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Singh B, Andersson M, Edsfeldt A, Sonesson B, Gunnarsson M, Dias NV. Estimation of the Added Cancer Risk Derived From EVAR and CTA Follow-Up. J Endovasc Ther 2023:15266028231219435. [PMID: 38140719 DOI: 10.1177/15266028231219435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
OBJECTIVE The aim of this study was to assess the risk of radiation-induced cancer development in patients that have undergone an infrarenal EVAR, stratifying the relative contributions of the procedure and the preoperative and postoperative CTAs. METHODS AND MATERIALS The organ-specific absorbed radiation doses from CTA and the EVAR procedure were estimated from the radiation exposures of 95 and 45 male patients, respectively. Lifetime attributable risk (LAR) cancer predictions were calculated for 14 different organs. Life expectancy was assumed from a previous cohort of patients undergoing infra-renal EVAR. RESULTS The calculated total excess cancer risk was 0.0046, ie, 1 out of 220 patients will develop a neoplasm after being exposed to the ionizing radiation from the preoperative CTA, the EVAR and annual CTA examinations for 15 years. The procedure and the preoperative CTA contributed with 38% of the total excess risk, while the rest was derived from the follow-up. If the entire CTA based follow-up would have been eliminated, an excess risk of 0.0018 (1/560) would remain. CONCLUSIONS 1 out of 219 patients who have undergone EVAR of an infra-renal AAA have a lifetime risk of developing cancer secondary to the radiation exposures related to the procedure and the CTAs used preoperatively and during follow-up. This risk derives mostly from the yearly postoperative CTAs, underlining the potential benefits of reducing or replacing their use. CLINICAL IMPACT A simulation-based estimation reinforced the potential deleterious effects of the radiation exposure for patients undergoing Endovascular Aneurysm Repair (EVAR) of Abdominal Aortic Aneurysms (AAA) and subsequently followed by yearly Computer Tomography Angiographies (CTAs). The risk could be as high as 1 out 219 patients developing a neoplasm after 15 years. The largest exposure derives from the follow-up CTAs and efforts to minimize their use as well as the intraoperative radiation are greatly needed. The simulation-based estimations done in this study reinforce potential deleterious effects of the radiation exposure for patients undergoing EVAR of AAA. Efforts should be done to minimize the intraoperative radiation and the number of CTAs used during follow-up.
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Affiliation(s)
- Bharti Singh
- Vascular Center Malmö-Lund, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Martin Andersson
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Medical Radiation Physics Malmö, Department of Translational Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Andreas Edsfeldt
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Cardiology, University Hospital of Skåne, Lund/Malmö, Sweden
- Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden
| | - Björn Sonesson
- Vascular Center Malmö-Lund, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Mikael Gunnarsson
- Medical Radiation Physics Malmö, Department of Translational Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Nuno V Dias
- Vascular Center Malmö-Lund, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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Harbron RW, Abdelhalim MA, Ainsbury EA, Eakins JS, Modarai B. Editor's Choice - Estimated Radiation Dose to the Operator During Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2023; 66:178-185. [PMID: 37011855 DOI: 10.1016/j.ejvs.2023.03.041] [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: 09/26/2021] [Revised: 03/11/2023] [Accepted: 03/29/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE To estimate operator organ doses from fluoroscopically guided infrarenal endovascular aneurysm repair (EVAR) procedures, using the detailed exposure information contained in radiation dose structured reports. METHODS Conversion factors relating kerma area product (PKA) to primary operator organ doses were calculated using Monte Carlo methods for 91 beam angles and seven x-ray spectra typical of clinical practice. A computer program was written, which selects the appropriate conversion factor for each exposure listed in a structured report and multiplies it by the respective PKA. This system was used to estimate operator doses for 81 EVAR procedures for which structured reports were available. The impact of different shielding scenarios and variations in operator position was also investigated. RESULTS Without any shielding, the median estimated effective dose was 113 μSv (interquartile range [IQR] 71, 252 μSv). The highest median organ doses were for the colon (154 μSv, IQR 81, 343) and stomach (133 μSv, IQR 76, 307). These dose estimates represent all exposures, including fluoroscopy and non-fluoroscopic digital acquisitions. With minimal shielding provided by 0.25 mm of Pb covering the torso and upper legs, the effective dose was reduced by a factor of around 6. With additional shielding from ceiling and table shields, a 25 to 50 fold reduction in dose is achievable. Estimated doses were highest where the primary beam was pointed directly away from the operator. CONCLUSION The models suggest that with optimal use of shielding, operator doses can be reduced to levels equivalent to one to two days of natural background exposure and well below statutory dose limits.
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Affiliation(s)
- Richard W Harbron
- Institute of Population Health Sciences, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK; NIHR Health Protection Research Unit in Chemical and Radiation Threats and Hazards, Newcastle University, Newcastle upon Tyne, UK; European Organisation for Nuclear Research (CERN), Geneva, Switzerland.
| | - Mohamed A Abdelhalim
- 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, UK
| | - Elizabeth A Ainsbury
- NIHR Health Protection Research Unit in Chemical and Radiation Threats and Hazards, Newcastle University, Newcastle upon Tyne, UK; Public Health England Centre for Radiation, Chaemical and Environmental Threats and Hazards, Chilton, UK
| | - Jonathan S Eakins
- NIHR Health Protection Research Unit in Chemical and Radiation Threats and Hazards, Newcastle University, Newcastle upon Tyne, UK; Public Health England Centre for Radiation, Chaemical and Environmental Threats and Hazards, Chilton, UK
| | - 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, UK
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BMI-Based organ doses in endovascular aneurysm repair interventions utilising Monte Carlo simulation. Appl Radiat Isot 2023; 195:110740. [PMID: 36857815 DOI: 10.1016/j.apradiso.2023.110740] [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: 06/27/2022] [Revised: 01/01/2023] [Accepted: 02/20/2023] [Indexed: 02/23/2023]
Abstract
In this study, the effect of body-mass-index (BMI) on organ doses (ODs) during infrarenal endovascular-aneurysm-repair (EVAR) procedures was evaluated. Patient- and intra-operative data from fifty-nine EVAR procedures were inserted into VirtualDose-IR software to calculate ODs. For overweight, obesity class-I and obesity class-II, ODs were up to 147%, 412% and 775% higher than those for normal weight-patients, respectively. A large variation was observed in ODs published in literature mainly due to the differences in the software and the technical parameters used for the calculations.
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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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Zewde N, Ria F, Rehani MM. Organ doses and cancer risk assessment in patients exposed to high doses from recurrent CT exams. Eur J Radiol 2022; 149:110224. [DOI: 10.1016/j.ejrad.2022.110224] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 01/24/2022] [Accepted: 02/16/2022] [Indexed: 11/03/2022]
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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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Harbron RW, Abdelhalim M, Ainsbury EA, Eakins JS, Alam A, Lee C, Modarai B. Patient radiation dose from x-ray guided endovascular aneurysm repair: a Monte Carlo approach using voxel phantoms and detailed exposure information. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2020; 40:704-726. [PMID: 32428884 DOI: 10.1088/1361-6498/ab944e] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Endovascular aneurysm repair (EVAR) is a well-established minimally invasive technique that relies on x-ray guidance to introduce a stent through the femoral artery and manipulate it into place. The aim of this study was to estimate patient organ and effective doses from EVAR procedures using anatomically realistic computational phantoms and detailed exposure information from radiation dose structured reports (RDSR). Methods: Lookup tables of conversion factors relating kerma area product (PKA) to organ doses for 49 different beam angles were produced using Monte Carlo simulations (MCNPX2.7) with International Commission on Radiological Protection (ICRP) adult male and female voxel phantoms for EVAR procedures of varying complexity (infra-renal, fenestrated/branched and thoracic EVAR). Beam angle specific correction factors were calculated to adjust doses according to x-ray energy. A MATLAB function was written to find the appropriate conversion factor in the lookup table for each exposure described in the RDSR, perform energy corrections and multiply by the respective exposure PKA. Using this approach, organ doses were estimated for 183 EVAR procedures in which RDSRs were available. A number of simplified dose estimation methodologies were also investigated for situations in which RDSR data are not available. Results: Mean estimated bone marrow doses were 57 (range: 2-247), 86 (2-328) and 54 (8-250) mGy for infra-renal, fenestrated/branched and thoracic EVAR, respectively. Respective effective doses were 27 (1-208), 54 (1-180) and 37 (5-167) mSv. Dose estimates using non-individualised, average conversion factors, along with those produced using the alternative Monte Carlo code PCXMC, yielded reasonably similar results overall, though variation for individual procedures could exceed 100% for some organs. In conclusion, radiation doses from x-ray guided endovascular aneurysm repairs are potentially high, though this must be placed in the context of the life sparing nature and high success rate for this procedure.
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Affiliation(s)
- Richard W Harbron
- Population Health Sciences Institute, Newcastle University, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne NE1 4LP, United Kingdom. NIHR Health Protection Research Unit in Chemical and Radiation Threats and Hazards, Newcastle University, Newcastle-upon-Tyne United Kingdom
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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: 13] [Impact Index Per Article: 3.3] [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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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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Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, ESVS Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57:8-93. [DOI: 10.1016/j.ejvs.2018.09.020] [Citation(s) in RCA: 873] [Impact Index Per Article: 174.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Almén A, Lundh C, Båth M. Challenges assessing radiation risk in image-guided treatments-implications on optimisation of radiological protection. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2018; 38:1064-1076. [PMID: 29900877 DOI: 10.1088/1361-6498/aacc83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The present work explores challenges when assessing organ dose and effective dose concerning image-guided treatments. During these treatments considerable x-ray imaging is employed using technically advanced angiographic x-ray equipment. Thus, the radiation dose to organs and the related radiation risk are relatively difficult to assess. This has implications on the optimisation process, in which assessing radiation dose is one important part. In this study, endovascular aortic repair treatments were investigated. Organ dose and effective dose were assessed using Monte Carlo calculations together with a detailed specification of the exposure situation and patient size. The resulting normalised organ dose and effective dose with respect to kerma-area product for patient sizes and radiation qualities representative for the patient group were evaluated. The variability and uncertainty were investigated and their possible impact on optimisation of radiation protection was discussed. Exposure parameters, source to detector distances etc varied between treatments and also varied between image acquisitions during one treatment. Thus the derived normalised organ dose and effective dose exhibited a large range of values depending greatly on used exposure parameters and patient configuration. The derived normalised values for effective dose varied approximately between 0.05 and 0.30 mSv per Gy·cm2 when taking patient sizes and exposure parameters into consideration, the values for organ doses exhibited even larger variation. The study shows a possible systematic error for derived organ doses and effective dose up to a factor of 7 if detailed exposure or patient characteristics are not known and/or not taken into consideration. The intra-treatment variability was also substantial and the normalised dose values varied up to a factor of 2 between image acquisitions during one treatment. The study shows that the use of conversion factors that are not adapted to the clinic can cause the radiation dose to be exaggerated or underestimated considerably. A conclusion from the present study is that the systematic error could be large and should be estimated together with random errors. A large uncertainty makes it difficult to detect true differences in radiation dose between methods and technology-a prerequisite for optimising radiation protection for image-guided treatments.
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Affiliation(s)
- A Almén
- Medical Radiation Physics, Department of Translational Medicine, Lund University, SE-205 02 Malmö, Sweden. Radiation Physics, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, SE-221 85 Lund, Sweden
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Machado R, Ferreira VMD, Loureiro L, Gonçalves J, Oliveira P, Almeida R. Radiation Exposure in Endovascular Infra-Renal Aortic Aneurysm Repair and Factors that Influence It. Braz J Cardiovasc Surg 2017; 31:415-421. [PMID: 28076617 PMCID: PMC5407135 DOI: 10.5935/1678-9741.20160084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/30/2016] [Indexed: 11/20/2022] Open
Abstract
Objective The endovascular repair of aortic abdominal aneurysms exposes the patients
and surgical team to ionizing radiation with risk of direct tissue damage
and induction of gene mutation. This study aims to describe our standard of
radiation exposure in endovascular aortic aneurysm repair and the factors
that influence it. Methods Retrospective analysis of a prospective database of patients with abdominal
infra-renal aortic aneurysms submitted to endovascular repair. This study
evaluated the radiation doses (dose area product (DAP)), fluoroscopy
durations and their relationships to the patients, aneurysms, and
stent-graft characteristics. Results This study included 127 patients with a mean age of 73 years. The mean DAP
was 4.8 mGy.m2, and the fluoroscopy time was 21.8 minutes. Aortic
bilateral iliac aneurysms, higher body mass index, aneurysms with diameters
larger than 60 mm, necks with diameters larger than 28 mm, common iliac
arteries with diameters larger than 20 mm, and neck angulations superior to
50 degrees were associated with an increased radiation dose. The number of
anatomic risk factors present was associated with increased radiation
exposure and fluoroscopy time, regardless of the anatomical risk
factors. Conclusion The radiation exposure during endovascular aortic aneurysm repair is
significant (mean DAP 4.8 mGy.m2) with potential hazards to the
surgical team and the patients. The anatomical characteristics of the
aneurysm, patient characteristics, and the procedure's technical difficulty
were all related to increased radiation exposure during endovascular aortic
aneurysm repair procedures. Approximately 40% of radiation exposure can be
explained by body mass index, neck angulation, aneurysm diameter, neck
diameter, and aneurysm type.
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Affiliation(s)
- Rui Machado
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | | | - Luis Loureiro
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - João Gonçalves
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Pedro Oliveira
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
| | - Rui Almeida
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
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Nyheim T, Staxrud LE, Jørgensen JJ, Jensen K, Olerud HM, Sandbæk G. Radiation exposure in patients treated with endovascular aneurysm repair: what is the risk of cancer, and can we justify treating younger patients? Acta Radiol 2017; 58:323-330. [PMID: 27279268 DOI: 10.1177/0284185116651002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Endovascular aneurysm repair (EVAR) is becoming the mainstay treatment of abdominal aortic aneurisms (AAA). The postoperative follow-up regime includes a lifelong series of CT angiograms (CTAs) at different intervals in addition to EVAR, which will confer significant cumulative radiation exposure over time. Purpose To examine the impact of age and follow-up regime over time on cumulative radiation exposure and attributable cancer risk after EVAR. Material and Methods We calculated a mean effective dose (ED) for the EVAR procedure, CTA, and plain abdominal X-rays (PAX). Cumulative ED was calculated for standard, complex, and simplified surveillance over 5, 10, and 15 years for different age groups. Results For EVAR, the mean ED was 34 mSv (range, 12-75 mSv) per procedure. For PAX, the ED was 1.1 mSv (range, 0.3-4.4 mSv), and for CTA it was 8.0 mSv (range, 2-20 mSv). For a 55-year-old man, an attributable cancer risk (ACR) in standard surveillance at 5 and 15 years of follow-up was 0.35% and 0.65%, respectively. The corresponding values were 0.22% and 0.37% for a 75-year-old man. When using a simplified follow-up, the ACRs for a 55-year-old at 5 and 15 years were 0.30% and 0.37%, respectively. These values were 0.18% and 0.21% for a 75-year-old man. A complex follow-up with half-yearly CTA over similar age and time span doubled the ACR. Conclusion Treating younger patients with EVAR poses a low ACR of 0.65% (15-year standard surveillance) compared to a lifetime cancer risk of 44%. A simplified surveillance should be used if treating younger patients, which will halve the ACR over 15 years.
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Affiliation(s)
- Thomas Nyheim
- Vascular Department, Oslo University Hospital, Oslo, Norway
- Medical faculty, University of Oslo, Oslo, Norway
| | - Lars E Staxrud
- Vascular Department, Oslo University Hospital, Oslo, Norway
| | - Jørgen J Jørgensen
- Vascular Department, Oslo University Hospital, Oslo, Norway
- Medical faculty, University of Oslo, Oslo, Norway
| | | | - Hilde M Olerud
- Buskerud and Vestfold University College, Faculty of Health Sciences, Kongsberg, Norway
- Norwegian Radiation Protection Authority, Østerås, Norway
| | - Gunnar Sandbæk
- Medical faculty, University of Oslo, Oslo, Norway
- Centre for Thoracic, Vascular and Interventional Radiology, Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
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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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Editor's Choice – Minimizing Radiation Exposure During Endovascular Procedures: Basic Knowledge, Literature Review, and Reporting Standards. Eur J Vasc Endovasc Surg 2015; 50:21-36. [DOI: 10.1016/j.ejvs.2015.01.014] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/27/2015] [Indexed: 12/30/2022]
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