.3 and 111.1 mGy (average 23.7 mGy), 1.1 and 92.1 mGy (average 19.6 mGy), respectively. A wide range of patient doses was reported in the literature. The radiation dose received by the patients was comparative or lower than most of the previously reported values. However, higher doses can be revealed due to the X-ray system's non-optimum use and extended FTs, mainly affected by complex clinical conditions, patients' body habitus and vascular surgeon experience. The large variation of patient doses highlights the potential to optimise the EVAR procedure by considering the balance between the radiation dose and the required image quality. Additional studies need to be conducted in increasing the vascular surgeons' awareness regarding patient dose and radiation protection issues during EVAR procedures.
Collapse
Affiliation(s)
- Fotios O Efthymiou
- Department of Medical Physics, School of Medicine, University of Patras, 26504 Patras, Greece
| | - Vasileios I Metaxas
- Department of Medical Physics, School of Medicine, University of Patras, 26504 Patras, Greece
| | - Christos P Dimitroukas
- Department of Medical Physics, School of Medicine, University of Patras, 26504 Patras, Greece
- Department of Medical Physics, University Hospital of Patras, 26504 Patras, Greece
| | - Stavros K Kakkos
- Department of Vascular Surgery, School of Medicine, University of Patras, 26504 Patras, Greece
- Department of Vascular Surgery, University Hospital of Patras, 26504 Patras, Greece
| | - George S Panayiotakis
- Department of Medical Physics, School of Medicine, University of Patras, 26504 Patras, Greece
- Department of Medical Physics, University Hospital of Patras, 26504 Patras, Greece
| |
Collapse
|
5
|
Goelz L, Kim S, Güthoff C, Eichenauer F, Eisenschenk A, Mutze S, Asmus A. ACTION trial: a prospective study on diagnostic Accuracy of 4D CT for diagnosing Instable ScaphOlunate DissociatioN. BMC Musculoskelet Disord 2021; 22:84. [PMID: 33451307 PMCID: PMC7811226 DOI: 10.1186/s12891-021-03946-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 01/02/2021] [Indexed: 11/12/2022] Open
Abstract
Background Early detection of scapholunate ligament (SLL) tears is essential after minor and major trauma to the wrist. The differentiation between stable and instable injuries determines therapeutic measures which aim to prevent osteoarthritis. Arthroscopy has since been the diagnostic gold standard in suspected SLL tears because non-invasive methods have failed to exclude instable injuries reliably. This prospective study aims to determine the diagnostic accuracy of dynamic, 4D computed tomography (CT) of the wrist for diagnosing instable SLL tears. Methods Single center, prospective trial including 40 patients with suspected SLL tears scheduled for arthroscopy. Diagnostic accuracy of 4D CT will be tested against the reference standard arthroscopy. Radiologists will be blinded to the results of arthroscopy and hand surgeons to radiological reports. A historical cohort of 80 patients which was diagnosed using cineradiography before implementation of 4D CT at the study site will serve as a comparative group. Discussion Static imaging lacks the ability to detect instable SLL tears after wrist trauma. Dynamic methods such as cineradiography and dynamic magnetic resonance imaging (MRI) are complex and require specific technical infrastructure in specialized centers. Modern super-fast dual source CT scanners are gaining popularity and are being installed gradually in hospitals and ambulances. These scanners enable dynamic imaging in a quick and simple manner. Establishment of dynamic 4D CT of the wrist in patients with suspected SLL tears in in- and outpatient settings could improve early detection rates. Reliable identification of instable injuries through 4D CT scans might reduce the number of unnecessary diagnostic arthroscopies in the future. Trial registration This study was registered prospectively at the German Clinical Trials Register (DRKS) DRKS00021110. Universal Trial Number (WHO-UTN): U1111–1249-7884.
Collapse
Affiliation(s)
- Leonie Goelz
- Dept. of Radiology and Neuroradiology, BG Unfallkrankenhaus, Berlin, Germany. .,Inst. For Diagnostic Radiology, University Medicine Greifswald, Greifswald, Germany.
| | - Simon Kim
- Dept. of Hand Surgery and Microsurgery, University Medicine Greifswald, Greifswald, Germany
| | - Claas Güthoff
- Center for Clinical Research, BG Unfallkrankenhaus, Berlin, Germany
| | - Frank Eichenauer
- Dept. of Hand-, Replantation- and Microsurgery, BG Unfallkrankenhaus, Berlin, Germany
| | - Andreas Eisenschenk
- Dept. of Hand Surgery and Microsurgery, University Medicine Greifswald, Greifswald, Germany.,Dept. of Hand-, Replantation- and Microsurgery, BG Unfallkrankenhaus, Berlin, Germany
| | - Sven Mutze
- Dept. of Radiology and Neuroradiology, BG Unfallkrankenhaus, Berlin, Germany.,Inst. For Diagnostic Radiology, University Medicine Greifswald, Greifswald, Germany
| | - Ariane Asmus
- Dept. of Hand-, Replantation- and Microsurgery, BG Unfallkrankenhaus, Berlin, Germany
| |
Collapse
|
6
|
George J, Tadros RO, Rao A, Png CYM, Han DK, Ilonzo N, Faries PL, McKinsey JF. Duplex Ultrasound Can Successfully Identify Endoleaks and Renovisceral Stent Patency in Patients Undergoing Complex Endovascular Aneurysm Repair. Vasc Endovascular Surg 2020; 55:234-238. [PMID: 33317440 DOI: 10.1177/1538574420980605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Efficacy of duplex ultrasound (DU) surveillance of complex EVAR such as FEVAR and ChEVAR has not been studied. All patients undergoing FEVAR or ChEVAR at a single multihospital institution were retrospectively reviewed. Postoperative surveillance included DU at 1 month and CTA at 3 months. 82 patients met inclusion criteria including 39 (47.6%) ChEVAR and 43 (52.4%) FEVAR cases. DU identified endoleak with aneurysm sac enlargement in 3 cases requiring reintervention. CTA at 3 months detected 2 new endoleaks without growth and 1 renal artery stent occlusion. Replacement of initial postoperative imaging with DU did not result in any missed endoleaks, deaths, ruptures, or branch occlusions.
Collapse
Affiliation(s)
- Justin George
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami O Tadros
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajit Rao
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Y Maximilian Png
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel K Han
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Ilonzo
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter L Faries
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James F McKinsey
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
7
|
Haga Y, Chida K, Sota M, Kaga Y, Abe M, Inaba Y, Suzuki M, Meguro T, Zuguchi M. Hybrid Operating Room System for the Treatment of Thoracic and Abdominal Aortic Aneurysms: Evaluation of the Radiation Dose Received by Patients. Diagnostics (Basel) 2020; 10:diagnostics10100846. [PMID: 33086733 PMCID: PMC7589961 DOI: 10.3390/diagnostics10100846] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/09/2020] [Accepted: 10/10/2020] [Indexed: 11/16/2022] Open
Abstract
In recent years, endovascular treatment of aortic aneurysms has attracted considerable attention as a promising alternative to traditional surgery. Hybrid operating room systems (HORSs) are increasingly being used to perform endovascular procedures. The clinical benefits of endovascular treatments using HORSs are very clear, and these procedures are increasing in number. In procedures such as thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR), wires and catheters are used to deliver and deploy the stent graft in the thoracic/abdominal aorta under fluoroscopic control, including DSA. Thus, the radiation dose to the patient is an important issue. We determined radiation dose indicators (the dose–area product (DAP) and air karma (AK) parameters) associated with endovascular treatments (EVAR and TEVAR) using a HORS. As a result, the mean ± standard deviation (SD) DAPs of TEVAR and EVAR were 323.7 ± 161.0 and 371.3 ± 186.0 Gy × cm2, respectively. The mean ± SD AKs of TEVAR and EVAR were 0.92 ± 0.44 and 1.11 ± 0.54 Gy, respectively. The mean ± SD fluoroscopy times of TEVAR and EVAR were 13.4 ± 7.1 and 23.2 ± 11.7 min, respectively. Patient radiation dose results in this study of endovascular treatments using HORSs showed no deterministic radiation effects, such as skin injuries. However, radiation exposure during TEVAR and EVAR cannot be ignored. The radiation dose should be evaluated in HORSs during endovascular treatments. Reducing/optimizing the radiation dose to the patient in HORSs is important.
Collapse
Affiliation(s)
- Yoshihiro Haga
- Course of Radiological Technology, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba, Sendai, Miyagi 980-8575, Japan; (Y.H.); (M.S.); (Y.I.); (M.S.); (M.Z.)
- Department of Radiology, Sendai Kousei Hospital, 4-15 Hirosemachi, Aoba, Sendai 980-0873, Japan; (Y.K.); (M.A.)
| | - Koichi Chida
- Course of Radiological Technology, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba, Sendai, Miyagi 980-8575, Japan; (Y.H.); (M.S.); (Y.I.); (M.S.); (M.Z.)
- Department of Radiation Disaster Medicine, International Research Institute of Disaster Science, Tohoku University, 468-1 Aramaki Aza-Aoba, Aoba, Sendai, Miyagi 980-0845, Japan
- Correspondence: ; Tel.: +81-22-717-7943
| | - Masahiro Sota
- Course of Radiological Technology, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba, Sendai, Miyagi 980-8575, Japan; (Y.H.); (M.S.); (Y.I.); (M.S.); (M.Z.)
- Department of Radiology, Sendai Kousei Hospital, 4-15 Hirosemachi, Aoba, Sendai 980-0873, Japan; (Y.K.); (M.A.)
| | - Yuji Kaga
- Department of Radiology, Sendai Kousei Hospital, 4-15 Hirosemachi, Aoba, Sendai 980-0873, Japan; (Y.K.); (M.A.)
| | - Mitsuya Abe
- Department of Radiology, Sendai Kousei Hospital, 4-15 Hirosemachi, Aoba, Sendai 980-0873, Japan; (Y.K.); (M.A.)
| | - Yohei Inaba
- Course of Radiological Technology, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba, Sendai, Miyagi 980-8575, Japan; (Y.H.); (M.S.); (Y.I.); (M.S.); (M.Z.)
- Department of Radiation Disaster Medicine, International Research Institute of Disaster Science, Tohoku University, 468-1 Aramaki Aza-Aoba, Aoba, Sendai, Miyagi 980-0845, Japan
| | - Masatoshi Suzuki
- Course of Radiological Technology, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba, Sendai, Miyagi 980-8575, Japan; (Y.H.); (M.S.); (Y.I.); (M.S.); (M.Z.)
- Department of Radiation Disaster Medicine, International Research Institute of Disaster Science, Tohoku University, 468-1 Aramaki Aza-Aoba, Aoba, Sendai, Miyagi 980-0845, Japan
| | - Taiichiro Meguro
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, 4-15 Hirose-machi, Aoba, Sendai 980-0873, Japan;
| | - Masayuki Zuguchi
- Course of Radiological Technology, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba, Sendai, Miyagi 980-8575, Japan; (Y.H.); (M.S.); (Y.I.); (M.S.); (M.Z.)
| |
Collapse
|
8
|
Harbron RW, Abdelhalim M, Ainsbury EA, Eakins JS, Alam A, Lee C, Modarai B. Patient radiation dose from x-ray guided endovascular aneurysm repair: a Monte Carlo approach using voxel phantoms and detailed exposure information. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2020; 40:704-726. [PMID: 32428884 DOI: 10.1088/1361-6498/ab944e] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Endovascular aneurysm repair (EVAR) is a well-established minimally invasive technique that relies on x-ray guidance to introduce a stent through the femoral artery and manipulate it into place. The aim of this study was to estimate patient organ and effective doses from EVAR procedures using anatomically realistic computational phantoms and detailed exposure information from radiation dose structured reports (RDSR). Methods: Lookup tables of conversion factors relating kerma area product (PKA) to organ doses for 49 different beam angles were produced using Monte Carlo simulations (MCNPX2.7) with International Commission on Radiological Protection (ICRP) adult male and female voxel phantoms for EVAR procedures of varying complexity (infra-renal, fenestrated/branched and thoracic EVAR). Beam angle specific correction factors were calculated to adjust doses according to x-ray energy. A MATLAB function was written to find the appropriate conversion factor in the lookup table for each exposure described in the RDSR, perform energy corrections and multiply by the respective exposure PKA. Using this approach, organ doses were estimated for 183 EVAR procedures in which RDSRs were available. A number of simplified dose estimation methodologies were also investigated for situations in which RDSR data are not available. Results: Mean estimated bone marrow doses were 57 (range: 2-247), 86 (2-328) and 54 (8-250) mGy for infra-renal, fenestrated/branched and thoracic EVAR, respectively. Respective effective doses were 27 (1-208), 54 (1-180) and 37 (5-167) mSv. Dose estimates using non-individualised, average conversion factors, along with those produced using the alternative Monte Carlo code PCXMC, yielded reasonably similar results overall, though variation for individual procedures could exceed 100% for some organs. In conclusion, radiation doses from x-ray guided endovascular aneurysm repairs are potentially high, though this must be placed in the context of the life sparing nature and high success rate for this procedure.
Collapse
Affiliation(s)
- Richard W Harbron
- Population Health Sciences Institute, Newcastle University, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne NE1 4LP, United Kingdom. NIHR Health Protection Research Unit in Chemical and Radiation Threats and Hazards, Newcastle University, Newcastle-upon-Tyne United Kingdom
| | | | | | | | | | | | | |
Collapse
|
9
|
Kordzadeh A, Hanif MA, Ramirez MJ, Railton N, Prionidis I, Browne T. Prediction, pattern recognition and modelling of complications post-endovascular infra renal aneurysm repair by artificial intelligence. Vascular 2020; 29:171-182. [PMID: 32829694 DOI: 10.1177/1708538120949658] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The study evaluates the plausibility and applicability of prediction, pattern recognition and modelling of complications post-endovascular aneurysm repair (EVAR) by artificial intelligence for more accurate surveillance in practice. METHODS A single-centre prospective data collection on (n = 250) EVAR cases with n = 26 preoperative attributes (factors) on endpoint of endoleak (types I-VI), occlusion, migration and mortality over a 13-year period was conducted. In addition to the traditional statistical analysis, data was subjected to machine learning algorithm through artificial neural network. The predictive accuracy (specificity and -1 sensitivity) on each endpoint is presented with percentage and receiver operative curve. The pattern recognition and model classification were conducted using discriminate analysis, decision tree, logistic regression, naive Bayes and support vector machines, and the best fit model was deployed for pattern recognition and modelling. RESULTS The accuracy of the training, validation and predictive ability of artificial neural network in detection of endoleak type I was 95, 96 and 94%, type II (94, 83, 90 and 82%) and type III was 96, 94 and 96%, respectively. Endpoints are associated with increase in weights through predictive modeling that were not detected through statistical analytics. The overall accuracy of the model was >86%. CONCLUSION The study highlights the applicability, accuracy and reliability of artificial intelligence in the detection of adverse outcomes post-EVAR for an accurate surveillance stratification.
Collapse
Affiliation(s)
- Ali Kordzadeh
- Department of Vascular, Endovascular and Renal Access, Mid Essex Hospitals Services NHS Trust, Broomfield Hospital, Essex, UK
| | - Mohammad A Hanif
- Department of Interventional Radiology, Mid Essex Hospitals Services NHS Trust, Broomfield Hospital, Essex, UK
| | - Manfred J Ramirez
- Department of Vascular, Endovascular and Renal Access, Mid Essex Hospitals Services NHS Trust, Broomfield Hospital, Essex, UK
| | - Nicholas Railton
- Department of Interventional Radiology, Mid Essex Hospitals Services NHS Trust, Broomfield Hospital, Essex, UK
| | - Ioannis Prionidis
- Department of Vascular, Endovascular and Renal Access, Mid Essex Hospitals Services NHS Trust, Broomfield Hospital, Essex, UK
| | - Thomas Browne
- Department of Vascular, Endovascular and Renal Access, Mid Essex Hospitals Services NHS Trust, Broomfield Hospital, Essex, UK
| |
Collapse
|
10
|
Abstract
Endovascular aneurysm repair (EVAR) is now the preferred procedure for abdominal aortic aneurysm repair. As a result of the need for fluoroscopy during EVAR, radiation exposure is a potential hazard. We studied the quantity of radiation delivered during EVAR to identify risks for excessive exposure. Fluoroscopy time, contrast volume used, and procedural details were recorded prospectively during EVARs. Using data collected from similar EVARs, an equation was derived to calculate approximate dose-area product (DAP) from fluoroscopy time. DAP values were then compared between procedures in which a relevant postdeployment procedure (PDP) was necessary intraoperatively with those without. Clinical data on 17 patients were collected. The mean age of patients was 68 (±9) years. Fluoroscopy times and approximate DAP values were found to be significantly higher in the seven patients with a PDP compared with the 10 patients without an intraoperative PDP (31.2 [±9.6] vs 22.7 [±6.0] minutes, P = 0.033 and 537 [±165] vs 390 [±103] Gy-cm2, P = 0.033, respectively). The average amount of contrast volume used was not significantly different between groups. Radiation emitted during EVARs with PDPs was significantly greater relative to those without PDPs. Device design and operators should thus aim to decrease PDPs and to minimize fluoroscopy time.
Collapse
Affiliation(s)
- Michael Butler
- From the Department of Surgery, University of California, Irvine Medical Center, Orange, California; and the Surgical Service, Veterans Administration Medical Center, Long Beach, California
| | - Madhukar S. Patel
- From the Department of Surgery, University of California, Irvine Medical Center, Orange, California; and the Surgical Service, Veterans Administration Medical Center, Long Beach, California
| | - Samuel E. Wilson
- From the Department of Surgery, University of California, Irvine Medical Center, Orange, California; and the Surgical Service, Veterans Administration Medical Center, Long Beach, California
| |
Collapse
|
11
|
Miller DL. Review of air kerma‐area product, effective dose and dose conversion coefficients for non‐cardiac interventional fluoroscopy procedures. Med Phys 2020; 47:975-982. [DOI: 10.1002/mp.13990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 11/08/2022] Open
Affiliation(s)
- Donald L. Miller
- Center for Devices and Radiological Health U.S. Food and Drug Administration Silver Spring MD 20993USA
| |
Collapse
|
12
|
Peroperative Intravascular Ultrasound for Endovascular Aneurysm Repair versus Peroperative Angiography: A Pilot Study in Fit Patients with Favorable Anatomy. Ann Vasc Surg 2019; 64:54-61. [PMID: 31726201 DOI: 10.1016/j.avsg.2019.11.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this study was to compare intravascular ultrasound (IVUS) assistance for endovascular aortic aneurysm repair (EVAR) to standard assistance by angiography. METHODS From June 2015 to June 2017, 173 consecutive patients underwent EVAR. In this group, 69 procedures were IVUS-assisted with X-ray exposure limited to completion angiography for safety purposes because an IVUS probe does not yet incorporate a duplex probe (group A), and 104 were angiography-assisted procedures (group B). All IVUS-assisted procedures were performed by vascular surgeons with basic duplex ultrasound (DUS) training. The primary study endpoints were mean radiation dose, duration of fluoroscopy, amount of contrast media administered, procedure-related outcomes, and renal clearance expressed as the glomerular filtration rate (GFR) before and after the procedure. Secondary endpoints were operative mortality, morbidity, and arterial access complications. RESULTS Mean duration of fluoroscopy time was significantly lower for IVUS-assisted procedures (24 ± 15 min vs. 40 ± 30 min for angiography-assisted procedures, P < 0.01). Moreover, mean radiation dose (Air KERMA) was significantly lower in IVUS-assisted procedures (76m Gy [44-102] vs. 131 mGy [58-494]), P < 0.01. IVUS-assisted procedures required fewer contrast media than standard angiography-assisted procedures (60 ± 20 mL vs. 120 ± 40 mL, P < 0.01). The mean duration of the procedure was comparable in the two groups (120 ± 30 min vs. 140 ± 30 min, P = 0.07). No difference in renal clearance before and after the procedure was observed in either of the two groups (99.0 ± 4/97.8 ± 2 mL/min in group A and 98.0 ± 3/97.6 ± 5 mL/min in group B) (P = 0.28). The mean length of follow-up was nine months (6-30 months). No postoperative mortality, morbidity, or arterial access complications occurred. No type 1 endoleak was observed. Early type II endoleaks were observed in 21 patients (11%), 12 in the angiography-assisted group (11%) and nine in the IVUS-assisted group (12%). They were not associated with sac enlargement ≥5 mm diameter and therefore did not require any additional treatment. CONCLUSIONS Compared with standard angiography-assisted EVAR, IVUS significantly reduces renal load with contrast media, fluoroscopy time, and radiation dose while preserving endograft deployment efficiency. Confirmation from a large prospective study with improved IVUS probes will be required before IVUS-assisted EVAR alone can become standard practice.
Collapse
|
13
|
Kalender G, Lisy M, Stock UA, Endisch A, Kornberger A. Long-term radiation exposure in patients undergoing EVAR: Reflecting clinical day-to-day practice to assess realistic radiation burden. Clin Hemorheol Microcirc 2019; 71:451-461. [PMID: 30248048 DOI: 10.3233/ch-170344] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Endovascular repair of aortic aneurysms (EVAR) has become an established treatment option currently applied in an increasing numbers of patients with aortic aneurysms. Advantages include reduced surgical trauma, procedural time, intensive care unit and hospital lengths of stay, blood loss as well as morbidity and mortality.The optimal imaging modalities in EVAR follow-up as well as the appropriate intervals between these follow-ups remain subject of controversial discussion. Objective of this study was the evaluation of the realistic radiation exposure and risk estimate postop EVAR treatment.Of the follow-ups required according to the surveillance schedule during the first year post-EVAR, only 68.3% were actually implemented. Of those required from the second year onwards, an average of 70% was actually performed. During the observation period, each patient underwent a mean of 4.3 CTAs. The median ED calculated from all CTAs was 24. 5 mSv. The minimum and maximum cumulative EDs for the entire observation period were 55 mSv and 310 mSv, respectively.
Collapse
Affiliation(s)
- G Kalender
- Department of Vascular and Endovascular Surgery, DRK Hospital Berlin Köpenick, Berlin, Germany
| | - M Lisy
- Department of Vascular and Endovascular Surgery, Krankenhaus Nordwest Frankfurt, Germany
| | - U A Stock
- Department of Cardiac and Transplant Surgery, Royal Brompton and Harefield NHS Trust, Harefield, UK
| | - A Endisch
- Department of Vascular and Endovascular Surgery, Asklepios Hospital Bad Tölz, Germany
| | - A Kornberger
- Department of Vascular, Thoracic and Cardiovascular Surgery, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| |
Collapse
|
14
|
Wermelink B, Willigendael EM, Smit C, Beuk RJ, Brusse-Keizer M, Meerwaldt R, Geelkerken RH. Radiation exposure in an endovascular aortic aneurysm repair program after introduction of a hybrid operating theater. J Vasc Surg 2019; 70:1927-1934.e2. [PMID: 31327609 DOI: 10.1016/j.jvs.2019.01.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/31/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND A hybrid operating theater (HOT) enables optimal image quality, improved ergonomics, and excellent sterility for complex endovascular and hybrid procedures. We hypothesize that the commissioning of a new HOT involves a learning curve. It is unclear how steep the learning curve of these advanced HOTs is. The main purpose of this research was to evaluate radiation exposure parameters in a new HOT for a team of vascular surgeons experienced with infrarenal endovascular aneurysm repair (EVAR) procedures in a conventional operating room with a mobile C-arm. In addition, a comparison of the dose-area product (DAP) achieved in this study and in the literature was made. METHODS Before commissioning of the HOT, four vascular surgeons completed a comprehensive HOT training program. From the commissioning of the HOT, clinical and procedural data for all consecutive acute and elective patients treated with EVAR were retrospectively collected for a period of 18 months (January 2016-June 2017). A literature review was conducted of the dose-area product in EVAR procedures performed with a dedicated fixed system or mobile C-arm to analyze how this study performed compared with the literature. RESULTS In the 18-month study period, 77 patients were treated with EVAR (59 electively and 18 acutely), from whom the data were obtained. There was no significant change in radiation exposure parameters over time. From the commissioning of the HOT, EVAR procedures were performed with radiation exposure parameters similar to those of studies found in experienced vascular centers using fixed systems. CONCLUSIONS Concerning radiation exposure parameters, the commissioning of a new HOT was not accompanied by a learning curve. Radiation exposure parameters achieved in this study were similar to those of studies from experienced and dedicated vascular centers.
Collapse
Affiliation(s)
- Bryan Wermelink
- Department of Vascular Surgery, Medical Spectrum Twente, Enschede, the Netherlands; TechMed Centre, Faculty of Science and Technology, University of Twente, Enschede, the Netherlands.
| | - Edith M Willigendael
- Department of Vascular Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - Casper Smit
- Medical Technology, Medical Spectrum Twente, Enschede, the Netherlands
| | - Roland J Beuk
- Department of Vascular Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - Robbert Meerwaldt
- Department of Vascular Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medical Spectrum Twente, Enschede, the Netherlands; TechMed Centre, Faculty of Science and Technology, University of Twente, Enschede, the Netherlands
| |
Collapse
|
15
|
Fusion Imaging Reduces Radiation and Contrast Medium Exposure During Endovascular Revascularization of Iliac Steno-Occlusive Disease. Cardiovasc Intervent Radiol 2019; 42:1635-1643. [PMID: 31187227 DOI: 10.1007/s00270-019-02250-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/21/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION To evaluate feasibility, safety and efficacy of fusion imaging in order to guide endovascular revascularization of iliac steno-occlusive disease. MATERIALS AND METHODS Retrospectively, we identified twenty-six patients (20 male, mean age 63 ± 8y; Rutherford II-V) who underwent revascularization of a chronic total occlusion (n = 6; 23%) or severe stenosis (n = 20; 77%) of the common and/or external iliac artery. Median lesion length was 33 mm (IQR 20-60). In one group of patients (NEW; n = 11), fusion imaging with 2-D/3-D registration was used to guide revascularization. No baseline digital subtraction angiography (DSA) had been acquired in these patients. In another group of patients (OLD; n = 15), no fusion imaging had been utilized and at least one DSA run had been performed to guide the procedure. In both groups, final DSA of the treated lesions was performed. Number of DSA runs, radiation and contrast medium exposure, technical success (residual stenosis < 30%) and complications were analyzed. RESULTS Median DSA runs needed in OLD for guidance were n = 2 (IQR 2-3) and in NEW n = 0 (IQR 0-0; p = 0.001). Compared to OLD, median dose area product (DAP) was reduced by 17,118 mGy*cm2 (IQR 10,407-23,614; p = 0.016) if fusion imaging guidance had been used (NEW). Based on the median DAP of the final angiogram in NEW, median DAP reduction was 6007 mGy*cm2 (IQR 5012-16,105; p = 0.1). Median total contrast medium volume injected in NEW was 45 ml (IQR 30-90) and in OLD 120 ml (IQR 100-140; p = 0.001). Technical success was 100% for both groups. In 1/27 patients (3.7%) a minor complication (embolism) occurred. CONCLUSION Fusion imaging proved to be feasible as well as safe and significantly reduces radiation and contrast medium exposure during endovascular revascularization of iliac steno-occlusive disease.
Collapse
|
16
|
Grima MJ, Karthikesalingam A, Holt PJ, Kerr D, Chetter I, Harrison S, Sayers R, Roy I, Vallabhaneni SR, Dominic P, Bachoo P, Griffin J, Lewis D, Hardman J, Rihan A, Brooks M, Woodburn K, Godfrey D, Nordon I, Vidal-Diez A, Stenson K, Bahia S, Patterson B, Oladokun D, De Bruin J, Loftus I, Thompson MM, Lowe C, Ashrafi M, Ghosh J, Ashleigh R. Multicentre Post-EVAR Surveillance Evaluation Study (EVAR-SCREEN). Eur J Vasc Endovasc Surg 2019; 57:521-526. [DOI: 10.1016/j.ejvs.2018.10.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 10/27/2018] [Indexed: 11/29/2022]
|
17
|
Harky A, Zywicka E, Santoro G, Jullian L, Joshi M, Dimitri S. Is contrast-enhanced ultrasound (CEUS) superior to computed tomography angiography (CTA) in detection of endoleaks in post-EVAR patients? A systematic review and meta-analysis. J Ultrasound 2019; 22:65-75. [PMID: 30771104 DOI: 10.1007/s40477-019-00364-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/08/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE The purpose of this systematic review and meta-analysis was to assess the sensitivity and specificity of contrast-enhanced ultrasound (CEUS) compared to computed tomography angiography (CTA) for the detection of endoleaks within endovascular aortic aneurysm repair (EVAR) surveillance at time of follow up. METHODS A comprehensive literature search was undertaken among the four major databases (PubMed, Embase, Scopus and Ovid) to identify all articles assessing diagnostic specificity and accuracy with comparative modality (CEUS vs CTA) for endoleaks in adult patients at time of follow-up following EVAR. Databases where evaluated and assessed to October 2018. RESULTS A total of 1773 patients were analysed from across 18 included studies in the quantitative analysis of the parameters of interest. There was no significant difference in detection rate of endoleak type I with detection rate 4.3% for both groups OR 1.09, 95% CI [0.78, 1.53], p = 0.62; type II endoleak detection rate was 22% in the CEUS group vs 23% in the CTA group OR 1.16, 95% CI [0.75-1.79], p = 0.50; while type III detection rate was 1.8% in CEUS group vs 2% in CTA group OR 0.85, 95% CI [0.43, 1.68], p = 0.64. However, the sensitivity rate for endoleak detection was higher in CEUS (p = 0.001) while no difference in specificity rate was noted (p = 0.28). There was higher rate of missed endoleaks in CTA groups (n = 12 vs n = 20). CONCLUSION Evidences from this study suggest that contrast-enhanced ultrasound scan post-EVAR can be utilised as safe and effective method in screening for endoleaks during post-EVAR surveillance without exposing the patient for additional risk of radiation and contrast. CEUS conveys no inferiority to CTA in detecting endoleaks.
Collapse
Affiliation(s)
- Amer Harky
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, CH2 1UL, UK.
| | - Ewa Zywicka
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, CH2 1UL, UK
| | - Giovanni Santoro
- Department of General Surgery, Warrington and Halton NHS Foundation Trust, Warrington, WA5 1QG, UK
| | - Lucas Jullian
- Department of Cardiac Surgery, Barts Heart Centre, London, EC1A 7BE, UK
| | - Mihika Joshi
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, CH2 1UL, UK
| | - Sameh Dimitri
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, CH2 1UL, UK
| |
Collapse
|
18
|
García-Vázquez V, von Haxthausen F, Jäckle S, Schumann C, Kuhlemann I, Bouchagiar J, Höfer AC, Matysiak F, Hüttmann G, Goltz JP, Kleemann M, Ernst F, Horn M. Navigation and visualisation with HoloLens in endovascular aortic repair. Innov Surg Sci 2018; 3:167-177. [PMID: 31579781 PMCID: PMC6604581 DOI: 10.1515/iss-2018-2001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/29/2018] [Indexed: 01/30/2023] Open
Abstract
Introduction Endovascular aortic repair (EVAR) is a minimal-invasive technique that prevents life-threatening rupture in patients with aortic pathologies by implantation of an endoluminal stent graft. During the endovascular procedure, device navigation is currently performed by fluoroscopy in combination with digital subtraction angiography. This study presents the current iterative process of biomedical engineering within the disruptive interdisciplinary project Nav EVAR, which includes advanced navigation, image techniques and augmented reality with the aim of reducing side effects (namely radiation exposure and contrast agent administration) and optimising visualisation during EVAR procedures. This article describes the current prototype developed in this project and the experiments conducted to evaluate it. Methods The current approach of the Nav EVAR project is guiding EVAR interventions in real-time with an electromagnetic tracking system after attaching a sensor on the catheter tip and displaying this information on Microsoft HoloLens glasses. This augmented reality technology enables the visualisation of virtual objects superimposed on the real environment. These virtual objects include three-dimensional (3D) objects (namely 3D models of the skin and vascular structures) and two-dimensional (2D) objects [namely orthogonal views of computed tomography (CT) angiograms, 2D images of 3D vascular models, and 2D images of a new virtual angioscopy whose appearance of the vessel wall follows that shown in ex vivo and in vivo angioscopies]. Specific external markers were designed to be used as landmarks in the registration process to map the tracking data and radiological data into a common space. In addition, the use of real-time 3D ultrasound (US) is also under evaluation in the Nav EVAR project for guiding endovascular tools and updating navigation with intraoperative imaging. US volumes are streamed from the US system to HoloLens and visualised at a certain distance from the probe by tracking augmented reality markers. A human model torso that includes a 3D printed patient-specific aortic model was built to provide a realistic test environment for evaluation of technical components in the Nav EVAR project. The solutions presented in this study were tested by using an US training model and the aortic-aneurysm phantom. Results During the navigation of the catheter tip in the US training model, the 3D models of the phantom surface and vessels were visualised on HoloLens. In addition, a virtual angioscopy was also built from a CT scan of the aortic-aneurysm phantom. The external markers designed for this study were visible in the CT scan and the electromagnetically tracked pointer fitted in each marker hole. US volumes of the US training model were sent from the US system to HoloLens in order to display them, showing a latency of 259±86 ms (mean±standard deviation). Conclusion The Nav EVAR project tackles the problem of radiation exposure and contrast agent administration during EVAR interventions by using a multidisciplinary approach to guide the endovascular tools. Its current state presents several limitations such as the rigid alignment between preoperative data and the simulated patient. Nevertheless, the techniques shown in this study in combination with fibre Bragg gratings and optical coherence tomography are a promising approach to overcome the problems of EVAR interventions.
Collapse
Affiliation(s)
- Verónica García-Vázquez
- Institute for Robotics and Cognitive Systems, University of Lübeck, Ratzeburger Allee 160, Lübeck 23562, Germany
| | - Felix von Haxthausen
- Institute for Robotics and Cognitive Systems, University of Lübeck, Lübeck, Germany
| | - Sonja Jäckle
- Fraunhofer MEVIS - Institute for Medical Image Computing, Lübeck, Germany
| | - Christian Schumann
- Fraunhofer MEVIS - Institute for Medical Image Computing, Bremen, Germany
| | - Ivo Kuhlemann
- Institute for Robotics and Cognitive Systems, University of Lübeck, Lübeck, Germany
| | - Juljan Bouchagiar
- Division of Vascular- and Endovascular Surgery, Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Anna-Catharina Höfer
- Division of Vascular- and Endovascular Surgery, Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Florian Matysiak
- Division of Vascular- and Endovascular Surgery, Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Gereon Hüttmann
- Institute of Biomedical Optics, University of Lübeck, Lübeck, Germany
| | - Jan Peter Goltz
- Division of Interventional Radiology, Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Markus Kleemann
- Division of Vascular- and Endovascular Surgery, Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Floris Ernst
- Institute for Robotics and Cognitive Systems, University of Lübeck, Lübeck, Germany
| | - Marco Horn
- Division of Vascular- and Endovascular Surgery, Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.,Vascular Unit, Department of Surgery, Prince of Wales Hospital, Sydney, Australia
| |
Collapse
|
19
|
Fiorella D, Lylyk P, Szikora I, Kelly ME, Albuquerque FC, McDougall CG, Nelson PK. Curative cerebrovascular reconstruction with the Pipeline embolization device: the emergence of definitive endovascular therapy for intracranial aneurysms. J Neurointerv Surg 2018; 10:i9-i18. [DOI: 10.1136/jnis.2009.000083.rep] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 04/03/2009] [Indexed: 11/03/2022]
Abstract
Endovascular, endosaccular, coil embolization has emerged as an established therapy for both ruptured and unruptured cerebral aneurysms. However, many aneurysms are not cured using conventional endovascular techniques. Coil embolization often results in incomplete aneurysm occlusion or recanalization in the ensuing months after treatment. The Pipeline embolization device (PED; Chestnut Medical) represents a new generation endoluminal implant which is designed to treat aneurysms by reconstructing the diseased parent artery. Immediately after implantation, the PED functions to divert flow from the aneurysm, creating an environment conducive to thrombosis. With time, the PED is incorporated into the vessel wall as neointimal–endothelial overgrowth occurs along the construct. Ultimately, this process results in the durable complete exclusion of the aneurysm from the cerebrovasculature and a definitive endoluminal reconstruction of the diseased parent artery.
Collapse
|
20
|
Radiation dose during endovascular aneurysm repair (EVAR): upgrade of an angiographic system from standard to Eco mode. Radiol Med 2018; 123:966-972. [DOI: 10.1007/s11547-018-0924-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022]
|
21
|
Fidalgo Domingos L, San Norberto García EM, Gutiérrez Castillo D, Flota Ruiz C, Estévez Fernández I, Vaquero Puerta C. Radioprotection Measures during the Learning Curve with Hybrid Operating Rooms. Ann Vasc Surg 2018; 50:253-258. [PMID: 29501596 DOI: 10.1016/j.avsg.2017.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/07/2017] [Accepted: 12/17/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND Endovascular procedures come with a potential risk of radiation hazards both to patients and to the vascular staff. Classically, most endovascular interventions took place in regular operating rooms (ORs) using a fluoroscopy C-arm unit controlled by a third party. Hybrid operating rooms (HORs) provide an optimal surgical suit with all the qualities of a fixed C-arm device, while allowing the device to be controlled by the surgical team. The latest studies suggest that an operator-controlled system may reduce the radiation dose. The purpose of the present study is to determine the amount of absorbed radiation using an HOR in comparison with a portable C-arm unit and to assess whether the radioprotection awareness of the surgical team influences the radiation exposure. The primary end point was the effective dose in milliSievert (mSv) for the surgical team and the average dose-area product (ADAP) in Gray-meters squared (Gym2) for patients. METHODS The values of absorbed radiation of the surgical team's dosimeters were collected from January 2015 to May 2016. The HOR was installed in June 2015, and a radioprotection seminar was given in October 2015. The HOR-issued radiation, measured by the maximum dose-area product, ADAP, average dose (AD) per procedure, maximum dose per procedure per month, maximum fluoroscopy time, average fluoroscopic time, peak skin dose, and average skin dose (ASD), was collected monthly from September 2015 to July 2016. The timeline was divided into 3 periods: 5 months pre-HOR (Pre-HOR), 5 months after the HOR installation (PreS-HOR), and 5 months after a radioprotection seminar (PostS-HOR). RESULTS The average number of procedures per month was 22.55 (±4.9), including endovascular aneurysm repair/thoracic endovascular aneurysm repair, carotid, visceral, and upper and lower limb endovascular revascularization. The average amount of absorbed radiation by the surgeons during PreS-HOR was 1.07 ± 0.4 mSv, which was higher than the other periods (Pre-HOR 0.06 ± 0.03 mSv, P = 0.002; PostS-HOR 0.14 ± 0.09 mSv, P = 0.000, respectively). The ADAP during PreS-HOR was 0.016 ± 0.01 Gym2, which was lower than the PostS-HOR (0.001 ± 0.002 Gym2) (P = 0.034). The AD during PreS-HOR was 0.78 ± 0.3 Gy and 0.39 ± 0.3 Gy during PostS-HOR (P = 0.098). The ASD during PreS-HOR was 0.40 ± 0.2 Gy and 0.20 ± 0.1 Gy during PostS-HOR (P = 0.099). CONCLUSIONS In our experience, the HOR increases the amount of absorbed radiation for both patients and surgeons. The radioprotection seminars are of utmost importance to provide a continued training and optimize the use of ionizing radiation while using an HOR. Despite the awareness of the surgical team in the radioprotection field, the amount of absorbed radiation using an HOR is higher than the one using a C-Arm unit.
Collapse
Affiliation(s)
- Liliana Fidalgo Domingos
- Department of Angiology and Vascular Surgery, Valladolid University Hospital, Valladolid, Spain.
| | | | | | - Cintia Flota Ruiz
- Department of Angiology and Vascular Surgery, Valladolid University Hospital, Valladolid, Spain
| | | | - Carlos Vaquero Puerta
- Department of Angiology and Vascular Surgery, Valladolid University Hospital, Valladolid, Spain
| |
Collapse
|
22
|
Pégorié A, Amabile J, Dondey M, Boddaert G, De Carbonnières A, Bauss A, Pierret C, Entine F, Michel X, Erauso T, Gagna G. Chirurgie endovasculaire : évaluation de l’exposition radiologique et proposition d’axes d’amélioration. ARCH MAL PROF ENVIRO 2018. [DOI: 10.1016/j.admp.2017.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
23
|
A systematic review of surveillance after endovascular aortic repair. J Vasc Surg 2018; 67:320-331.e37. [DOI: 10.1016/j.jvs.2017.04.058] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/23/2017] [Indexed: 11/17/2022]
|
24
|
Machado R, Ferreira VMD, Loureiro L, Gonçalves J, Oliveira P, Almeida R. Radiation Exposure in Endovascular Infra-Renal Aortic Aneurysm Repair and Factors that Influence It. Braz J Cardiovasc Surg 2017; 31:415-421. [PMID: 28076617 PMCID: PMC5407135 DOI: 10.5935/1678-9741.20160084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/30/2016] [Indexed: 11/20/2022] Open
Abstract
Objective The endovascular repair of aortic abdominal aneurysms exposes the patients
and surgical team to ionizing radiation with risk of direct tissue damage
and induction of gene mutation. This study aims to describe our standard of
radiation exposure in endovascular aortic aneurysm repair and the factors
that influence it. Methods Retrospective analysis of a prospective database of patients with abdominal
infra-renal aortic aneurysms submitted to endovascular repair. This study
evaluated the radiation doses (dose area product (DAP)), fluoroscopy
durations and their relationships to the patients, aneurysms, and
stent-graft characteristics. Results This study included 127 patients with a mean age of 73 years. The mean DAP
was 4.8 mGy.m2, and the fluoroscopy time was 21.8 minutes. Aortic
bilateral iliac aneurysms, higher body mass index, aneurysms with diameters
larger than 60 mm, necks with diameters larger than 28 mm, common iliac
arteries with diameters larger than 20 mm, and neck angulations superior to
50 degrees were associated with an increased radiation dose. The number of
anatomic risk factors present was associated with increased radiation
exposure and fluoroscopy time, regardless of the anatomical risk
factors. Conclusion The radiation exposure during endovascular aortic aneurysm repair is
significant (mean DAP 4.8 mGy.m2) with potential hazards to the
surgical team and the patients. The anatomical characteristics of the
aneurysm, patient characteristics, and the procedure's technical difficulty
were all related to increased radiation exposure during endovascular aortic
aneurysm repair procedures. Approximately 40% of radiation exposure can be
explained by body mass index, neck angulation, aneurysm diameter, neck
diameter, and aneurysm type.
Collapse
Affiliation(s)
- Rui Machado
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | | | - Luis Loureiro
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - João Gonçalves
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Pedro Oliveira
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
| | - Rui Almeida
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| |
Collapse
|
25
|
Identification of Factors Influencing Cumulative Long-Term Radiation Exposure in Patients Undergoing EVAR. Int J Vasc Med 2017; 2017:9763075. [PMID: 29250445 PMCID: PMC5700475 DOI: 10.1155/2017/9763075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/24/2017] [Accepted: 10/03/2017] [Indexed: 02/01/2023] Open
Abstract
Patients who undergo endovascular repair of aortic aneurysms (EVAR) require life-long surveillance because complications including, in particular, endoleaks, aneurysm rupture, and graft dislocation are diagnosed in a certain share of the patient population and may occur at any time after the original procedure. Radiation exposure in patients undergoing EVAR and post-EVAR surveillance has been investigated by previous authors. Arriving at realistic exposure data is essential because radiation doses resulting from CT were shown to be not irrelevant. Efforts directed at identification of factors impacting the level of radiation exposure in both the course of the EVAR procedure and post-EVAR endovascular interventions and CTAs are warranted as potentially modifiable factors may offer opportunities to reduce the radiation. In the light of the risks found to be associated with radiation exposure and considering the findings above, those involved in EVAR and post-EVAR surveillance should aim at optimal dose management.
Collapse
|
26
|
El-Sayed T, Patel AS, Cho JS, Kelly JA, Ludwinski FE, Saha P, Lyons OT, Smith A, Modarai B. Radiation-Induced DNA Damage in Operators Performing Endovascular Aortic Repair. Circulation 2017; 136:2406-2416. [PMID: 29054934 PMCID: PMC5753831 DOI: 10.1161/circulationaha.117.029550] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 09/15/2017] [Indexed: 12/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Radiation exposure during fluoroscopically guided interventions such as endovascular aortic repair (EVAR) is a growing concern for operators. This study aimed to measure DNA damage/repair markers in operators perfoming EVAR. Methods: Expression of the DNA damage/repair marker, γ-H2AX and DNA damage response marker, phosphorylated ataxia telangiectasia mutated (pATM), were quantified in circulating lymphocytes in operators during the peri-operative period of endovascular (infrarenal, branched, and fenestrated) and open aortic repair using flow cytometry. These markers were separately measured in the same operators but this time wearing leg lead shielding in addition to upper body protection and compared with those operating with unprotected legs. Susceptibility to radiation damage was determined by irradiating operators’ blood in vitro. Results: γ-H2AX and pATM levels increased significantly in operators immediately after branched endovascular aortic repair/fenestrated endovascular aortic repair (P<0.0003 for both). Only pATM levels increased after infrarenal endovascular aortic repair (P<0.04). Expression of both markers fell to baseline in operators after 24 hours (P<0.003 for both). There was no change in γ-H2AX or pATM expression after open repair. Leg protection abrogated γ-H2AX and pATM response after branched endovascular aortic repair/fenestrated endovascular aortic repair. The expression of γ-H2AX varied significantly when operators’ blood was exposed to the same radiation dose in vitro (P<0.0001). Conclusions: This is the first study to detect an acute DNA damage response in operators performing fluoroscopically guided aortic procedures and highlights the protective effect of leg shielding. Defining the relationship between this response and cancer risk may better inform safe levels of chronic low-dose radiation exposure.
Collapse
Affiliation(s)
- Tamer El-Sayed
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, King's College London, BHF Centre of Excellence at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Ashish S Patel
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, King's College London, BHF Centre of Excellence at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jun S Cho
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, King's College London, BHF Centre of Excellence at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - James A Kelly
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, King's College London, BHF Centre of Excellence at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Francesca E Ludwinski
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, King's College London, BHF Centre of Excellence at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Prakash Saha
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, King's College London, BHF Centre of Excellence at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Oliver T Lyons
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, King's College London, BHF Centre of Excellence at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Alberto Smith
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, King's College London, BHF Centre of Excellence at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Bijan Modarai
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, King's College London, BHF Centre of Excellence at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | | |
Collapse
|
27
|
Attallah O, Karthikesalingam A, Holt PJ, Thompson MM, Sayers R, Bown MJ, Choke EC, Ma X. Using multiple classifiers for predicting the risk of endovascular aortic aneurysm repair re-intervention through hybrid feature selection. Proc Inst Mech Eng H 2017; 231:1048-1063. [PMID: 28925817 DOI: 10.1177/0954411917731592] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Feature selection is essential in medical area; however, its process becomes complicated with the presence of censoring which is the unique character of survival analysis. Most survival feature selection methods are based on Cox's proportional hazard model, though machine learning classifiers are preferred. They are less employed in survival analysis due to censoring which prevents them from directly being used to survival data. Among the few work that employed machine learning classifiers, partial logistic artificial neural network with auto-relevance determination is a well-known method that deals with censoring and perform feature selection for survival data. However, it depends on data replication to handle censoring which leads to unbalanced and biased prediction results especially in highly censored data. Other methods cannot deal with high censoring. Therefore, in this article, a new hybrid feature selection method is proposed which presents a solution to high level censoring. It combines support vector machine, neural network, and K-nearest neighbor classifiers using simple majority voting and a new weighted majority voting method based on survival metric to construct a multiple classifier system. The new hybrid feature selection process uses multiple classifier system as a wrapper method and merges it with iterated feature ranking filter method to further reduce features. Two endovascular aortic repair datasets containing 91% censored patients collected from two centers were used to construct a multicenter study to evaluate the performance of the proposed approach. The results showed the proposed technique outperformed individual classifiers and variable selection methods based on Cox's model such as Akaike and Bayesian information criterions and least absolute shrinkage and selector operator in p values of the log-rank test, sensitivity, and concordance index. This indicates that the proposed classifier is more powerful in correctly predicting the risk of re-intervention enabling doctor in selecting patients' future follow-up plan.
Collapse
Affiliation(s)
- Omneya Attallah
- 1 Department of Electronics and Communications, College of Engineering and Technology, Arab Academy for Science and Technology, Alexandria, Egypt.,2 School of Engineering and Applied Science, Aston University, Birmingham, UK
| | - Alan Karthikesalingam
- 3 St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Peter Je Holt
- 3 St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Matthew M Thompson
- 3 St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Rob Sayers
- 4 NIHR Leicester Cardiovascular Biomedical Research Unit and Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Matthew J Bown
- 4 NIHR Leicester Cardiovascular Biomedical Research Unit and Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Eddie C Choke
- 4 NIHR Leicester Cardiovascular Biomedical Research Unit and Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Xianghong Ma
- 2 School of Engineering and Applied Science, Aston University, Birmingham, UK
| |
Collapse
|
28
|
Sun Z, Ng CKC. Use of Synchrotron Radiation to Accurately Assess Cross-Sectional Area Reduction of the Aortic Branch Ostia Caused by Suprarenal Stent Wires. J Endovasc Ther 2017; 24:870-879. [PMID: 28922970 DOI: 10.1177/1526602817732315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To compare in vivo the use of synchrotron radiation to computed tomography angiography (CTA) for the measurement of cross-sectional area (CSA) reduction of the aortic branch ostia caused by suprarenal stent-graft wires. METHODS This study was performed with a Zenith stent-graft placed in a phantom of the human aorta to simulate treatment of abdominal aortic aneurysm. Synchrotron radiation scans were performed using beam energies between 40 and 100 keV and spatial resolution of 19.88 μm per pixel. CSA reduction of the aortic branch ostia by suprarenal stent wires was calculated based on these exposure factors and compared with measurements from CTA images acquired on a 64-row scanner with slice thicknesses of 1.0, 1.5, and 2.0 mm. RESULTS Images acquired with synchrotron radiation showed <10% of the CSA occupied by stent wires when a single wire crossed a renal artery ostium and <20% for 2 wires crossing a renovisceral branch ostium. The corresponding areas ranged from 24% to 25% for a single wire and from 40% to 48% for double wires crossing the branch ostia when measured on CT images. The stent wire was accurately assessed on synchrotron radiation with a diameter between 0.38±0.01 and 0.53±0.03 mm, which is close to the actual size of 0.47±0.01 mm. The wire diameter measured on CT images was greatly overestimated (1.15±0.01 to 1.57±0.02 mm). CONCLUSION CTA has inferior spatial resolution that hinders accurate assessment of CSA reduction. This experiment demonstrated the superiority of synchrotron radiation over CTA for more accurate assessment of aortic stent wires and CSA reduction of the aortic branch ostia.
Collapse
Affiliation(s)
- Zhonghua Sun
- 1 Department of Medical Radiation Sciences, Curtin University, Perth, Western Australia, Australia
| | - Curtise K C Ng
- 1 Department of Medical Radiation Sciences, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
29
|
Attallah O, Karthikesalingam A, Holt PJE, Thompson MM, Sayers R, Bown MJ, Choke EC, Ma X. Feature selection through validation and un-censoring of endovascular repair survival data for predicting the risk of re-intervention. BMC Med Inform Decis Mak 2017; 17:115. [PMID: 28774329 PMCID: PMC5543447 DOI: 10.1186/s12911-017-0508-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/24/2017] [Indexed: 12/25/2022] Open
Abstract
Background Feature selection (FS) process is essential in the medical area as it reduces the effort and time needed for physicians to measure unnecessary features. Choosing useful variables is a difficult task with the presence of censoring which is the unique characteristic in survival analysis. Most survival FS methods depend on Cox’s proportional hazard model; however, machine learning techniques (MLT) are preferred but not commonly used due to censoring. Techniques that have been proposed to adopt MLT to perform FS with survival data cannot be used with the high level of censoring. The researcher’s previous publications proposed a technique to deal with the high level of censoring. It also used existing FS techniques to reduce dataset dimension. However, in this paper a new FS technique was proposed and combined with feature transformation and the proposed uncensoring approaches to select a reduced set of features and produce a stable predictive model. Methods In this paper, a FS technique based on artificial neural network (ANN) MLT is proposed to deal with highly censored Endovascular Aortic Repair (EVAR). Survival data EVAR datasets were collected during 2004 to 2010 from two vascular centers in order to produce a final stable model. They contain almost 91% of censored patients. The proposed approach used a wrapper FS method with ANN to select a reduced subset of features that predict the risk of EVAR re-intervention after 5 years to patients from two different centers located in the United Kingdom, to allow it to be potentially applied to cross-centers predictions. The proposed model is compared with the two popular FS techniques; Akaike and Bayesian information criteria (AIC, BIC) that are used with Cox’s model. Results The final model outperforms other methods in distinguishing the high and low risk groups; as they both have concordance index and estimated AUC better than the Cox’s model based on AIC, BIC, Lasso, and SCAD approaches. These models have p-values lower than 0.05, meaning that patients with different risk groups can be separated significantly and those who would need re-intervention can be correctly predicted. Conclusion The proposed approach will save time and effort made by physicians to collect unnecessary variables. The final reduced model was able to predict the long-term risk of aortic complications after EVAR. This predictive model can help clinicians decide patients’ future observation plan. Electronic supplementary material The online version of this article (doi:10.1186/s12911-017-0508-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Omneya Attallah
- School of Engineering and Applied Science, Aston University, B4 7ET, Birmingham, UK.,Department of Electronics and Communications, College of Engineering and Technology, Arab Academy for Science and Technology, Alexandria, Egypt
| | | | | | | | - Rob Sayers
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Matthew J Bown
- Vascular Surgery Group, University of Leicester, Leicester, UK
| | - Eddie C Choke
- Vascular Surgery Group, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, University of Leicester, Leicester, LE2 7LX, UK
| | - Xianghong Ma
- School of Engineering and Applied Science, Aston University, B4 7ET, Birmingham, UK.
| |
Collapse
|
30
|
Tuthill E, O'Hora L, O'Donohoe M, Panci S, Gilligan P, Campion D, Trenti R, Fox E, Catania D, Rainford L. Investigation of reference levels and radiation dose associated with abdominal EVAR (endovascular aneurysm repair) procedures across several European Centres. Eur Radiol 2017; 27:4846-4856. [PMID: 28523354 DOI: 10.1007/s00330-017-4791-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 02/02/2017] [Accepted: 03/06/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Endovascular aneurysm repair (EVAR) is considered the treatment of choice for abdominal aortic aneurysms with suitable anatomy. In order to improve radiation safety, European Directive (2013/59) requires member states to implement diagnostic reference levels (DRLs) in radio-diagnostic and interventional procedures. This study aimed to determine local DRLs for EVAR across five European centres and identify an interim European DRL, which currently remains unestablished. METHODS Retrospective data was collected for 180 standard EVARs performed between January 2014 and July 2015 from five specialist centres in Ireland (n=2) and Italy (n=3). Data capture included: air kerma-area product (PKA), total air kerma at the reference point (Ka,r), fluoroscopic time (FT), number of acquisitions, frame rate of acquisition, type of acquisition, patient height, weight, and gender. RESULTS The mean values for each site A, B, C, D, and E were: PKAs of 4343 ± 994 μGym2, 18,200 ± 2141 μGym2, 11,423 ± 1390 μGym2, 7796 ± 704 μGym2, 31,897 ± 5798 μGym2; FTs of 816 ± 92 s, 950 ± 150 s, 708 ± 70 s, 972 ± 61 s, 827 ± 118 s; and number of acquisitions of 6.72 ± 0.56, 10.38 ± 1.54, 4.74 ± 0.19, 5.64 ± 0.36, 7.28 ± 0.65, respectively. The overall pooled 75th percentile PKA was 15,849 μGym2. CONCLUSION Local reference levels were identified. The pooled data has been used to establish an interim European DRL for EVAR procedures. KEY POINTS • Abdominal endovascular aneurysm repair (EVAR) requires the use of ionising radiation. • EVAR is a minimally invasive procedure for the treatment of abdominal aortic aneurysms. • Diagnostic reference levels (DRLs) are used to monitor patient radiation exposure. • Radiation dose data was collected from five European centres for EVAR procedures. • Local DRLs have been determined and an interim European DRL is proposed.
Collapse
Affiliation(s)
- E Tuthill
- Diagnostic Imaging, School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
| | - L O'Hora
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - M O'Donohoe
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - S Panci
- San Giovanni di Dio Hospital, Florence, Italy
| | | | - D Campion
- Mauriziano-Umberto Hospital, Turin, Italy
| | - R Trenti
- Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - E Fox
- Mater Private Hospital, Dublin, Ireland
| | - D Catania
- AITRI, Association of Italian Interventional Radiographers, Milan, Italy
| | - L Rainford
- Diagnostic Imaging, School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| |
Collapse
|
31
|
Stahlberg E, Planert M, Panagiotopoulos N, Horn M, Wiedner M, Kleemann M, Barkhausen J, Goltz JP. Pre-operative Simulation of the Appropriate C-arm Position Using Computed Tomography Post-processing Software Reduces Radiation and Contrast Medium Exposure During EVAR Procedures. Eur J Vasc Endovasc Surg 2016; 53:269-274. [PMID: 27965020 DOI: 10.1016/j.ejvs.2016.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 10/21/2016] [Indexed: 02/04/2023]
Abstract
OBJECTIVE/BACKGROUND The aim was to evaluate the feasibility and efficacy of a new method for pre-operative calculation of an appropriate C-arm position for iliac bifurcation visualisation during endovascular aortic repair (EVAR) procedures by using three dimensional computed tomography angiography (CTA) post-processing software. METHODS Post-processing software was used to simulate C-arm angulations in two dimensions (oblique, cranial/caudal) for appropriate visualisation of distal landing zones at the iliac bifurcation during EVAR. Retrospectively, 27 consecutive EVAR patients (25 men, mean ± SD age 73 ± 7 years) were identified; one group of patients (NEW; n = 12 [23 iliac bifurcations]) was compared after implementation of the new method with a group of patients who received a historic method (OLD; n = 15 [23 iliac bifurcations]), treated with EVAR before the method was applied. RESULTS In the OLD group, a median of 2.0 (interquartile range [IQR] 1-3) digital subtraction angiography runs were needed per iliac bifurcation versus 1.0 (IQR 1-1) runs in the NEW group (p = .007). The median dose area products per iliac bifurcation were 11951 mGy*cm2 (IQR 7308-16663 mGy*cm2) for the NEW, and 39394 mGy*cm2 (IQR 19066-53702 mGy*cm2) for the OLD group, respectively (p = .001). The median volume of contrast per iliac bifurcation was 13.0 mL (IQR: 13-13 mL) in the NEW and 26 mL (IQR 13-39 mL) in the OLD group (p = .007). CONCLUSION Pre-operative simulation of the appropriate C-arm angulation in two dimensions using dedicated computed tomography angiography post-processing software is feasible and significantly reduces radiation and contrast medium exposure.
Collapse
Affiliation(s)
- E Stahlberg
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Lübeck, Germany.
| | - M Planert
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - N Panagiotopoulos
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - M Horn
- Department for Surgery, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - M Wiedner
- Department for Surgery, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - M Kleemann
- Department for Surgery, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - J Barkhausen
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - J P Goltz
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Lübeck, Germany
| |
Collapse
|
32
|
de Ruiter QMB, Reitsma JB, Moll FL, van Herwaarden JA. Meta-analysis of Cumulative Radiation Duration and Dose During EVAR Using Mobile, Fixed, or Fixed/3D Fusion C-Arms. J Endovasc Ther 2016; 23:944-956. [DOI: 10.1177/1526602816668305] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Purpose: To investigate the total fluoroscopy time and radiation exposure dose during endovascular aortic repairs using mobile, fixed, or fixed C-arms with 3-dimensional image fusion (3D-IF). Methods: A systematic search was performed to identify original articles reporting fluoroscopy time (FT) and the kerma area product (KAP) during endovascular aortic repairs. Data were grouped by noncomplex or complex (fenestrated, branched, or chimney) repairs and stratified by type of C-arm. The search identified 27 articles containing 51 study groups (35 noncomplex and 16 complex) that included 3444 patients. Random-effects meta-analysis and meta-regression models were used to calculate the pooled mean estimates of KAP and FT, as well as any effect of equipment or type of intervention. Results are presented with the 95% confidence interval and the statistical heterogeneity ( I2). Results: Within the noncomplex procedure studies, a significant (p<0.001) increase was found in the pooled mean KAP estimate in the fixed C-arm group (181 Gy·cm2, 95% CI 129 to 233; I2=99.7) compared with the mobile C-arm (78 Gy·cm2, 95% CI 59.6 to 97.3; I2=99.6). For complex cases, use of 3D-IF showed a significantly (p<0.001) lower mean KAP (139 Gy·cm2, 95% CI 85 to 191; I2=94%) compared to using fixed C-arms without 3D-IF (487 Gy·cm2, 95% CI 331 to 643; I2=94%). Conclusion: For equivalent fluoroscopy times, the use of a fixed C-arm in noncomplex procedures leads to higher patient radiation doses compared to a mobile C-arm. Complex procedures, which are predominantly performed using fixed C-arms, are associated with the highest radiation dose per intervention. Using fixed C-arms combined with 3D-IF techniques during complex cases might seem an adequate method to compensate for the higher radiation doses measured when a fixed C-arm is used.
Collapse
Affiliation(s)
| | - Johannes B. Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | | |
Collapse
|
33
|
Endoleak Assessment Using Computational Fluid Dynamics and Image Processing Methods in Stented Abdominal Aortic Aneurysm Models. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2016; 2016:9567294. [PMID: 27660648 PMCID: PMC5021907 DOI: 10.1155/2016/9567294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/02/2016] [Accepted: 08/09/2016] [Indexed: 11/18/2022]
Abstract
Endovascular aortic aneurysm repair (EVAR) is a predominant surgical procedure to reduce the risk of aneurysm rupture in abdominal aortic aneurysm (AAA) patients. Endoleak formation, which eventually requires additional surgical reoperation, is a major EVAR complication. Understanding the etiology and evolution of endoleak from the hemodynamic perspective is crucial to advancing the current posttreatments for AAA patients who underwent EVAR. Therefore, a comprehensive flow assessment was performed to investigate the relationship between endoleak and its surrounding pathological flow fields through computational fluid dynamics and image processing. Six patient-specific models were reconstructed, and the associated hemodynamics in these models was quantified three-dimensionally to calculate wall stress. To provide a high degree of clinical relevance, the mechanical stress distribution calculated from the models was compared with the endoleak positions identified from the computed tomography images of patients through a series of imaging processing methods. An endoleak possibly forms in a location with high local wall stress. An improved stent graft (SG) structure is conceived accordingly by increasing the mechanical strength of the SG at peak wall stress locations. The presented analytical paradigm, as well as numerical analysis using patient-specific models, may be extended to other common human cardiovascular surgeries.
Collapse
|
34
|
Bryce Y, Rogoff P, Romanelli D, Reichle R. Endovascular repair of abdominal aortic aneurysms: vascular anatomy, device selection, procedure, and procedure-specific complications. Radiographics 2016; 35:593-615. [PMID: 25763741 DOI: 10.1148/rg.352140045] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abdominal aortic aneurysm (AAA) is abnormal dilatation of the aorta, carrying a substantial risk of rupture and thereby marked risk of death. Open repair of AAA involves lengthy surgery time, anesthesia, and substantial recovery time. Endovascular aneurysm repair (EVAR) provides a safer option for patients with advanced age and pulmonary, cardiac, and renal dysfunction. Successful endovascular repair of AAA depends on correct selection of patients (on the basis of their vascular anatomy), choice of the correct endoprosthesis, and familiarity with the technique and procedure-specific complications. The type of aneurysm is defined by its location with respect to the renal arteries, whether it is a true or false aneurysm, and whether the common iliac arteries are involved. Vascular anatomy can be divided more technically into aortic neck, aortic aneurysm, pelvic perfusion, and iliac morphology, with grades of difficulty with respect to EVAR, aortic neck morphology being the most common factor to affect EVAR appropriateness. When choosing among the devices available on the market, one must consider the patient's vascular anatomy and choose between devices that provide suprarenal fixation versus those that provide infrarenal fixation. A successful technique can be divided into preprocedural imaging, ancillary procedures before AAA stent-graft placement, the procedure itself, postprocedural medical therapy, and postprocedural imaging surveillance. Imaging surveillance is important in assessing complications such as limb thrombosis, endoleaks, graft migration, enlargement of the aneurysm sac, and rupture. Last, one must consider the issue of radiation safety with regard to EVAR.
Collapse
Affiliation(s)
- Yolanda Bryce
- From the Department of Radiology, Mount Auburn Hospital, 330 Mount Auburn St, Cambridge, MA 02138
| | | | | | | |
Collapse
|
35
|
van den Haak R, Hamans B, Zuurmond K, Verhoeven B, Koning O. Significant Radiation Dose Reduction in the Hybrid Operating Room Using a Novel X-ray Imaging Technology. Eur J Vasc Endovasc Surg 2015; 50:480-6. [DOI: 10.1016/j.ejvs.2015.06.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 06/17/2015] [Indexed: 11/28/2022]
|
36
|
Endofugas tipo 2 en una población tratada con endoprótesis Gore® Excluder: incidencia, persistencia y crecimiento del saco aneurismático. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2015.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
37
|
Radiation exposure in endovascular repair of abdominal and thoracic aortic aneurysms. J Vasc Surg 2015; 62:753-61. [DOI: 10.1016/j.jvs.2015.05.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 05/14/2015] [Indexed: 11/22/2022]
|
38
|
Karthikesalingam A, Attallah O, Ma X, Bahia SS, Thompson L, Vidal-Diez A, Choke EC, Bown MJ, Sayers RD, Thompson MM, Holt PJ. An Artificial Neural Network Stratifies the Risks of Reintervention and Mortality after Endovascular Aneurysm Repair; a Retrospective Observational study. PLoS One 2015; 10:e0129024. [PMID: 26176943 PMCID: PMC4503678 DOI: 10.1371/journal.pone.0129024] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/03/2015] [Indexed: 12/16/2022] Open
Abstract
Background Lifelong surveillance after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) is considered mandatory to detect potentially life-threatening endograft complications. A minority of patients require reintervention but cannot be predictively identified by existing methods. This study aimed to improve the prediction of endograft complications and mortality, through the application of machine-learning techniques. Methods Patients undergoing EVAR at 2 centres were studied from 2004-2010. Pre-operative aneurysm morphology was quantified and endograft complications were recorded up to 5 years following surgery. An artificial neural networks (ANN) approach was used to predict whether patients would be at low- or high-risk of endograft complications (aortic/limb) or mortality. Centre 1 data were used for training and centre 2 data for validation. ANN performance was assessed by Kaplan-Meier analysis to compare the incidence of aortic complications, limb complications, and mortality; in patients predicted to be low-risk, versus those predicted to be high-risk. Results 761 patients aged 75 +/- 7 years underwent EVAR. Mean follow-up was 36+/- 20 months. An ANN was created from morphological features including angulation/length/areas/diameters/volume/tortuosity of the aneurysm neck/sac/iliac segments. ANN models predicted endograft complications and mortality with excellent discrimination between a low-risk and high-risk group. In external validation, the 5-year rates of freedom from aortic complications, limb complications and mortality were 95.9% vs 67.9%; 99.3% vs 92.0%; and 87.9% vs 79.3% respectively (p<0.001) Conclusion This study presents ANN models that stratify the 5-year risk of endograft complications or mortality using routinely available pre-operative data.
Collapse
Affiliation(s)
- Alan Karthikesalingam
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
| | - Omneya Attallah
- College of Engineering and Applied Science, Aston University, Birmingham, B4 7ET, United Kingdom
- Department of Electronics and Communications Engineering, Arab Academy for Science and Technology and Maritime Transport, Alexandria, Egypt
| | - Xianghong Ma
- College of Engineering and Applied Science, Aston University, Birmingham, B4 7ET, United Kingdom
| | - Sandeep Singh Bahia
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
- * E-mail:
| | - Luke Thompson
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
| | - Alberto Vidal-Diez
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
- Department of Community Health Sciences, St George’s University of London, London, SW17 0QT, United Kingdom
| | - Edward C. Choke
- Vascular Surgery Group, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom
| | - Matt J. Bown
- Vascular Surgery Group, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom
| | - Robert D. Sayers
- Vascular Surgery Group, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom
| | - Matt M. Thompson
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
| | - Peter J. Holt
- Department of Outcomes Research, St George’s Vascular Institute, London, SW17 0QT, United Kingdom
| |
Collapse
|
39
|
Editor's Choice – Minimizing Radiation Exposure During Endovascular Procedures: Basic Knowledge, Literature Review, and Reporting Standards. Eur J Vasc Endovasc Surg 2015; 50:21-36. [DOI: 10.1016/j.ejvs.2015.01.014] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/27/2015] [Indexed: 12/30/2022]
|
40
|
Typical exposure parameters, organ doses and effective doses for endovascular aortic aneurysm repair: Comparison of Monte Carlo simulations and direct measurements with an anthropomorphic phantom. Eur Radiol 2015; 25:2617-26. [PMID: 25854215 DOI: 10.1007/s00330-015-3673-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 02/04/2015] [Accepted: 02/13/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Radiation exposure of patients during endovascular aneurysm repair (EVAR) procedures ranks in the upper sector of medical exposure. Thus, estimation of radiation doses achieved during EVAR is of great importance. MATERIAL AND METHODS Organ doses (OD) and effective doses (ED) administered to 17 patients receiving EVAR were determined (1) from the exposure parameters by performing Monte Carlo simulations in mathematical phantoms and (2) by measurements with thermoluminescent dosimeters in a physical anthropomorphic phantom. RESULTS The mean fluoroscopy time was 26 min, the mean dose area product was 24995 cGy cm2. The mean ED was 34.8 mSv, ODs up to 626 mSv were found. Whereas digital subtraction angiographies (DSA) and fluoroscopies each contributed about 50% to the cumulative ED, the ED rates of DSAs were found to be ten times higher than those of fluoroscopies. Doubling of the field size caused an ED rate enhancement up to a factor of 3. CONCLUSION EVAR procedures cause high radiation exposure levels that exceed the values published thus far. As a consequence, (1) DSAs should be only performed when necessary and with a low image rate, (2) fluoroscopies should be kept as short as possible, and (3) field sizes should be minimized. KEY POINTS • During endovascular aneurysm repair (EVAR) considerable patient doses are achieved. • For each EVAR procedure organ (OD) and effective (ED) doses were determined. • The mean ED was 34.8 mSv, the highest OD was 626 mSv. • Number of DSAs, fluoroscopy durations and field sizes should be minimized.
Collapse
|
41
|
Russ M, O'Hara R, Setlur Nagesh SV, Mokin M, Jimenez C, Siddiqui A, Bednarek D, Rudin S, Ionita C. Treatment Planning for Image-Guided Neuro-Vascular Interventions Using Patient-Specific 3D Printed Phantoms. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2015; 9417. [PMID: 26778878 DOI: 10.1117/12.2081997] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Minimally invasive endovascular image-guided interventions (EIGIs) are the preferred procedures for treatment of a wide range of vascular disorders. Despite benefits including reduced trauma and recovery time, EIGIs have their own challenges. Remote catheter actuation and challenging anatomical morphology may lead to erroneous endovascular device selections, delays or even complications such as vessel injury. EIGI planning using 3D phantoms would allow interventionists to become familiarized with the patient vessel anatomy by first performing the planned treatment on a phantom under standard operating protocols. In this study the optimal workflow to obtain such phantoms from 3D data for interventionist to practice on prior to an actual procedure was investigated. Patient-specific phantoms and phantoms presenting a wide range of challenging geometries were created. Computed Tomographic Angiography (CTA) data was uploaded into a Vitrea 3D station which allows segmentation and resulting stereo-lithographic files to be exported. The files were uploaded using processing software where preloaded vessel structures were included to create a closed-flow vasculature having structural support. The final file was printed, cleaned, connected to a flow loop and placed in an angiographic room for EIGI practice. Various Circle of Willis and cardiac arterial geometries were used. The phantoms were tested for ischemic stroke treatment, distal catheter navigation, aneurysm stenting and cardiac imaging under angiographic guidance. This method should allow for adjustments to treatment plans to be made before the patient is actually in the procedure room and enabling reduced risk of peri-operative complications or delays.
Collapse
Affiliation(s)
- M Russ
- Toshiba Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY
| | - R O'Hara
- Toshiba Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY
| | - S V Setlur Nagesh
- Toshiba Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY
| | - M Mokin
- Toshiba Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY
| | - C Jimenez
- Toshiba Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY; University of Antioquia-GIB-Eafit, Medellin, Colombia
| | - A Siddiqui
- Toshiba Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY
| | - D Bednarek
- Toshiba Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY
| | - S Rudin
- Toshiba Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY
| | - C Ionita
- Toshiba Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY
| |
Collapse
|
42
|
Bruschi A, Michelagnoli S, Chisci E, Mazzocchi S, Panci S, Didona A, Ghirelli A, Zatelli G. A comparison study of radiation exposure to patients during EVAR and Dyna CT in an angiosuite vs. an operating theatre. RADIATION PROTECTION DOSIMETRY 2015; 163:491-498. [PMID: 25013032 DOI: 10.1093/rpd/ncu228] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The aim of this study was to assess the patient dosimetric impact of endovascular abdominal aortic aneurysm repair (EVAR), both in an operating theatre (OR) and in an angiosuite (AS), with the facility of Dynamic CT (Dyna CT, Siemens AG, Berlin, Germany). One hundred and forty-six consecutive EVAR procedures dating from May 2011 to March 2013 were analysed. These were performed either in an OR (n = 97) using a mobile C-arm or in an AS (n = 49) equipped with a ceiling-mounted angiography system. Air kerma area product (P(KA)) and total air kerma at reference point (K(a,r)) values were reported for all procedures and Dyna CT. Radiation exposure during EVAR was quite low in the majority of patients but nearly 50 % higher if performed in AS vs. OR. Median Dyna CT K(a,r) was the same as an entire EVAR procedure in OR. The higher patient's radiation exposure recorded in the AS should be balanced with the technical advantages given to the EVAR procedure.
Collapse
Affiliation(s)
- Andrea Bruschi
- Medical Physics Specialization School, University of Florence, Florence, Italy
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, Azienda Sanitaria di Firenze, Florence, Italy
| | - Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit, Azienda Sanitaria di Firenze, Florence, Italy
| | - Silvia Mazzocchi
- Medical Physics Unit, Azienda Sanitaria di Firenze, Florence, Italy
| | - Simone Panci
- Department of Radiology, Azienda Sanitaria di Firenze, Florence, Italy
| | - Annamaria Didona
- Medical Physics Specialization School, University of Florence, Florence, Italy
| | | | - Giovanna Zatelli
- Medical Physics Unit, Azienda Sanitaria di Firenze, Florence, Italy
| |
Collapse
|
43
|
Ruz R, Lee K, Power AH, DeRose G, Forbes TL, Dubois L. Anatomic and procedural determinants of fluoroscopy time during elective endovascular aortic aneurysm repair. Vascular 2015; 24:19-24. [DOI: 10.1177/1708538115573395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To identify both the procedural and anatomic factors which determine duration of fluoroscopy during elective endovascular aortic aneurysm repair (EVAR). Methods We retrospectively analyzed our prospectively maintained EVAR database for the relationship between fluoroscopy time and both procedural (type of graft, configuration, number of components, surgeon) and anatomic factors reflective of aneurysm complexity (15 variables). Results A total of 128 patients underwent elective EVAR with a mean fluoroscopy time of 5.7 ± 3.4 min. The type of grafts used consisted of 41 (32%) Zenith, 85 (66.4%) Endurant and 2 (1.6%) Anaconda, with 105 (82%) being bifurcated and 23 (18%) being aorto-uni-iliac (AUI) in configuration. Both the surgeon performing the procedure ( p = 0.001) and graft configuration (bifurcated vs. AUI, p = 0.03) were found to be predictive of fluoroscopy time; while procedural and anatomic variables were not. Conclusions The surgeon’s efficiency in the use of fluoroscopy during EVAR is the most important determinant of total fluoroscopy time. Anatomic complexity, make of device, and number of components inserted have minimal impact on duration of fluoroscopy. An endovascular surgeon’s ability to curtail fluoroscopy duration is the key component in minimizing radiation exposure to both the surgical team and the patient.
Collapse
Affiliation(s)
- Ricardo Ruz
- Division of Vascular Surgery, London Health Sciences Centre & Western University, London, ON, Canada
| | - Kevin Lee
- Division of Vascular Surgery, London Health Sciences Centre & Western University, London, ON, Canada
| | - Adam H Power
- Division of Vascular Surgery, London Health Sciences Centre & Western University, London, ON, Canada
| | - Guy DeRose
- Division of Vascular Surgery, London Health Sciences Centre & Western University, London, ON, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, London Health Sciences Centre & Western University, London, ON, Canada
| | - Luc Dubois
- Division of Vascular Surgery, London Health Sciences Centre & Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| |
Collapse
|
44
|
Shen Y, Sun Z, Xu L, Li Y, Zhang N, Yan Z, Fan Z. High-pitch, low-voltage and low-iodine-concentration CT angiography of aorta: assessment of image quality and radiation dose with iterative reconstruction. PLoS One 2015; 10:e0117469. [PMID: 25643353 PMCID: PMC4314070 DOI: 10.1371/journal.pone.0117469] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/25/2014] [Indexed: 11/18/2022] Open
Abstract
Objective To assess the image quality of aorta obtained by dual-source computed tomography angiography (DSCTA), performed with high pitch, low tube voltage, and low iodine concentration contrast medium (CM) with images reconstructed using iterative reconstruction (IR). Methods One hundred patients randomly allocated to receive one of two types of CM underwent DSCTA with the electrocardiogram-triggered Flash protocol. In the low-iodine group, 50 patients received CM containing 270 mg I/mL and were scanned at low tube voltage (100 kVp). In the high-iodine CM group, 50 patients received CM containing 370 mg I/mL and were scanned at the tube voltage (120 kVp). The filtered back projection (FBP) algorithm was used for reconstruction in both groups. In addition, the IR algorithm was used in the low-iodine group. Image quality of the aorta was analyzed subjectively by a 3-point grading scale and objectively by measuring the CT attenuation in terms of the signal- and contrast-to-noise ratios (SNR and CNR, respectively). Radiation and CM doses were compared. Results The CT attenuation, subjective image quality assessment, SNR, and CNR of various aortic regions of interest did not differ significantly between two groups. In the low-iodine group, images reconstructed by FBP and IR demonstrated significant differences in image noise, SNR, and CNR (p<0.05). The low-iodine group resulted in 34.3% less radiation (4.4 ± 0.5 mSv) than the high-iodine group (6.7 ± 0.6 mSv), and 27.3% less iodine weight (20.36 ± 2.65 g) than the high-iodine group (28 ± 1.98 g). Observers exhibited excellent agreement on the aortic image quality scores (κ = 0.904). Conclusions CT images of aorta could be obtained within 2 s by using a DSCT Flash protocol with low tube voltage, IR, and low-iodine-concentration CM. Appropriate contrast enhancement was achieved while maintaining good image quality and decreasing the radiation and iodine doses.
Collapse
Affiliation(s)
- Yanguang Shen
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
- Department of Radiology, Hospital Affiliated to Hainan Medical College, Haikou, City of Hainan Province, China
| | - Zhonghua Sun
- Discipline of Medical Imaging, Department of Imaging and Applied Physics, Curtin University, Perth, Australia
| | - Lei Xu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yu Li
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Nan Zhang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Zixu Yan
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Zhanming Fan
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
- * E-mail:
| |
Collapse
|
45
|
Brambilla M, Cerini P, Lizio D, Vigna L, Carriero A, Fossaceca R. Cumulative radiation dose and radiation risk from medical imaging in patients subjected to endovascular aortic aneurysm repair. Radiol Med 2015; 120:563-70. [PMID: 25572540 DOI: 10.1007/s11547-014-0485-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 08/27/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE This study was undertaken to quantify the cumulative effective dose (CED) of radiation and the dose to relevant organs in endovascular aortic repair (EVAR) patients, to assess radiation risks and to evaluate the clinical usefulness of multi-detector computed tomography (MDCT) follow-up. MATERIALS AND METHODS The radiation exposures were obtained from 71 consecutive EVAR patients with a follow-up duration ≥1 year. Dose calculations were performed on an individual basis and expressed as effective doses and organ doses. Radiation risk was expressed as risk of exposure-induced death (%), using the biological effects of ionising radiation model. Two radiologists independently assessed the images for abdominal aortic aneurysm expansion without endoleaks, thrombotic occlusion, endoleaks and device migration. They first reviewed arterial imaging alone and subsequently added non-contrast and delayed phases to determine the overall performance. RESULTS The median total CED and annual CED were 224 and 104 mSv per patient-year. The median cumulative organ doses were 191, 205, 230, 269 and 271 mSv for lung, bone marrow, liver, colon and stomach, respectively. The average risk of exposure-induced death was 0.8 % (i.e., odds 1 in 130). All the findings related to EVAR outcome and leading to a change in patient management were visible during the arterial phase of the MDCT angiography. Omission of the unenhanced scan and the venous phase of the MDCT angiography would have led to a significant reduction of about 60 % of the associated MDCT radiation exposure in a single patient. CONCLUSIONS EVAR patients received high radiation doses and the excess cancer risk attributable to radiation exposure is not negligible. The unenhanced scan and the venous phase of the MDCT angiography could have been omitted without compromising the utility of the examination and with a significant reduction of doses and associated risks.
Collapse
Affiliation(s)
- Marco Brambilla
- Medical Physics Department, University Hospital "Maggiore della Carità", C.so Mazzini 18, 28100, Novara, Italy,
| | | | | | | | | | | |
Collapse
|
46
|
Comparison of radiation dose exposure in patients undergoing percutaneous coronary intervention vs. peripheral intervention. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2014; 10:308-13. [PMID: 25489329 PMCID: PMC4252332 DOI: 10.5114/pwki.2014.46776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 06/15/2014] [Accepted: 09/05/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction Most endovascular techniques are associated with patient and personal exposure to radiation during the procedure. Ionising radiation can cause deterministic effects, such as skin injury, as well as stochastic effects, which increase the long-term risk of malignancy. Endovascular operators need to be aware of radiation danger and take all necessary steps to minimise the risk to patients and staff. Some procedures, especially percutaneous peripheral artery revascularisation, are associated with increased radiation dose due to time-consuming operations. There is limited data comparing radiation dose during percutaneous coronary intervention (PCI) with percutaneous transluminal angioplasty (PTA) of peripheral arteries. Aim To compare the radiation dose in percutaneous coronary vs. peripheral interventions in one centre with a uniform system of protection methods. Material and methods A total of 352 patients were included in the study. This included 217 patients undergoing PCI (single and multiple stenting) and 135 patients undergoing PTA (in lower extremities, carotid artery, renal artery, and subclavian artery). Radiation dose, fluoroscopy time, and total procedural time were reviewed. Cumulative radiation dose was measured in gray (Gy) units. Results The total procedural time was significantly higher in PTA (PCI vs. PTA: 60 (45–85) min vs. 75 (50–100) min), p < 0.001. The radiation dose for PCI procedures was significantly higher in comparison to PTA (PCI vs. PTA: 1.36 (0.83–2.23) Gy vs. 0.27 (0.13–0.46) Gy), p < 0.001. There was no significant difference in the fluoroscopy time (PCI vs. PTA: 12.9 (8.2–21.5) min vs. 14.4 (8.0–22.6) min), p = 0.6. The analysis of correlation between radiation dose and fluoroscopy time in PCI and PTA interventions separately shows a strong correlation in PCI group (r = 0.785). However, a weak correlation was found in PTA group (r = 0.317). Conclusions The radiation dose was significantly higher during PCI in comparison to PTA procedures despite comparable fluoroscopy time and longer total procedure time in PTA. Fluoroscopy time is a reliable parameter to control the radiation dose exposure in coronary procedures. The increasing complexity of endovascular interventions has resulted in the increase of radiation dose exposure during PCI procedures.
Collapse
|
47
|
Sun Z, Al Moudi M, Cao Y. CT angiography in the diagnosis of cardiovascular disease: a transformation in cardiovascular CT practice. Quant Imaging Med Surg 2014; 4:376-96. [PMID: 25392823 DOI: 10.3978/j.issn.2223-4292.2014.10.02] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 09/26/2014] [Indexed: 12/11/2022]
Abstract
Computed tomography (CT) angiography represents the most important technical development in CT imaging and it has challenged invasive angiography in the diagnostic evaluation of cardiovascular abnormalities. Over the last decades, technological evolution in CT imaging has enabled CT angiography to become a first-line imaging modality in the diagnosis of cardiovascular disease. This review provides an overview of the diagnostic applications of CT angiography (CTA) in cardiovascular disease, with a focus on selected clinical challenges in some common cardiovascular abnormalities, which include abdominal aortic aneurysm (AAA), aortic dissection, pulmonary embolism (PE) and coronary artery disease. An evidence-based review is conducted to demonstrate how CT angiography has changed our approach in the diagnosis and management of cardiovascular disease. Radiation dose reduction strategies are also discussed to show how CT angiography can be performed in a low-dose protocol in the current clinical practice.
Collapse
Affiliation(s)
- Zhonghua Sun
- 1 Discipline of Medical Imaging, Department of Imaging and Applied Physics, Curtin University, Perth, 6102, Western Australia, Australia ; 2 Department of Medical Imaging and Nuclear Medicine, King Saud Medical City, Riyadh, Saudi Arabia ; 3 Department of Medical Imaging, Shandong Medical College, Jinan 276000, China
| | - Mansour Al Moudi
- 1 Discipline of Medical Imaging, Department of Imaging and Applied Physics, Curtin University, Perth, 6102, Western Australia, Australia ; 2 Department of Medical Imaging and Nuclear Medicine, King Saud Medical City, Riyadh, Saudi Arabia ; 3 Department of Medical Imaging, Shandong Medical College, Jinan 276000, China
| | - Yan Cao
- 1 Discipline of Medical Imaging, Department of Imaging and Applied Physics, Curtin University, Perth, 6102, Western Australia, Australia ; 2 Department of Medical Imaging and Nuclear Medicine, King Saud Medical City, Riyadh, Saudi Arabia ; 3 Department of Medical Imaging, Shandong Medical College, Jinan 276000, China
| |
Collapse
|
48
|
Impact of Hybrid Rooms with Image Fusion on Radiation Exposure during Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2014; 48:382-90. [DOI: 10.1016/j.ejvs.2014.05.026] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 05/30/2014] [Indexed: 01/05/2023]
|
49
|
Dindyal S, Rahman S, Kyriakides C. Review of the Use of Ionizing Radiation in Endovascular Aneurysm Repair. Angiology 2014; 66:607-12. [PMID: 25225195 DOI: 10.1177/0003319714548564] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endovascular repair for aortic aneurysm (EVAR) is rapidly increasing in popularity. The nature of this intervention requires significant exposure to ionizing radiation both during the procedure and for postoperative surveillance, generally in the form of computed tomography. Here the authors review the literature for radiation exposure during EVAR, both for the patient and the physician.
Collapse
Affiliation(s)
- S Dindyal
- Academic department of circulatory sciences, Vascular and Endovascular Surgery, Barts and The London NHS Trust, The Royal London Hospital, Whitechappel, London, United Kingdom
| | - S Rahman
- Academic department of circulatory sciences, Vascular and Endovascular Surgery, Barts and The London NHS Trust, The Royal London Hospital, Whitechappel, London, United Kingdom
| | - C Kyriakides
- Academic department of circulatory sciences, Vascular and Endovascular Surgery, Barts and The London NHS Trust, The Royal London Hospital, Whitechappel, London, United Kingdom
| |
Collapse
|
50
|
Miller DL. Efforts to optimize radiation protection in interventional fluoroscopy. HEALTH PHYSICS 2013; 105:435-444. [PMID: 24077043 DOI: 10.1097/hp.0b013e31829c355a] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
While it has been known for more than a century that radiation presents risks to both the physician and the patient, skin injuries from fluoroscopy became increasingly rare after the 1930s, and radiation risk from fluoroscopy appeared to be adequately controlled. However, beginning in approximately 1975, new technologies and materials for interventional devices were developed. These enabled new procedures, and as these were instituted, skin injuries again occurred in patients. Four central issues were identified: equipment, quality management, operator training, and occupational radiation protection. Recognition that these were areas for improvement provoked changes in technology and practice that continue today.
Collapse
Affiliation(s)
- Donald L Miller
- *Center for Devices and Radiological Health, Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring MD 20993
| |
Collapse
|