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Tsitsiou Y, Velan B, Ross R, Lakshminarayan R, Rogers A, Hamady M. National UK Survey of Radiation Doses During Endovascular Aortic Interventions. Cardiovasc Intervent Radiol 2024; 47:92-100. [PMID: 37968425 PMCID: PMC10770209 DOI: 10.1007/s00270-023-03592-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/11/2023] [Indexed: 11/17/2023]
Abstract
PURPOSE Endovascular aortic repair (EAR) interventions, endovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR), are associated with significant radiation exposures. We aimed to investigate the radiation doses from real-world practice and propose diagnostic reference level (DRL) for the UK. MATERIALS AND METHODS Radiation data and essential demographics were retrospectively collected from 24 vascular and interventional radiology centres in the UK for all patients undergoing EAR-standard EVAR or complex, branched/fenestrated (BEVAR/FEVAR), and TEVAR-between 2018 and 2021. The data set was further categorised according to X-ray unit type, either fixed or mobile. The proposed national DRL is the 75th percentile of the collective medians for procedure KAP (kerma area product), cumulative air kerma (CAK), fluoroscopy KAP and CAK. RESULTS Data from 3712 endovascular aortic procedures were collected, including 2062 cases were standard EVAR, 906 cases of BEVAR/FEVAR and 509 cases of TEVAR. The majority of endovascular procedures (3477/3712) were performed on fixed X-ray units. The proposed DRL for KAP was 162 Gy cm2, 175 Gy cm2 and 266 Gy cm2 for standard EVAR, TEVAR and BEVAR/FEVAR, respectively. CONCLUSION The development of DRLs is pertinent to EAR procedures as the first step to optimise the radiation risks to patients and staff while maintaining the highest patient care and paving the way for steps to reduce radiation exposures.
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Affiliation(s)
- Yvonne Tsitsiou
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK.
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Bar Velan
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK
| | - Rebecca Ross
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK
| | | | - Andy Rogers
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mohamad Hamady
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Tzanis E, Damilakis J. A neural network-enhanced methodology for the rapid establishment of local DRLs in interventional radiology: EVAR as a case example. Phys Med 2023; 114:103140. [PMID: 37741153 DOI: 10.1016/j.ejmp.2023.103140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/28/2023] [Accepted: 09/17/2023] [Indexed: 09/25/2023] Open
Abstract
PURPOSE To develop a neural network-enhanced workflow for the automatic and rapid establishment/update of local diagnostic reference levels (DRLs) in interventional radiology (IR) using endovascular aneurysm repair (EVAR) procedures as a case example. METHODS Radiation dose reports were collected retrospectively for 46 consecutive EVAR procedures. These reports served as demonstrative data for the development of the proposed methodology. An algorithm was developed to receive multiple dose reports, automatically extract the kerma area product (KAP), air kerma (Ka,r), number of exposure images, and fluoroscopy time (FT) from each report and calculate the first, second, third quartiles as well as the maximum and minimum values of the extracted parameters. To extract the values of interest from the dose reports, Tesseract, an open-source optical character recognition (OCR) engine was employed. Furthermore, the accuracy and time efficiency of the proposed methodology were assessed. Specifically, the values extracted from the algorithm were compared with the ground truth values and the algorithm's processing time was compared with the respective time needed to manually extract and process the values of interest. RESULTS The OCR-based algorithm managed to correctly recognize 182 from the 184 target values, resulting in an accuracy of 99%. Moreover, the proposed pipeline reduced the processing time for the establishment of DRLs by 98%. DRL value for EVAR procedures, set as the third quartile of KAP was found to be 551 Gy*cm2. CONCLUSION An accurate and time-efficient workflow was developed for the establishment of local DRLs in interventional radiology.
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Affiliation(s)
- Eleftherios Tzanis
- Department of Medical Physics, School of Medicine, University of Crete, P.O. Box 2208, 71003 Heraklion, Crete, Greece
| | - John Damilakis
- Department of Medical Physics, School of Medicine, University of Crete, P.O. Box 2208, 71003 Heraklion, Crete, Greece.
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Efthymiou FO, Kakkos SK, Metaxas VI, Dimitroukas CP, Moulakakis KG, Papadoulas SI, Kouri NK, Tsimpoukis AL, Nikolakopoulos KM, Papageorgopoulou CP, Panayiotakis GS. FACTORS INFLUENCING FLUOROSCOPY TIME IN ENDOVASCULAR TREATMENT OF ABDOMINAL ANEURYSMS: A RETROSPECTIVE STUDY. RADIATION PROTECTION DOSIMETRY 2023; 199:443-452. [PMID: 36782000 PMCID: PMC10686527 DOI: 10.1093/rpd/ncad025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 01/15/2023] [Accepted: 01/23/2023] [Indexed: 06/18/2023]
Abstract
Patients who undergo endovascular aortic aneurysm repair (EVAR) may require prolonged radiation exposure affected by several factors. The objectives of this study were to document fluoroscopy time (FT) during EVAR and identify possible factors that influence it. A retrospective analysis of a 180 patients' database with abdominal infrarenal aortic aneurysms submitted to EVAR during a 7-y period was performed. The FT is evaluated regarding risk factors and comorbidities, graft type and patient-related, clinical and technical parameters. FT's median (interquartile range) was 1011 (698-1500) s. Excluder and C3 Excluder were associated with significantly lower FT values when compared with other grafts. Hypertension, dyslipidemia, age ≥ 70 y, maximum aneurysm diameter ≥ 6 cm and procedure duration ≥2 h resulted in higher FT values. A significantly lower FT was found for the operations performed in the 7th y of the study's period compared with the previous 6 y, mainly because of the use of Excluder or C3 Excluder grafts. However, these grafts did not show any significant difference in FT values during the 7 y. A significant correlation between FT with age and procedure duration was found. Nevertheless, procedure duration is a poor FT predictor in linear and logistic regressions, although is significantly correlated with FT. Dyslipidemia, procedure duration and graft type are independent predictors of FT larger than the median, whereas only the procedure duration is a predictor for FT larger than the 75th percentile value. The identified factors regarding radiation protection issues should be considered when contemplating abdominal aortic aneurysm repair, however, without compromising the procedure's efficacy. Further work is necessary to identify more potential anatomical, clinical and technical factors affecting procedures' complexity and FT and patient radiation dose during EVAR interventions.
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Affiliation(s)
- Fotios O Efthymiou
- Department of Medical Physics, School of Medicine, University of Patras, Patras, Greece
| | - Stavros K Kakkos
- Department of Vascular Surgery, School of Medicine, University of Patras, Patras, Greece
| | - Vasileios I Metaxas
- Department of Medical Physics, School of Medicine, University of Patras, Patras, Greece
| | - Christos P Dimitroukas
- Department of Medical Physics, School of Medicine, University of Patras, Patras, Greece
- Department of Medical Physics, University Hospital of Patras, Patras, Greece
| | | | - Spyros I Papadoulas
- Department of Vascular Surgery, School of Medicine, University of Patras, Patras, Greece
| | - Natasa K Kouri
- Department of Vascular Surgery, School of Medicine, University of Patras, Patras, Greece
| | - Andreas L Tsimpoukis
- Department of Vascular Surgery, School of Medicine, University of Patras, Patras, Greece
| | | | | | - George S Panayiotakis
- Department of Medical Physics, School of Medicine, University of Patras, Patras, Greece
- Department of Medical Physics, University Hospital of Patras, Patras, Greece
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Tristram J, Steuwe A, Kröpil F, Thomas C, Rubbert C, Antoch G, Boos J. Typical doses and typical values for fluoroscopic diagnostic and interventional procedures. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2022; 42:021510. [PMID: 35130526 DOI: 10.1088/1361-6498/ac5294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 02/07/2022] [Indexed: 06/14/2023]
Abstract
To implement typical doses (TD) and typical values (TV) for fluoroscopic diagnostic and interventional procedures. A total of 3811 fluoroscopic procedures performed within 34 months on three devices were included in this retrospective study. Dose-, patient- and procedure-related information were extracted using the institutional dose management system (DMS). TD/TV were defined as median dose and calculated for the five most frequent procedures per device for dose area product (DAP), cumulative air kerma (CAK) and fluoroscopy time (FT). National diagnostic reference levels and other single facility studies were compared to our results. Additionally, the five procedures with the highest doses of each device were analysed. To evaluate the data coverage of the DMS compared to the picture archiving and communication system (PACS), procedure lists were extracted from the PACS and compared to the procedure information extracted from the DMS. TD/TV for 15 procedures were implemented. Among all devices, TD for DAP ranged between 0.6 Gycm2for port catheter control (n= 64) and 145.9 Gycm2for transarterial chemoembolisation (n= 84). TD for CAK ranged between 5 mGy for port catheter control and 1397 mGy for aneurysm treatment (n= 129) and TV for FT ranged between 0.3 min for upper cavography (n= 67) and 51.4 min for aneurysm treatment. TD for DAP and CAK were lower or within the range of other single facility studies. The five procedures with the highest median DAP per device were identified, 6 of 15 procedures were also found to be among the most frequent procedures. Data coverage of the DMS compared to the PACS ranged between 71% (device 2, stroke treatment) and 78% (device 1, lower limb angiography) for the most common procedure per device. Thus, in 22%-29% of cases dose data of the performed procedure was not transferred into the DMS. We implemented TD/TV for fluoroscopic diagnostic and interventional procedures which enable a comprehensive dose analysis and comparison with previously published values.
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Affiliation(s)
- Juliana Tristram
- Medical Faculty, Department of Diagnostic and Institutional Radiology, University Dusseldorf, D-40225 Dusseldorf, Germany
| | - Andrea Steuwe
- Medical Faculty, Department of Diagnostic and Institutional Radiology, University Dusseldorf, D-40225 Dusseldorf, Germany
| | - Feride Kröpil
- Medical Faculty, Department of Surgery, University Dusseldorf, D-40225 Dusseldorf, Germany
| | - Christoph Thomas
- Medical Faculty, Department of Diagnostic and Institutional Radiology, University Dusseldorf, D-40225 Dusseldorf, Germany
| | - Christian Rubbert
- Medical Faculty, Department of Diagnostic and Institutional Radiology, University Dusseldorf, D-40225 Dusseldorf, Germany
| | - Gerald Antoch
- Medical Faculty, Department of Diagnostic and Institutional Radiology, University Dusseldorf, D-40225 Dusseldorf, Germany
| | - Johannes Boos
- Medical Faculty, Department of Diagnostic and Institutional Radiology, University Dusseldorf, D-40225 Dusseldorf, Germany
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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.
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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
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Kakkos SK, Efthymiou FO, Metaxas VI, Dimitroukas CP, Panayiotakis GS. Factors affecting radiation exposure in endovascular repair of abdominal aortic aneurysms: a pilot study. INT ANGIOL 2020; 40:125-130. [PMID: 33315209 DOI: 10.23736/s0392-9590.20.04508-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Radiation exposure during endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) is a potential issue. Several studies have identified factors affecting radiation exposure, although they are limited. The aim of this study was to identify independent factors affecting radiation exposure in patients with AAA undergoing standard EVAR. METHODS Forty-eight consecutive patients underwent elective EVAR for infrarenal AAA managed between April 2019 and April 2020. Fluoroscopy time (FT) and kerma area product (KAP) were the main outcome measures. RESULTS Median (interquartile range) FT and KAP values were 1018 (653-1619) s and 2.68 (2.08-3.81) mGy·m2, respectively. C3 Excluder graft use and main body insertion site from the right femoral were associated with significantly lower FT. Coronary artery disease, endografts with two docking limbs, AAA diameter, neck angle and length, procedure duration, contrast amount, and hospitalization were associated with significantly higher FT. Neck angle was the single independent perioperative factor related to FT higher than the median value observed in the study (P=0.004, odds ratio: 1.073, 95% confidence interval: 1.023-1.126). The use of the C3 Excluder device was associated with lower KAP. AAA diameter, neck angle, procedure duration, contrast medium amount and postoperative hospitalization were associated with higher KAP. AAA diameter was the single independent factor related to KAP higher than the median value observed in the study (P=0.013, odds ratio: 3.73, 95% confidence interval: 1.32-10.56). CONCLUSIONS This study has identified factors affecting radiation exposure during standard EVAR for infrarenal AAAs. These factors should be taken into account when contemplating AAA repair.
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Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, Medical School, University of Patras, Patras, Greece -
| | - Fotios O Efthymiou
- Department of Medical Physics, Medical School, University of Patras, Patras, Greece
| | - Vasileios I Metaxas
- Department of Medical Physics, Medical School, University of Patras, Patras, Greece
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