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Sanders AP, Swerdlow NJ, Jabbour G, Schermerhorn ML. The effect of Fiber Optic RealShape technology on the reduction of radiation during complex endovascular surgery. J Vasc Surg 2024; 79:954-961. [PMID: 37931886 PMCID: PMC10960673 DOI: 10.1016/j.jvs.2023.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Despite the advantages that fenestrated endovascular aortic repair has over open repair, it is accompanied by the consequence of radiation exposure, which can result in long-term complications for both the patient and surgical staff. Fiber Optic RealShape (FORS) technology is a novel advancement that uses emitted light from a fiber optic wire and enables the surgeon to cannulate vessels in real time without live fluoroscopy. This technology has been implemented at select centers to study its effectiveness for cannulation of target vessels and its impact on procedural radiation. METHODS We collected prospective data on physician-modified endograft (PMEG) cases before and after the introduction of FORS technology. FORS PMEGs were matched with up to three conventional fluoroscopy cases by number of target vessels, inclusion of a bifurcated device below, aneurysm extent, and patient body mass index. The procedural radiation parameters were compared between these cohorts. Within the FORS cohort, we analyzed the rate of successful target vessel cannulation for all cases done with this technology (including cases other than PMEGs), and we compared the radiation between the cannulations using only FORS with those that abandoned FORS for conventional fluoroscopy. RESULTS Nineteen FORS PMEGs were able to be matched to 45 conventional fluoroscopy cases. Procedures that used FORS technology had significantly reduced total air kerma (527 mGy vs 964 mGy), dose area product (121 Gy∗cm2 vs 186 Gy∗cm2), fluoroscopy dose (72.1 Gy∗cm2 vs 132.5 Gy∗cm2), and fluoroscopy time (45 minutes vs 72 minutes). There was no difference in procedure length, total contrast, or digital subtraction angiography. Within FORS cases, 66% of cannulations were completed using only FORS. Cannulations using only FORS had significant reduction of navigation air kerma (5.0 mGy vs 26.5 mGy), dose area product (1.2 Gy∗cm2 vs 5.1 Gy∗cm2), and fluoroscopy time (0.6 minutes vs 2.3 minutes) compared with cannulations abandoning FORS for conventional fluoroscopy. CONCLUSIONS This study demonstrates the advantages of FORS for total procedural radiation as well as during individual cannulation tasks. The implementation of FORS for target vessel catheterization has the potential to decrease the total degree of radiation exposure for the patient and surgical staff during complex endovascular aortic surgeries.
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Affiliation(s)
- Andrew P Sanders
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Nicholas J Swerdlow
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Surgery, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gabriel Jabbour
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Kuriyama T, Moritake T, Nakagami K, Morota K, Hitomi G, Kitamura H. Background Factors Affecting the Radiation Exposure of the Lens of the Eye among Nurses in Interventional Radiology: A Quantitative Observational Study. NURSING REPORTS 2024; 14:413-427. [PMID: 38391077 PMCID: PMC10885035 DOI: 10.3390/nursrep14010032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
With the International Commission on Radiological Protection's (ICRP) reduction in the radiation dose threshold for cataracts, evaluating and preventing radiation exposure to the lens of the eye among interventional radiology (IR) staff have become urgent tasks. In this study, we focused on differences in lens-equivalent dose (HT Lens) to which IR nurses in three hospitals were exposed and aimed to identify factors underlying these differences. According to analyses of time-, distance-, and shielding-related factors, the magnitude of the HT Lens dose to which IR nurses were exposed could be explained not by time or shielding but by the distance between the X-ray exposure field and the location of the IR nurse. This distance tended to be shorter in hospitals with fewer staff. The most effective means of reducing the exposure of the lenses of IR nurses' eyes to radiation is to position them at least two meters from the radiation source during angiography procedures. However, some hospitals must provide IR departments with comparatively few staff. In work environments where it is infeasible to reduce exposure by increasing distance, interventions to reduce time by managing working practices and investment in shielding equipment are also important. This study was not registered.
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Affiliation(s)
- Tomoko Kuriyama
- Department of Occupational and Community Health Nursing, School of Health Sciences, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan
| | - Takashi Moritake
- Department of Radiation Regulatory Science Research, National Institute of Radiological Sciences, National Institute for Quantum Science and Technology, Chiba 263-8555, Japan
| | - Koichi Nakagami
- Department of Radiology, Hospital of the University of Occupational and Environmental Health, Japan, Kitakyushu 807-8556, Japan
| | - Koichi Morota
- Department of Radiology, Shinkomonji Hospital, Kitakyushu 800-0057, Japan
| | - Go Hitomi
- Department of Radiological Technology, Kawasaki Medical School Hospital, Kurashiki 701-0192, Japan
| | - Hiroko Kitamura
- Occupational Health Training Center, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan
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Chiang HW, Chuang TC, Chen TR. Underestimation of Occupational Radiation Exposure During Endovascular Abdominal Aortic Aneurysm Repair. HEALTH PHYSICS 2024; 126:56-62. [PMID: 37819216 DOI: 10.1097/hp.0000000000001744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
ABSTRACT During interventional procedures of endovascular abdominal aortic aneurysm repair (EVAR), the dosimeter was conventionally placed on chest facing toward the surgical table, instead of the main source of scatter radiation. Purpose of this study is to evaluate the underestimation of occupational radiation exposure. Phantom experiments were performed in a hybrid operating room equipped with an interventional angiography system. Electric personal dosimeters were placed at the level of eyes, chest, abdomen, and gonad of three positions, representing the principal operator (PO), assistant operator (AO), and sterile nurse (SN). Personal dose equivalent was measured with two different orientations of radiation detection, facing the table and facing the phantom, respectively. In addition to fluoroscopy, the dose produced by digital subtraction angiography was also measured to estimate the radiation exposure of routine EVAR. In this study, staff doses of 26 EVAR cases were also collected in our hospital to correlate the estimated dose. Our results show that the facing-phantom dose normalized by dose area product of patient is significantly higher than the facing-table dose when the latter is regularly seen in clinical practice. This underestimation could be even worse at a more distant position (e.g., AO and SN) as the incident angle of scatter radiation is larger. Besides, the estimated dose is highly correlated with the on-site measured dose (R 2 ~ 0.8) at chest and gonad of the PO.
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Affiliation(s)
- Hsien-Wen Chiang
- Department of Electrical Engineering, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Tzu-Chao Chuang
- Department of Electrical Engineering, National Sun Yat-Sen University, Kaohsiung, Taiwan
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Martinez Del Carmen DT, Saldaña Gutierrez P, Vila Coll R, Iborra Ortega E. Radiation Exposure in Endovascular Surgery According to Complexity: Protocol for a Prospective Observational Study. Methods Protoc 2023; 6:mps6030049. [PMID: 37218909 DOI: 10.3390/mps6030049] [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: 02/27/2023] [Revised: 04/07/2023] [Accepted: 04/19/2023] [Indexed: 05/24/2023] Open
Abstract
In the past decades, we have witnessed tremendous developments in endovascular surgery. Nowadays, highly complex procedures are performed by minimally invasive means. A key point is equipment improvement. Modern C-arms provide advanced imaging capabilities, facilitating endovascular navigation with an adequate open surgical environment. Nevertheless, radiation exposure remains an issue of concern. This study aims to analyze radiation used during endovascular procedures according to complexity, comparing a mobile X-ray system with a hybrid room (fixed X-ray system). This is an observational and prospective study based on a cohort of non-randomized patients treated by endovascular procedures in a Vascular Surgery department using two imaging systems. The study is planned for a 3-year duration with a recruitment period of 30 months (beginning 20 July 2021) and a 1-month follow-up period for each patient. This is the first prospective study designed to describe the radiation dose according to the complexity of the procedure. Another strength of this study is that radiologic variables are obtained directly from the C-arm and no additional measurements are required for feasibility benefit. The results from this study will help us determine the level of radiation in different endovascular procedures, in view of their complexity.
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Affiliation(s)
| | - Pablo Saldaña Gutierrez
- Medical Physics and Radiological Protection Department, Institut Català d'Oncologia|Hospital Universitari de Bellvitge, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ramon Vila Coll
- Angiology and Vascular Surgery Department, Hospital Universitari de Bellvitge, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Elena Iborra Ortega
- Angiology and Vascular Surgery Department, Hospital Universitari de Bellvitge, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
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Wilson-Stewart KS, Fontanarosa D, Malacova E, Trapp JV. Fluoroscopically guided vascular and cardiac transcatheter procedures: a comparison of occupational and patient dose by anatomical region. Phys Eng Sci Med 2023; 46:353-365. [PMID: 36877360 PMCID: PMC10030543 DOI: 10.1007/s13246-023-01226-7] [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: 08/15/2022] [Accepted: 01/27/2023] [Indexed: 03/07/2023]
Abstract
X-ray guided procedures are being performed by an increasing variety of medical specialties. Due to improvements in vascular transcatheter therapies, there is an increasing overlap of imaged anatomy between medical specialties. There is concern that non-radiology fluoroscopic operators may not have sufficient training to be well informed of the potential implications of radiation exposure and mitigation strategies to reduce dose. This was a prospective, observational, single center study to compare occupational and patient dose levels when imaging different anatomical regions during fluoroscopically guided cardiac and endovascular procedures. Occupational radiation dose was measured at the level of the temple of 24 cardiologists and 3 vascular surgeons (n = 1369), 32 scrub nurses (n = 1307) and 35 circulating nurses (n = 885). The patient dose was recorded for procedures (n = 1792) performed in three angiography suites. Abdominal imaging during endovascular aneurysm repair (EVAR) procedures was associated with a comparatively high average patient, operator and scrub nurse dose despite additional table-mounted lead shields. Air kerma was relatively high for procedures performed in the chest, and chest + pelvis. Higher dose area product and staff eye dose were recorded during procedures of the chest + pelvis due to the use of digital subtraction angiography to evaluate access route prior to/during transaortic valve implantation. Scrub nurses were exposed to higher average radiation levels than the operator during some procedures. Staff should be cognizant of the potentially higher radiation burden to patients and exposed personnel during EVAR procedures and cardiac procedures using digital subtraction angiography.
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Affiliation(s)
- Kelly S Wilson-Stewart
- School of Chemistry and Physics, Faculty of Science, Queensland University of Technology, 2 George Street, Brisbane, QLD, 4000, Australia.
- Cardiovascular Suites, Greenslopes Private Hospital, Ramsay Health Care, Newdegate Street, Greenslopes, Brisbane, QLD, 4120, Australia.
- Centre for Biomedical Technologies (CBT), Queensland University of Technology, 149 Victoria Park Road, Kelvin Grove, Brisbane, QLD, 4059, Australia.
| | - Davide Fontanarosa
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, 2 George Street, Brisbane, QLD, 4000, Australia
- Centre for Biomedical Technologies (CBT), Queensland University of Technology, 149 Victoria Park Road, Kelvin Grove, Brisbane, QLD, 4059, Australia
| | - Eva Malacova
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, 2 George Street, Brisbane, QLD, 4000, Australia
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD, 4006, Australia
| | - Jamie V Trapp
- School of Chemistry and Physics, Faculty of Science, Queensland University of Technology, 2 George Street, Brisbane, QLD, 4000, Australia
- Centre for Biomedical Technologies (CBT), Queensland University of Technology, 149 Victoria Park Road, Kelvin Grove, Brisbane, QLD, 4059, Australia
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Wilson-Stewart KS, Fontanarosa D, Malacova E, Trapp JV. A comparison of patient dose and occupational eye dose to the operator and nursing staff during transcatheter cardiac and endovascular procedures. Sci Rep 2023; 13:2391. [PMID: 36765105 PMCID: PMC9918729 DOI: 10.1038/s41598-023-28704-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 01/23/2023] [Indexed: 02/12/2023] Open
Abstract
The number and complexity of transcatheter procedures continue to increase, raising concerns regarding radiation exposure to patients and staff. Procedures such as transaortic valve implantations (TAVI) have led to cardiologists adopting higher dose techniques, such as digital subtraction angiography (DSA). This study compared the estimated patient and occupational eye dose during coronary angiography (CA), percutaneous coronary intervention (PCI), TAVI workups (TWU), TAVI, endovascular aneurysm repairs (EVAR), and other peripheral diagnostic (VD) and interventional (VI) vascular procedures. A quantitative analysis was performed on patient dose during 299 endovascular and 1498 cardiac procedures. Occupational dose was measured for the cardiologists (n = 24), vascular surgeons (n = 3), scrub (n = 32) and circulator nurses (n = 35). TAVI and EVAR were associated with the highest average dose for all staff, and significantly higher patient dose area product, probably attributable to the use of DSA. Scrub nurses were exposed to higher average doses than the operator and scout nurse during CA, VD and VI. Circulating nurses had the highest average levels of exposure during TAVI. This study has demonstrated that EVAR and TAVI have similar levels of occupational and patient dose, with a notable increase in circulator dose during TAVI. The use of DSA during cardiac procedures is associated with an increase in patient and staff dose, and cardiologists should evaluate whether DSA is necessary. Scrub nurses may be exposed to higher levels of occupational dose than the operator.
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Affiliation(s)
- Kelly S Wilson-Stewart
- School of Chemistry and Physics, Faculty of Science, Queensland University of Technology, 2 George Street, Brisbane, QLD, 4000, Australia. .,Centre for Biomedical Technologies, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, 4059, Australia. .,Cardiovascular Suites, Greenslopes Private Hospital, Greenslopes, Brisbane, QLD, 4120, Australia.
| | - Davide Fontanarosa
- Centre for Biomedical Technologies, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, 4059, Australia.,School of Clinical Sciences, Faculty of Health, Queensland University of Technology, 2 George Street, Brisbane, QLD, 4000, Australia
| | - Eva Malacova
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, 2 George Street, Brisbane, QLD, 4000, Australia.,QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Brisbane, QLD, 2006, Australia
| | - Jamie V Trapp
- School of Chemistry and Physics, Faculty of Science, Queensland University of Technology, 2 George Street, Brisbane, QLD, 4000, Australia.,Centre for Biomedical Technologies, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, 4059, Australia
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7
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Jungi S, Ante M, Geisbüsch P, Hoedlmoser H, Kleinau P, Böckler D. Protected and Unprotected Radiation Exposure to the Eye Lens During Endovascular Procedures in Hybrid Operating Rooms. Eur J Vasc Endovasc Surg 2022; 64:567-572. [PMID: 35760276 DOI: 10.1016/j.ejvs.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 04/22/2022] [Accepted: 06/19/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Radiation cataract has been observed at lower doses than previously thought, therefore the annual limit for equivalent dose to the eye lens has been reduced from 150 to 20 mSv. This study evaluated radiation exposure to the eye lens of operators working in a hybrid operating room before and after implementation of a dose reduction program. METHODS From April to October 2019, radiation exposure to the first operator was measured during all consecutive endovascular procedures performed in the hybrid operating room using BeOSL Hp(3) eye lens dosimeters placed both outside and behind the lead glasses (0.75 mm lead equivalent). Measured values were compared with data from a historic control group from the same hospital before implementation of the dose reduction program. RESULTS A total of 181 consecutive patients underwent an endovascular procedure in the hybrid operating room. The median unprotected eye lens dose (outside lead glasses) of the main operator was 0.049 mSv for endovascular aortic repair (EVAR) (n = 30), 0.042 mSv for thoracic endovascular aortic repair (TEVAR) (n = 23), 0.175 mSv for complex aortic fenestrated or branched endovascular procedures (F/BEVAR; n = 15), and 0.042 mSv for peripheral interventions (n = 80). Compared with the control period, EVAR had 75% lower, TEVAR 79% lower, and F/BEVAR 55% lower radiation exposure to the unprotected eye lens of the first operator. The lead glasses led to a median reduction in the exposure to the eye lens by a factor of 3.4. CONCLUSION The implementation of a dose reduction program led to a relevant reduction in radiation exposure to the head and eye lens of the first operator in endovascular procedures. With optimum radiation protection measures, including a ceiling mounted shield and lead glasses, more than 440 EVARs, 280 TEVARs, or 128 FEVARs could be performed per year before the dose limit for the eye lens of 20 mSv was reached.
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Affiliation(s)
- Silvan Jungi
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany; Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marius Ante
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Philipp Geisbüsch
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | | | | | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany.
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8
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Tzanis E, Perisinakis K, Ioannou CV, Tsetis D, Damilakis J. A novel personalized dosimetry method for endovascular aneurysm repair (EVAR) procedures. Eur Radiol 2021; 31:6547-6554. [PMID: 33675386 DOI: 10.1007/s00330-021-07789-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/20/2021] [Accepted: 02/15/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate radiation doses for the primarily irradiated organs/tissues of patients subjected to standard endovascular aneurysm repair (EVAR) procedures using a novel personalized dosimetry method. METHODS Dosimetric and anthropometric data were collected prospectively for eight patients who underwent standard EVAR procedures. Patient-specific Monte Carlo simulations were performed to estimate organ/tissue doses from each of the fluoroscopic and digital subtraction angiography acquisitions involved in EVAR. Individual-specific cumulative absorbed doses were estimated for the skin, spinal bone marrow, heart, kidneys, liver, colon, bladder, pancreas, stomach, and spleen and compared to corresponding values estimated through a commercially available dosimetric software package that employs standardized phantoms. RESULTS The highest organ/tissue radiation doses from EVAR were found for the skin, spinal bone marrow, kidneys, and spleen as 192.4 mGy, 96.7 mGy, 72.9 mGy, and 33.6 mGy respectively, while the doses to the heart, liver, colon, bladder, pancreas, and stomach were 6.3 mGy, 14.4 mGy, 18.4 mGy, 14.8 mGy, 21.6 mGy, and 11.2 mGy respectively. Corresponding dose values using standardized phantoms were found to differ up to 151%. CONCLUSION Considerable radiation doses may be received by primarily exposed organs/tissues during standard EVAR. The specific size/anatomy of the patient and the variation in exposure parameters/beam angulation between different projections commonly involved in EVAR procedures should be taken into account if reliable organ dose data are to be derived. KEY POINTS • A novel patient-specific dosimetry method was utilized to estimate radiation doses to the primarily irradiated organs/tissues of patients subjected to standard endovascular aneurysm repair procedures. • The use of standardized mathematical anthropomorphic phantoms to derive organ dose from fluoroscopically guided procedures may result in considerable inaccuracies due to differences in the assumed organ position/volume/shape compared to patients.
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Affiliation(s)
- Eleftherios Tzanis
- Department of Medical Physics, Medical School, University of Crete, P.O. Box 2208, Heraklion, 71003, Crete, Greece
| | - Kostas Perisinakis
- Department of Medical Physics, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece
| | - Christos V Ioannou
- Department of Cardiothoracic and Vascular Surgery, Vascular Surgery Unit, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece
| | - Dimitrios Tsetis
- Department of Radiology, Interventional Radiology Unit, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece
| | - John Damilakis
- Department of Medical Physics, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece.
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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.
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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.)
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10
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Editor's Choice - Comprehensive Literature Review of Radiation Levels During Endovascular Aortic Repair in Cathlabs and Operating Theatres. Eur J Vasc Endovasc Surg 2020; 60:374-385. [PMID: 32682690 DOI: 10.1016/j.ejvs.2020.05.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 04/02/2020] [Accepted: 05/21/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Occupational exposure is a growing concern among the endovascular specialist community. Several types of imaging equipment are available, such as mobile C arms or hybrid rooms, and some have been shown to deliver higher levels of radiation. A literature review was conducted to identify studies reporting dose data during standard (EVAR) and complex abdominal aortic endovascular repair (fenestrated/branched EVAR [F/BEVAR]). METHODS A search of the MEDLINE and the Cochrane databases was performed by two independent investigators using the medical subject heading terms "aortic aneurysms", "radiation", and "humans" over a search period of 10 years. Studies with full text available in English and reporting radiation data independently from the imaging equipment type were included. Experimental studies were excluded. RESULTS The lowest dose-area product levels during EVAR and F/BEVAR were identified in hybrid rooms, while the highest were with fixed systems. When adherence to the as low as reasonably achievable principles was stipulated by the authors, dose reports tended to be among the lowest. Several studies, especially of F/BEVAR, report concerning levels of radiation for both patients and staff. CONCLUSION Modern imaging equipment type, team involvement with radiation management, and the support of recent imaging technologies such as fusion help to reduce the dose delivered during standard and complex EVAR. Investment in modern imaging technology should be considered in every centre providing endovascular management of aortic aneurysms.
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Tzanis E, Ioannou CV, Tsetis D, Lioudaki S, Matthaiou N, Damilakis J. Complexity-based local diagnostic reference levels (DRLs) for standard endovascular aneurysm repair (EVAR) procedures. Phys Med 2020; 73:89-94. [DOI: 10.1016/j.ejmp.2020.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/24/2020] [Accepted: 04/15/2020] [Indexed: 01/29/2023] Open
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Rohlffs F, Spanos K, Debus ES, Heidemann F, Tsilimparis N, Kölbel T. Modern Image Acquisition System Reduces Radiation Exposure to Patients and Staff During Complex Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2020; 59:295-300. [DOI: 10.1016/j.ejvs.2019.07.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 06/26/2019] [Accepted: 07/05/2019] [Indexed: 01/31/2023]
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Comparison of Patient Radiation Dose and Contrast Use during EVAR in a Dedicated Hybrid Vascular OR and Mobile Imaging. Ann Vasc Surg 2019; 61:278-283. [PMID: 31336160 DOI: 10.1016/j.avsg.2019.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/17/2019] [Accepted: 04/10/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aim of the study is to determine whether performing endovascular aortic aneurysm repair (EVAR) in a dedicated vascular hybrid operating room (OR) is associated with a decreased patient radiation and contrast dose compared with mobile C-arm imaging in a conventional OR. METHODS This is a retrospective study of patients undergoing standard EVAR from 2009-2016. "Standard EVAR" was defined as the elective EVAR performed with bifurcated graft for infrarenal aneurysm with no iliac aneurysms. Patients were divided into 2 groups. Group 1 included EVARs performed in conventional theater with a mobile C-arm (January 2009 to June 2012) and group 2 EVARs performed in the dedicated vascular hybrid OR (July 2012 to December 2016). Data collected included patient demographics, aneurysm diameter, neck length, radiation dose, screening time, and contrast use of each patient. RESULTS There were 286 patients, 78 and 208 patients in group 1 and 2, respectively. There was no difference in age (77.6 years [76.3-78.9] vs. 76.6 years [75.9-77.9], P > 0.05), body mass index (26.5 kg/m2 [25.1-28.0] vs. 27.9 kg/m2 [27.1-28.7] P > 0.05), and mean aneurysm diameter (6.48 cms [6.13-6.82] vs. 6.81 cms [6.0-7.7], P > 0.05) between groups. Patients in group 2 received approximately half the mean radiation dose (16,807 cGy cm2 [±11,078] vs. 8,233 cGy cm2 [±7,471], P < 0.001), shorter fluoroscopy time (36.02 min [±21.3] vs. 26.96 min [±19], P = 0.001), and less contrast use (114 mls [±44.2] vs. 158 mls [±63.9], P < 0.001). CONCLUSIONS Performing EVAR in a dedicated vascular Hybrid OR may be associated with a lower patient radiation dose, shorter screening time, and less contrast use than performing EVAR in a conventional OR.
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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.
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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
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Markar SR, Vidal-Diez A, Sounderajah V, Mackenzie H, Hanna GB, Thompson M, Holt P, Lagergren J, Karthikesalingam A. A population-based cohort study examining the risk of abdominal cancer after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2019; 69:1776-1785.e2. [DOI: 10.1016/j.jvs.2018.09.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/09/2018] [Indexed: 10/27/2022]
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17
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Occupational exposure during endovascular aneurysm repair (EVAR) and aortoiliac percutaneous transluminal angioplasty (PTA) procedures. LA RADIOLOGIA MEDICA 2019; 124:539-545. [DOI: 10.1007/s11547-018-00985-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
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Wilson‐Stewart K, Shanahan M, Fontanarosa D, Davidson R. Occupational radiation exposure to nursing staff during cardiovascular fluoroscopic procedures: A review of the literature. J Appl Clin Med Phys 2018; 19:282-297. [PMID: 30294978 PMCID: PMC6236819 DOI: 10.1002/acm2.12461] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/19/2018] [Accepted: 07/14/2018] [Indexed: 11/16/2022] Open
Abstract
Fluoroscopy is a method used to provide real time x-ray imaging of the body during medical procedures to assist with medical diagnosis and treatment. Recent technological advances have seen an increase in the number of fluoroscopic examinations being performed. Nurses are an integral part of the team conducting fluoroscopic investigations and are often located close to the patient resulting in an occupational exposure to radiation. The purpose of this review was to examine recent literature which investigates occupational exposure received by nursing staff during cardiovascular fluoroscopic procedures. Articles published between 2011 and 2017 have been searched and comprehensively reviewed on the referenced medical search engines. Twenty-four relevant studies were identified among which seventeen investigated nursing dose comparative to operator dose. Seven researched the effectiveness of interventions in reducing occupational exposure to nursing staff. While doctors remain at the highest risk of exposure during procedures, evidence suggests that nursing staff may be at risk of exceeding recommended dose limits in some circumstances. There is also evidence of inconsistent use of personal protection such as lead glasses and skull caps by nursing staff to minimize radiation exposure. Conclusions: The review has highlighted a lack of published literature focussing on dose to nurses. There is a need for future research in this area to inform nursing staff of factors which may contribute to high occupational doses and of methods for minimizing the risk of exposure, particularly regarding the importance of utilizing radiation protective equipment.
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Affiliation(s)
- Kelly Wilson‐Stewart
- School of Clinical SciencesQueensland University of TechnologyBrisbaneQldAustralia
- Cardiovascular SuitesGreenslopes Private HospitalBrisbaneQldAustralia
- Faculty of HealthUniversity of CanberraCanberraACTAustralia
| | | | - Davide Fontanarosa
- School of Clinical SciencesQueensland University of TechnologyBrisbaneQldAustralia
- Institute of Health and Biomedical InnovationQueensland University of TechnologyBrisbaneQldAustralia
| | - Rob Davidson
- Faculty of HealthUniversity of CanberraCanberraACTAustralia
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Hertault A, Rhee R, Antoniou GA, Adam D, Tonda H, Rousseau H, Bianchini A, Haulon S. Radiation Dose Reduction During EVAR: Results from a Prospective Multicentre Study (The REVAR Study). Eur J Vasc Endovasc Surg 2018; 56:426-433. [DOI: 10.1016/j.ejvs.2018.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/01/2018] [Indexed: 10/14/2022]
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de Ruiter QMB, Jansen MM, Moll FL, Hazenberg CEVB, Kahya NN, van Herwaarden JA. Procedure and step-based analysis of the occupational radiation dose during endovascular aneurysm repair in the hybrid operating room. J Vasc Surg 2018; 67:1881-1890. [PMID: 29801556 DOI: 10.1016/j.jvs.2017.09.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 09/21/2017] [Indexed: 10/16/2022]
Abstract
OBJECTIVE This study measured the cumulative occupational X-ray radiation dose received by support staff during endovascular aortic procedures and during additional intraoperative steps in the hybrid operating room. METHODS Radiation dose measurements were performed during interventions on 65 patients receiving 90 stent grafts during endovascular aneurysm repair (EVAR), bifurcated EVAR, thoracic EVAR, iliac branched device deployment, aortouni-iliac stenting, and fenestrated/branched EVAR (F/BrEVAR). X-ray imaging was acquired using the Philips Allura FD20 Clarity System (Philips Medical Systems, Best, The Netherlands). The occupational radiation dose (also referred to as the estimated effective dose, E, measured in millisieverts) was measured with the DoseAware Xtend system (Philips Medical Systems) personal dosimeters. E was reported per staff member (ESTAFF), where "staff" was a generic term for each staff member included in the study: the first operator (FO), the second operator (ESO), a virtual maximum operator (MO), and all additional supporting staff, including the sterile nurse, nonsterile nurse, anaesthesiologist, and radiation technician. The primary outcome was the median cumulative ESTAFF (or EFO, EMO, and so on), which was presented as the median cumulative dose per intervention and stratified for several within-interventional EVAR and F/BrEVAR steps or stents. The second outcome was the percentage of the absorbed E by a supporting staff member in relation to the E measured by the reference badge attached on the C-arm (ESTAFF% or EFO%, EMO%, and so on). All outcomes are presented as median with interquartile range, unless stated differently. RESULTS The occupational effective dose in millisieverts of the MO (EMO) was 0.055 (0.029-0.082) for aortouni-iliac stenting (n = 6), 0.084 (0.054-0.141) during thoracic EVAR (n = 14), 0.036 (0.026-0.068) during bifurcated EVAR (n = 38), 0.054 (0.035-0.126) during iliac branched device deployment (n = 8), and 0.345 (0.235-0.757) during F/BrEVAR (n = 24). The median EMO in millisieverts was 0.025 (0.012-0.062) per renal target vessel (TV) and 0.146 (0.07-0.315) for a nonrenal visceral TV. During all noncomplex interventions, the EMO% was 4.4% (2.7%-7.3%), with the lowest median rate at 3.5% (2.5%-5%) for EVAR. The highest median rate EMO% was found for F/BrEVAR procedures: 8.2% (5.0%-14.4%). CONCLUSIONS With maximum operator shielding during femoral access, relative occupational radiation risk can be minimized. However, digital subtraction angiography image acquisition, recanalization of TVs, recanalization of superior mesenteric artery or celiac artery, and recanalization of branched TVs are predictors for increased occupational radiation dose risks caused by increased radiation doses to the patient and reduced options for shielding of the operator.
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Affiliation(s)
- Quirina M B de Ruiter
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marloes M Jansen
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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Hiraoka A, Shiraya S, Chikazawa G, Ishida A, Miyake K, Sakaguchi T, Yoshitaka H. Feasibility of three-dimensional fusion imaging with multimodality roadmap system during endovascular aortic repair. J Vasc Surg 2018; 68:1175-1182. [PMID: 29615355 DOI: 10.1016/j.jvs.2017.12.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 12/16/2017] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Endovascular procedures for aortic aneurysm repair have become widely accepted as safe and effective surgical options. We investigated the efficacy of the multimodality roadmap (MMR) system with biplane fluoroscopy to attempt to reduce the use of contrast medium and exposure to radiation during surgery. METHODS We retrospectively reviewed 263 consecutive cases with elective endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR). Patients were categorized into two groups, with and without introduction of the MMR system, which was applied in 164 patients (62.4%). The MMR- group included 62 EVAR and 37 TEVAR cases, and the MMR+ group consisted of 81 EVAR and 83 TEVAR cases. Radiation dose, contrast medium use, and complications were compared between the MMR- and MMR+ groups in the respective EVAR and TEVAR groups. RESULTS There was a significantly lower amount of contrast medium use in the MMR+ group compared with the MMR- group in EVAR (32.9 ± 10.6 g and 28.2 ± 10.2 g; P = .009) and TEVAR (31.7 ± 11.5 g and 26.9 ± 7.8 g; P = .009). In addition, significantly lower radiation exposure was observed in the MMR+ group of TEVAR (872 ± 623 mGy vs 638 ± 463 mGy; P = .033). The operative time of the MMR+ group was significantly shorter for patients with TEVAR compared with the MMR- group (96.4 ± 27.0 minutes vs 86.2 ± 23.9 minutes; P = .023). The incidence of access injury and other complications was similar in both EVAR and TEVAR groups. CONCLUSIONS The MMR system with three-dimensional fusion imaging can reduce the contrast medium dose in EVAR and the exposure to contrast medium and radiation in TEVAR.
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Affiliation(s)
- Arudo Hiraoka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan.
| | - Suguru Shiraya
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Atsuhisa Ishida
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Koichi Miyake
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
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Sailer AM, Vergoossen L, Paulis L, van Zwam WH, Das M, Wildberger JE, Jeukens CRLPN. Personalized Feedback on Staff Dose in Fluoroscopy-Guided Interventions: A New Era in Radiation Dose Monitoring. Cardiovasc Intervent Radiol 2017; 40:1756-1762. [PMID: 28500459 PMCID: PMC5651709 DOI: 10.1007/s00270-017-1690-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 05/03/2017] [Indexed: 10/31/2022]
Abstract
PURPOSE Radiation safety and protection are a key component of fluoroscopy-guided interventions. We hypothesize that providing weekly personal dose feedback will increase radiation awareness and ultimately will lead to optimized behavior. Therefore, we designed and implemented a personalized feedback of procedure and personal doses for medical staff involved in fluoroscopy-guided interventions. MATERIALS AND METHODS Medical staff (physicians and technicians, n = 27) involved in fluoroscopy-guided interventions were equipped with electronic personal dose meters (PDMs). Procedure dose data including the dose area product and effective doses from PDMs were prospectively monitored for each consecutive procedure over an 8-month period (n = 1082). A personalized feedback form was designed displaying for each staff individually the personal dose per procedure, as well as relative and cumulative doses. This study consisted of two phases: (1) 1-5th months: Staff did not receive feedback (n = 701) and (2) 6-8th months: Staff received weekly individual dose feedback (n = 381). An anonymous evaluation was performed on the feedback and occupational dose. RESULTS Personalized feedback was scored valuable by 76% of the staff and increased radiation dose awareness for 71%. 57 and 52% reported an increased feeling of occupational safety and changing their behavior because of personalized feedback, respectively. For technicians, the normalized dose was significantly lower in the feedback phase compared to the prefeedback phase: [median (IQR) normalized dose (phase 1) 0.12 (0.04-0.50) µSv/Gy cm2 versus (phase 2) 0.08 (0.02-0.24) µSv/Gy cm2, p = 0.002]. CONCLUSION Personalized dose feedback increases radiation awareness and safety and can be provided to staff involved in fluoroscopy-guided interventions.
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Affiliation(s)
- Anna M. Sailer
- Department of Radiology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94303 USA
| | - Laura Vergoossen
- Department of Radiology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Leonie Paulis
- Department of Radiology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Willem H. van Zwam
- Department of Radiology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Marco Das
- Department of Radiology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- CARIM School of Cardiovascular Diseases, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Joachim E. Wildberger
- Department of Radiology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- CARIM School of Cardiovascular Diseases, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Cécile R. L. P. N. Jeukens
- Department of Radiology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
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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.
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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.
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Bacchim Neto FA, Alves AFF, Mascarenhas YM, Giacomini G, Maués NHPB, Nicolucci P, de Freitas CCM, Alvarez M, Pina DRD. Efficiency of personal dosimetry methods in vascular interventional radiology. Phys Med 2017; 37:58-67. [DOI: 10.1016/j.ejmp.2017.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/03/2017] [Accepted: 04/11/2017] [Indexed: 01/01/2023] Open
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Baumann F, Peña C, Kloeckner R, Katzen BT, Gandhi R, Benenati JB. The Effect of a New Angiographic Imaging Technology on Radiation Dose in Visceral Embolization Procedures. Vasc Endovascular Surg 2017; 51:183-187. [PMID: 28424042 DOI: 10.1177/1538574417698903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the impact of a new angiographic imaging technology on radiation dose during visceral embolization procedures involving both fluoroscopy and digital subtraction angiography. MATERIAL AND METHODS A retrospective analysis from a single-center consecutive series of patients was performed comparing 2 angiographic imaging systems. The AlluraClarity (CIQ; Philips Healthcare, Best, the Netherlands) was used in 100 patients (n = 59 male, mean age: 70.6 years) from July 2013 to April 2014 and compared to the former AlluraXper (AX) technology used in 139 patients (n = 71 male, mean age: 70.1 years) from May 2011 to June 2013. Patients were categorized according to body mass index (BMI [kg/m2])-group 1: BMI <25, group 2: BMI ≥25 and <30, and group 3: BMI ≥30. Fluoroscopy time, the total dose of iodinated contrast administered, and procedural AirKerma (Ka, r [mGy]) were obtained. RESULTS Mean BMI was 26.4 ± 5.0 kg/m2 in the CIQ and 26.4 ± 7.1 kg/m2 in the AX group ( P = .93). Fluoroscopy time and the amount of contrast media were equally distributed. Ka, r was 1342.9 mGy versus 2214.8 mGy ( P < .001, t test) when comparing CIQ to AX. Comparing CIQ to AX, BMI subgroup analysis revealed a mean Ka, r of 970.1 to 1586.1 mGy ( P = .003, t test), 1484.7 to 2170.1 mGy ( P = .02, t test), and 1848.8 to 3348.9 mGy ( P = .001, t test) in BMI groups 1, 2, and 3, respectively. CONCLUSION The CIQ technology significantly reduced mean radiation dose by 39.4% for visceral embolization procedures when compared to fluoroscopy time and contrast media dose. This dose relationship was consistent across all BMI groups.
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Affiliation(s)
- Frederic Baumann
- 1 Miami Cardiac & Vascular Institute, Baptist Hospital, Miami, FL, USA.,2 Clinical and Interventional Angiology, University Hospital of Zurich, Zurich, Switzerland
| | - Constantino Peña
- 1 Miami Cardiac & Vascular Institute, Baptist Hospital, Miami, FL, USA
| | - Roman Kloeckner
- 2 Clinical and Interventional Angiology, University Hospital of Zurich, Zurich, Switzerland.,3 Clinic for Interventional Radiology, University Hospital of Mainz, Mainz, Germany
| | - Barry T Katzen
- 1 Miami Cardiac & Vascular Institute, Baptist Hospital, Miami, FL, USA
| | - Ripal Gandhi
- 1 Miami Cardiac & Vascular Institute, Baptist Hospital, Miami, FL, USA
| | - James B Benenati
- 1 Miami Cardiac & Vascular Institute, Baptist Hospital, Miami, FL, USA
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de Ruiter QM, Gijsberts CM, Hazenberg CE, Moll FL, van Herwaarden JA. Radiation Awareness for Endovascular Abdominal Aortic Aneurysm Repair in the Hybrid Operating Room. An Instant Patient Risk Chart for Daily Practice. J Endovasc Ther 2017; 24:425-434. [PMID: 28393672 PMCID: PMC5438080 DOI: 10.1177/1526602817697188] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: To determine which patient and C-arm characteristics are the strongest predictors of intraoperative patient radiation dose rates (DRs) during endovascular aneurysm repair (EVAR) procedures and create a patient risk chart. Methods: A retrospective analysis was performed of 74 EVAR procedures, including 16,889 X-ray runs using fixed C-arm imaging equipment. Four multivariate log-linear mixed models (with patient as a random effect) were constructed. Mean air kerma DR (DRAK, mGy/s) and the mean dose area product DR (DRDAP, mGycm2/s) were the outcome variables utilized for fluoroscopy as differentiated from digital subtraction angiography (DSA). These models were used to predict the maximum radiation duration allowed before a 2-Gy skin threshold (for DRAK) or a 500-Gycm2 threshold (for DRDAP) was reached. Results: The strongest predictor of DRAK and DRDAP for fluoroscopy imaging was the radiation protocol, with an increase of 200% when changing from “low” to “medium” and 410% from “low” to “normal.” The strongest predictors of DRAK and DRDAP for DSA were C-arm angulation, with an increase of 47% per 30° of angulation, and body mass index (BMI), with an increase of 58% for every 5-point increase in BMI. Based on these models, a patient with a BMI of 30 kg/m2, combined with 45° of rotation and a field size of 800 cm2 in the medium fluoroscopy protocol has a predicted DRAK of 0.39 mGy/s (or 85.5 minutes until the 2-Gy skin threshold is reached). While using comparable settings but switching the acquisition to a DSA with a “2 frames per second” protocol, the predicted DRAK will be 6.6 mGy/s (or 5.0 minutes until the 2-Gy threshold is reached). Conclusion: X-ray radiation DRs are constantly fluctuating during and between patients based on BMI, the protocols, C-arm position, and the image acquisitions that are used. An instant patient risk chart visualizes these radiation dose fluctuations and provides an overview of the expected duration of X-ray radiation, which can be used to predict when follow-up dose thresholds are reached during abdominal endovascular procedures.
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Affiliation(s)
- Quirina M de Ruiter
- 1 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Crystel M Gijsberts
- 2 ICIN-Netherlands Heart Institute, Utrecht, the Netherlands.,3 Laboratory of Experimental Cardiology, University Medical Center Utrecht, the Netherlands
| | | | - Frans L Moll
- 1 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
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27
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Goldsweig AM, Abbott JD, Aronow HD. Physician and Patient Radiation Exposure During Endovascular Procedures. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:10. [PMID: 28275940 DOI: 10.1007/s11936-017-0507-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OPINION STATEMENT Endovascular procedures expose both patients and physicians to fluoroscopic ionizing radiation that carries a dose-dependent risk of acute toxicity and a small, but demonstrable, long-term risk of malignancy due to resultant genetic mutations. Exposure doses vary widely based upon patient-related factors including body size and anatomic complexity, operator technique, procedure type (diagnostic vs. therapeutic), vascular bed imaged, and imaging equipment employed. Effective dosage may vary as much as 200-fold for physicians and 20-fold for patients depending upon the procedure: for example, complex aortic interventions with branched graft devices may convey mean effective doses of more than 0.4 mSv for physicians and 100 mSv for patients, whereas distal, small-vessel angiography may entail mean effective doses of less than 0.002 mSv for physicians and 5 mSv for patients. Particular attention is given to physicians' ocular exposure, which may cause cataract development, and to hand exposure, which is significantly higher than total body exposure when operators work near the x-ray beam. Given the risks of radiation exposure, numerous strategies have been developed to reduce both physician and patient doses. These measures include physician education about dose-reducing imaging techniques, development of low-dose imaging equipment, introduction of new radiation shielding drapes and caps, and real-time dose monitoring. Here, we review physician and patient effective doses of radiation by procedure type as reported in the literature and present recent data regarding dose-reduction strategies.
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Affiliation(s)
- Andrew M Goldsweig
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 731, Providence, RI, 02903, USA
| | - J Dawn Abbott
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 731, Providence, RI, 02903, USA
| | - Herbert D Aronow
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 731, Providence, RI, 02903, USA.
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Real-Time Patient and Staff Radiation Dose Monitoring in IR Practice. Cardiovasc Intervent Radiol 2016; 40:421-429. [PMID: 27942927 PMCID: PMC5288431 DOI: 10.1007/s00270-016-1526-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/01/2016] [Indexed: 10/29/2022]
Abstract
PURPOSE Knowledge of medical radiation exposure permits application of radiation protection principles. In our center, the first dedicated real-time, automated patient and staff dose monitoring system (DoseWise Portal, Philips Healthcare) was installed. Aim of this study was to obtain insight in the procedural and occupational doses. MATERIALS AND METHODS All interventional radiologists, vascular surgeons, and technicians wore personal dose meters (PDMs, DoseAware, Philips Healthcare). The dose monitoring system simultaneously registered for each procedure dose-related data as the dose area product (DAP) and effective staff dose (E) from PDMs. Use and type of shielding were recorded separately. All procedures were analyzed according to procedure type; these included among others cerebral interventions (n = 112), iliac and/or caval venous recanalization procedures (n = 68), endovascular aortic repair procedures (n = 63), biliary duct interventions (n = 58), and percutaneous gastrostomy procedure (n = 28). RESULTS Median (±IQR) DAP doses ranged from 2.0 (0.8-3.1) (percutaneous gastrostomy) to 84 (53-147) Gy cm2 (aortic repair procedures). Median (±IQR) first operator doses ranged from 1.6 (1.1-5.0) μSv to 33.4 (12.1-125.0) for these procedures, respectively. The relative exposure, determined as first operator dose normalized to procedural DAP, ranged from 1.9 in biliary interventions to 0.1 μSv/Gy cm2 in cerebral interventions, indicating large variation in staff dose per unit DAP among the procedure types. CONCLUSION Real-time dose monitoring was able to identify the types of interventions with either an absolute or relatively high staff dose, and may allow for specific optimization of radiation protection.
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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.
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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
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Antoniou GA, Senior Y, Iazzolino L, England A, McWilliams RG, Fisher RK, Torella F. Endovascular Aneurysm Sealing Is Associated With Reduced Radiation Exposure and Procedure Time Compared With Standard Endovascular Aneurysm Repair. J Endovasc Ther 2016; 23:285-9. [DOI: 10.1177/1526602816628283] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To compare indirect measures of radiation exposure and operating time between endovascular aneurysm sealing (EVAS) and endovascular aneurysm repair (EVAR) for the treatment of abdominal aortic aneurysm (AAA). Methods: The study compared 32 consecutive patients (mean age 78 years; 21 men) with AAA who underwent standard EVAS with 32 consecutive patients (mean age 78 years; 25 men) treated with EVAR between November 2013 and May 2015. Electronic medical records and image archiving databases were interrogated to retrieve relevant information and scans. Screening time and dose area product (DAP) were the primary outcome measures. Data are presented as median and interquartile range (IQR). Correlations were tested with the Spearman rank coefficient (ρ). Results: The screening time was shorter in EVAS than in EVAR [16 (IQR 14, 20) vs 32 (IQR 26, 38) minutes; p<0.001]. DAP was lower in EVAS than in EVAR [54 (IQR 42, 77) vs 111 (IQR 75, 157) Gy∙cm2; p<0.001]. Digital subtraction angiography delivered 20% (IQR 15%, 28%) of the DAP in EVAS compared with 14% (IQR 11%, 19%) in EVAR (p<0.001), but the absolute time used on digital subtraction was marginally lower in EVAS than in EVAR [1.07 (IQR 0.52, 1.23) vs 1.19 (IQR 0.70, 1.39) minutes; p=0.037]. The operating time was shorter for EVAS [121 (IQR 105, 146) vs 162 (IQR 145,186) minutes; p<0.001]. There was a moderate correlation between DAP and screening time (ρ=0.597, p<0.001), fluoroscopy time (ρ=0.595, p<0.001), digital subtraction time (ρ=0.301, p=0.015), and operating time (ρ=0.512, p<0.001). Conclusion: EVAS is associated with reduced radiation exposure and operating room usage compared with EVAR, which may have safety and financial implications.
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Affiliation(s)
- George A. Antoniou
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Yashika Senior
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Luigi Iazzolino
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Andrew England
- Department of Radiography, University of Salford, Manchester, UK
| | - Richard G. McWilliams
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Robert K. Fisher
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
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