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Whitehead JF, Hoffman CA, Wagner MG, Periyasamy S, Meram E, Keller ME, Speidel MA, Laeseke PF. Quantitative Digital Subtraction Angiography Measurement of Arterial Velocity at Low Radiation Dose Rates. Cardiovasc Intervent Radiol 2024; 47:1119-1126. [PMID: 38992198 DOI: 10.1007/s00270-024-03809-7] [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: 12/12/2023] [Accepted: 07/01/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE Quantitative digital subtraction angiography (qDSA) has been proposed to quantify blood velocity for monitoring treatment progress during blood flow altering interventions. The method requires high frame rate imaging [~ 30 frame per second (fps)] to capture temporal dynamics. This work investigates performance of qDSA in low radiation dose acquisitions to facilitate clinical translation. MATERIALS AND METHODS Velocity quantification accuracy was evaluated at five radiation dose rates in vitro and in vivo. Angiographic technique ranged from 30 fps digital subtraction angiography ( 29.3 ± 1.7 mGy / s at the interventional reference point) down to a 30 fps protocol at 23% higher radiation dose per frame than fluoroscopy ( 1.1 ± 0.2 mGy / s ). The in vitro setup consisted of a 3D-printed model of a swine hepatic arterial tree connected to a pulsatile displacement pump. Five different flow rates (3.5-8.8 mL/s) were investigated in vitro. Angiography-based fluid velocity measurements were compared across dose rates using ANOVA and Bland-Altman analysis. The experiment was then repeated in a swine study (n = 4). RESULTS Radiation dose rate reductions for the lowest dose protocol were 99% and 96% for the phantom and swine study, respectively. No significant difference was found between angiography-based velocity measurements at different dose rates in vitro or in vivo. Bland-Altman analysis found little bias for all lower-dose protocols (range: [- 0.1, 0.1] cm/s), with the widest limits of agreement ([- 3.3, 3.5] cm/s) occurring at the lowest dose protocol. CONCLUSIONS This study demonstrates the feasibility of quantitative blood velocity measurements from angiographic images acquired at reduced radiation dose rates.
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Affiliation(s)
- Joseph F Whitehead
- Department of Medical Physics, University of Wisconsin Madison, Madison, WI, USA
| | - Carson A Hoffman
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA
| | - Martin G Wagner
- Department of Medical Physics, University of Wisconsin Madison, Madison, WI, USA
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA
| | | | - Ece Meram
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA
| | - Marlin E Keller
- Department of Medical Physics, University of Wisconsin Madison, Madison, WI, USA
| | - Michael A Speidel
- Department of Medical Physics, University of Wisconsin Madison, Madison, WI, USA
- Department of Medicine, University of Wisconsin Madison, Madison, WI, USA
| | - Paul F Laeseke
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA.
- Department of Biomedical Engineering, University of Wisconsin Madison, Madison, WI, USA.
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Rockley M, Nana P, Rebet A, Fabre D, Haulon S. A procedural step analysis of radiation exposure in fenestrated endovascular aortic repair. J Vasc Surg 2024; 79:1306-1314.e2. [PMID: 38368998 DOI: 10.1016/j.jvs.2024.02.006] [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: 12/15/2023] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE Radiation exposure during complex endovascular aortic repair may be associated with tangible adverse effects in patients and operators. This study aimed to identify the steps of highest radiation exposure during fenestrated endovascular aortic repair (FEVAR) and to investigate potential intraoperative factors affecting radiation exposure. METHODS Prospective data of 31 consecutive patients managed exclusively with four-fenestration endografts between March 1, 2020, and July 1, 2022 were retrospectively analyzed. Leveraging the conformity of the applied technique, every FEVAR operation was considered a combination of six overall stages composed of 28 standardized steps. Intraoperative parameters, including air kerma, dose area product, fluoroscopy time, and number of digital subtraction angiographies (DSAs) and average angulations were collected and analyzed for each step. RESULTS The mean procedure duration and fluoroscopy time was 140 minutes (standard deviation [SD], 32 minutes), and 40 minutes (SD, 9.1 minutes), respectively. The mean air kerma was 814 mGy (SD, 498 mGy), and the mean dose area product was 66.8 Gy cm2 (SD, 33 Gy cm2). The percentage of air kerma of the entire procedure was distributed throughout the following procedure stages: preparation (13.9%), main body (9.6%), target vessel cannulation (27.8%), stent deployment (29.1%), distal aortoiliac grafting (14.3%), and completion (5.3%). DSAs represented 23.0% of the total air kerma. Target vessel cannulation and stent deployment presented the highest mean lateral angulation (67 and 63 degrees, respectively). Using linear regression, each minute of continuous fluoroscopy added 18.9 mGy of air kerma (95% confidence interval, 17.6-20.2 mGy), and each DSA series added 21.1 mGy of air kerma (95% confidence interval, 17.9-24.3 mGy). Body mass index and lateral angulation were significantly associated with increased air kerma (P < .001). CONCLUSIONS Cannulation of target vessels and bridging stent deployment are the steps requiring the highest radiation exposure during FEVAR cases. Optimized operator protection during these steps is mandatory.
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Affiliation(s)
- Mark Rockley
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, Paris Saclay University, Paris, France; Division of Vascular Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, Paris Saclay University, Paris, France
| | | | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, Paris Saclay University, Paris, France
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, Paris Saclay University, Paris, France.
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Whitehead JF, Hoffman CA, Wagner MG, Minesinger GM, Nikolau EP, Laeseke PF, Speidel MA. Interleaved x-ray imaging: A method for simultaneous acquisition of quantitative and diagnostic digital subtraction angiography. Med Phys 2024; 51:2468-2478. [PMID: 37856176 PMCID: PMC10994749 DOI: 10.1002/mp.16794] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Flow altering angiographic procedures suffer from ill-defined, qualitative endpoints. Quantitative digital subtraction angiography (qDSA) is an emerging technology that aims to address this issue by providing intra-procedural blood velocity measurements from time-resolved, 2D angiograms. To date, qDSA has used 30 frame/s DSA imaging, which is associated with high radiation dose rate compared to clinical diagnostic DSA (up to 4 frame/s). PURPOSE The purpose of this study is to demonstrate an interleaved x-ray imaging method which decreases the radiation dose rate associated with high frame rate qDSA while simultaneously providing low frame rate diagnostic DSA images, enabling the acquisition of both datasets in a single image sequence with a single injection of contrast agent. METHODS Interleaved x-ray imaging combines low radiation dose image frames acquired at a high rate with high radiation dose image frames acquired at a low rate. The feasibility of this approach was evaluated on an x-ray system equipped with research prototype software for x-ray tube control. qDSA blood velocity quantification was evaluated in a flow phantom study for two lower dose interleaving protocols (LD1:3.7 ± 0.02 mGy / s $3.7 \pm 0.02\ {\mathrm{mGy}}/{\mathrm{s}}$ and LD2:1.7 ± 0.04 mGy / s $1.7 \pm 0.04{\mathrm{\ mGy}}/{\mathrm{s}}$ ) and one conventional (full dose) protocol (11.4 ± 0.04 mGy / s ) $11.4 \pm 0.04{\mathrm{\ mGy}}/{\mathrm{s}})$ . Dose was measured at the interventional reference point. Fluid velocities ranging from 24 to 45 cm/s were investigated. Gold standard velocities were measured using an ultrasound flow probe. Linear regression and Bland-Altman analysis were used to compare ultrasound and qDSA. RESULTS The LD1 and LD2 interleaved protocols resulted in dose rate reductions of -67.7% and -85.5%, compared to the full dose qDSA scan. For the full dose protocol, the Bland-Altman limits of agreement (LOA) between qDSA and ultrasound velocities were [0.7, 6.7] cm/s with a mean difference of 3.7 cm/s. The LD1 interleaved protocol results were similar (LOA: [0.3, 6.9] cm/s, bias: 3.6 cm/s). The LD2 interleaved protocol resulted in slightly larger LOA: [-2.5, 5.5] cm/s with a decrease in the bias: 1.5 cm/s. Linear regression analysis showed a strong correlation between ultrasound and qDSA derived velocities using the LD1 protocol, with aR 2 ${R}^2$ of0.96 $0.96$ , a slope of1.05 $1.05$ and an offset of1.9 $1.9$ cm/s. Similar values were also found for the LD2 protocol, with aR 2 ${R}^2$ of0.93 $0.93$ , a slope of0.98 $0.98$ and an offset of2.0 $2.0$ cm/s. CONCLUSIONS The interleaved method enables simultaneous acquisition of low-dose high-rate images for intra-procedural blood velocity quantification (qDSA) and high-dose low-rate images for vessel morphology evaluation (diagnostic DSA).
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Affiliation(s)
- Joseph F. Whitehead
- Department of Medical Physics, University of Wisconsin - Madison, Madison, Wisconsin, 53705, United States of America
| | - Carson A. Hoffman
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, 53792, United States of America
| | - Martin G. Wagner
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, 53792, United States of America
| | - Grace M. Minesinger
- Department of Medical Physics, University of Wisconsin - Madison, Madison, Wisconsin, 53705, United States of America
| | - Ethan P. Nikolau
- Department of Medical Physics, University of Wisconsin - Madison, Madison, Wisconsin, 53705, United States of America
| | - Paul F. Laeseke
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, 53792, United States of America
| | - Michael A. Speidel
- Department of Medical Physics, University of Wisconsin - Madison, Madison, Wisconsin, 53705, United States of America
- Department of Medicine, University of Wisconsin - Madison, Madison, Wisconsin, 53705, United States of America
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Racic J, Pesic S, Nikolic Z, Pesic S, Ilijevski N. Case study scrub nurse role in aorto-bifemoral reconstruction with transbrachial balloon endoclamping technique. JOURNAL OF VASCULAR NURSING 2023; 41:209-211. [PMID: 38072574 DOI: 10.1016/j.jvn.2023.07.002] [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: 05/13/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 12/18/2023]
Abstract
INTRODUCTION Aortoiliac arterial disease is a chronic progressive disease which is characterized by steno-occlusive changes in the aorta and iliac arteries. The gold standard for the treatment of patients with the advanced stage of the disease is aorto-bifemoral reconstruction. Patients with circumferential juxtarenal calcifications of the aorta bear a high risk of intraoperative complications, due to difficult cross-clamping in such zones. CASE REPORT We present a case of a 73-year-old patient who has been admitted due to left leg rest pain and second toe ulceration. Multislice computed tomography showed significant stenosis of the aortoiliac segment with a circumferentially calcified abdominal aorta. Aortobifemoral reconstruction was performed featuring endoluminal occlusion of the aorta using a balloon catheter which was placed through the left brachial artery. The procedure and the postoperative course were uneventful, and the patient was discharged on the sixth postoperative day. CONCLUSION The hybrid endovascular and open surgery technique presented emerged as a valid alternative for selected high-risk patients. Scrub nurses should be familiarized with endovascular techniques and tools and be aware of the measures to be protected from the harmful effects of ionizing radiation.
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Affiliation(s)
- Jasna Racic
- Vascular Surgery Clinic, "Dedinje" Cardiovascular Institute, Heroja Milana Tepića 1 street, Belgrade 11000, Serbia
| | - Slobodan Pesic
- Vascular Surgery Clinic, "Dedinje" Cardiovascular Institute, Heroja Milana Tepića 1 street, Belgrade 11000, Serbia.
| | - Zorka Nikolic
- Vascular Surgery Clinic, "Dedinje" Cardiovascular Institute, Heroja Milana Tepića 1 street, Belgrade 11000, Serbia
| | - Snezana Pesic
- Vascular Surgery Clinic, "Dedinje" Cardiovascular Institute, Heroja Milana Tepića 1 street, Belgrade 11000, Serbia
| | - Nenad Ilijevski
- Vascular Surgery Clinic, "Dedinje" Cardiovascular Institute, Heroja Milana Tepića 1 street, Belgrade 11000, Serbia; School of Medicine, Belgrade University, Serbia
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Modarai B, Haulon S, Ainsbury E, Böckler D, Vano-Carruana E, Dawson J, Farber M, Van Herzeele I, Hertault A, van Herwaarden J, Patel A, Wanhainen A, Weiss S, Esvs Guidelines Committee, Bastos Gonçalves F, Björck M, Chakfé N, de Borst GJ, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kakkos SK, Koncar IB, Kolh P, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Document Reviewers, Bacher K, Brountzos E, Fanelli F, Fidalgo Domingos LA, Gargiulo M, Mani K, Mastracci TM, Maurel B, Morgan RA, Schneider P. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Radiation Safety. Eur J Vasc Endovasc Surg 2023; 65:171-222. [PMID: 36130680 DOI: 10.1016/j.ejvs.2022.09.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/15/2022] [Indexed: 01/24/2023]
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Klaassen J, Vijn LJ, Hazenberg CEVB, van Herwaarden JA. New tools to reduce radiation exposure during aortic endovascular procedures. Expert Rev Cardiovasc Ther 2022; 20:567-580. [PMID: 35726665 DOI: 10.1080/14779072.2022.2092096] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The evolution of endovascular surgery over the past 30 years has made it possible to treat increasingly complex vascular pathologies with an endovascular method. Although this generally speeds up the patient's recovery, the risks of health problems caused by long-term exposure to radioactive radiation increase. This warrants the demand for radiation-reducing tools to reduce radiation exposure during these procedures. AREAS COVERED For this systematic review Pubmed, Embase and Cochrane library databases were searched on 28 December 2021 to provide an overview of tools that are currently used or have the potential to contribute to reducing radiation exposure during endovascular aortic procedures. In addition, an overview is presented of radiation characteristics of clinical studies comparing a (potential) radiation-reducing device with conventional fluoroscopy use. EXPERT OPINION Radiation-reducing instruments such as fiber optic shape sensing or electromagnetic tracking devices offer the possibility to further reduce or even eliminate the use of radiation during endovascular procedures. In an era of increasing endovascular interventional complexity and awareness of the health risks of long-term radiation exposure, the use of these technologies could have a major impact on an ongoing challenge to move toward radiation-free endovascular surgery.
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Affiliation(s)
- Jurre Klaassen
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Linde J Vijn
- 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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Digital variance angiography allows about 70% decrease of DSA-related radiation exposure in lower limb X-ray angiography. Sci Rep 2021; 11:21790. [PMID: 34750427 PMCID: PMC8575921 DOI: 10.1038/s41598-021-01208-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 10/15/2021] [Indexed: 11/23/2022] Open
Abstract
Our aim was to investigate whether the previously observed higher contrast-to-noise ratio (CNR) and better image quality of Digital Variance Angiography (DVA) - compared to Digital Subtraction Angiography (DSA) - can be used to reduce radiation exposure in lower limb X-ray angiography. This prospective study enrolled 30 peripheral artery disease patients (mean ± SD age 70 ± 8 years) undergoing diagnostic angiography. In all patients, both normal (1.2 µGy/frame; 100%) and low-dose (0.36 µGy/frame; 30%) protocols were used for the acquisition of images in three anatomical regions (abdominal, femoral, crural). The CNR of DSA and DVA images were calculated, and the visual quality was evaluated by seven specialists using a 5-grade Likert scale. For investigating non-inferiority, the difference of low-dose DVA and normal dose DSA scores (DVA30-DSA100) was analyzed. DVA produced two- to three-fold CNR and significantly higher visual score than DSA. DVA30 proved to be superior to DSA100 in the crural region (difference 0.25 ± 0.07, p < 0.001), and there was no significant difference in the femoral (− 0.08 ± 0.06, p = 0.435) and abdominal (− 0.10 ± 0.09, p = 0.350) regions. Our data show that DVA allows about 70% reduction of DSA-related radiation exposure in lower limb X-ray angiography, providing a potential new radiation protection tool for the patients and the medical staff.
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de Ruiter QMB, Moll FL, Hazenberg CEVB, van Herwaarden JA. Radiation Awareness for Endovascular Abdominal Aortic Aneurysm Repair in the Hybrid Operating Room: An Instant Operator Risk Chart for Daily Practice. J Endovasc Ther 2021; 28:530-541. [PMID: 33851549 PMCID: PMC8276344 DOI: 10.1177/15266028211007458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: While the operator radiation dose rates are correlated to patient radiation dose rates, discrepancies may exist in the effect size of each individual radiation dose predictors. An operator dose rate prediction model was developed, compared with the patient dose rate prediction model, and converted to an instant operator risk chart. Materials and Methods: The radiation dose rates (DRoperator for the operator and DRpatient for the patient) from 12,865 abdomen X-ray acquisitions were selected from 50 unique patients undergoing standard or complex endovascular aortic repair (EVAR) in the hybrid operating room with a fixed C-arm. The radiation dose rates were analyzed using a log-linear multivariable mixed model (with the patient as the random effect) and incorporated varying (patient and C-arm) radiation dose predictors combined with the vascular access site. The operator dose rate models were used to predict the expected radiation exposure duration until an operator may be at risk to reach the 20 mSv year dose limit. The dose rate prediction models were translated into an instant operator radiation risk chart. Results: In the multivariate patient and operator fluoroscopy dose rate models, lower DRoperator than DRpatient effect size was found for radiation protocol (2.06 for patient vs 1.4 for operator changing from low to medium protocol) and C-arm angulation. Comparable effect sizes for both DRoperator and DRpatient were found for body mass index (1.25 for patient and 1.27 for the operator) and irradiated field. A higher effect size for the DRoperator than DRpatient was found for C-arm rotation (1.24 for the patient vs 1.69 for the operator) and exchanging from femoral access site to brachial access (1.05 for patient vs 2.5 for the operator). Operators may reach their yearly 20 mSv year dose limit after 941 minutes from the femoral access vs 358 minutes of digital subtraction angiography radiation from the brachial access. Conclusion: The operator dose rates were correlated to patient dose rate; however, C-arm angulation and changing from femoral to brachial vascular access site may disproportionally increase the operator radiation risk compared with the patient radiation risk. An instant risk chart may improve operator dose awareness during EVAR.
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Affiliation(s)
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands
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Kosiorowska K, Berezowski M, Beyersdorf F, Jasinski M, Kreibich M, Kondov S, Czerny M, Rylski B. Can a trainee perform endovascular aortic repair as effectively and safely as an experienced specialist? Interact Cardiovasc Thorac Surg 2020; 31:841-846. [PMID: 33164084 DOI: 10.1093/icvts/ivaa201] [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: 04/02/2020] [Revised: 07/27/2020] [Accepted: 08/16/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Endovascular aortic repair (EVAR) is a technically demanding procedure usually carried out by highly experienced surgeons. However, in this era of modern endovascular surgery with growing numbers of patients qualifying for the procedure, the need to enhance surgical training has emerged. Our aim was to compare the technical results of EVAR in patients operated on by trainees to that of those operated on by an endovascular expert. METHODS Between 2016 and 2018, a total of 119 patients diagnosed with an abdominal aorta disease requiring EVAR were admitted to our clinic. Overall, we included 96 patients who underwent preoperative and postoperative computed tomography angiography and EVAR performed either by an endovascular expert (N = 51) or a trainee (N = 45). RESULTS We detected no difference in the baseline characteristics, indication for EVAR and preoperative anatomy between patients operated on by trainees and our endovascular expert. We noted the same incidence of endoleak type Ia occurrence (n = 2 vs n = 2, P = 1.00), reintervention rate (n = 0 vs n = 0, P = 1.00) and in-hospital mortality (n = 0 vs n = 1, P = 1.00) for operations done by trainees and the expert, respectively. There was no difference in X-ray doses or time between the 2 groups. Despite longer median operation times [112 (first quartile: 84; third quartile: 129) vs 89 (75-104) min; P = 0.03] and in-hospital stays [10 (8-13) vs 8 (7-10) days, P = 0.007] of the patients operated on by trainees, the overall clinical success of EVAR was satisfactory in both groups. CONCLUSIONS An EVAR planned and performed by a trainee need not raise the cumulative risk of the procedure. Trainees who have undergone both mind and hand skills training can therefore carry out EVAR under the supervision of an experienced specialist as effectively and safely as experts do.
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Affiliation(s)
- Kinga Kosiorowska
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiac and Thoracic Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Mikołaj Berezowski
- Department of Cardiac and Thoracic Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marek Jasinski
- Department of Cardiac and Thoracic Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Doelare SAN, Smorenburg SPM, van Schaik TG, Blankensteijn JD, Wisselink W, Nederhoed JH, Lely RJ, Hoksbergen AWJ, Yeung KK. Image Fusion During Standard and Complex Endovascular Aortic Repair, to Fuse or Not to Fuse? A Meta-analysis and Additional Data From a Single-Center Retrospective Cohort. J Endovasc Ther 2020; 28:78-92. [PMID: 32964768 PMCID: PMC7816548 DOI: 10.1177/1526602820960444] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE To determine if image fusion will reduce contrast volume, radiation dose, and fluoroscopy and procedure times in standard and complex (fenestrated/branched) endovascular aneurysm repair (EVAR). MATERIALS AND METHODS A search of the PubMed, Embase, and Cochrane databases was performed in December 2019 to identify articles describing results of standard and complex EVAR procedures using image fusion compared with a control group. Study selection, data extraction, and assessment of the methodological quality of the included publications were performed by 2 reviewers working independently. Primary outcomes of the pooled analysis were contrast volume, fluoroscopy time, radiation dose, and procedure time. Eleven articles were identified comprising 1547 patients. Data on 140 patients satisfying the study inclusion criteria were added from the authors' center. Mean differences (MDs) are presented with the 95% confidence interval (CI). RESULTS For standard EVAR, contrast volume and procedure time showed a significant reduction with an MD of -29 mL (95% CI -40.5 to -18.5, p<0.001) and -11 minutes (95% CI -21.0 to -1.8, p<0.01), respectively. For complex EVAR, significant reductions in favor of image fusion were found for contrast volume (MD -79 mL, 95% CI -105.7 to -52.4, p<0.001), fluoroscopy time (MD -14 minutes, 95% CI -24.2 to -3.5, p<0.001), and procedure time (MD -52 minutes, 95% CI -75.7 to -27.9, p<0.001). CONCLUSION The results of this meta-analysis confirm that image fusion significantly reduces contrast volume, fluoroscopy time, and procedure time in complex EVAR but only contrast volume and procedure time for standard EVAR. Though a reduction was suggested, the radiation dose was not significantly affected by the use of fusion imaging in either standard or complex EVAR.
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Affiliation(s)
- Sabrina A N Doelare
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Stefan P M Smorenburg
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Theodorus G van Schaik
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Jan D Blankensteijn
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Willem Wisselink
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Johanna H Nederhoed
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Rutger J Lely
- Department of Radiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Arjan W J Hoksbergen
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Kak Khee Yeung
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands.,Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
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Doyen B, Maurel B, Hertault A, Vlerick P, Mastracci T, Van Herzeele I. Radiation Safety Performance is More than Simply Measuring Doses! Development of a Radiation Safety Rating Scale. Cardiovasc Intervent Radiol 2020; 43:1331-1341. [PMID: 32686038 DOI: 10.1007/s00270-020-02590-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Radiation safety performance is often evaluated using dose parameters measured by personal dosimeters and/or the C-arm, which provide limited information about teams' actual radiation safety behaviors. This study aimed to develop a rating scale to evaluate team radiation safety behaviors more accurately and investigate its reliability. MATERIALS AND METHODS A modified Delphi consensus was organized involving European vascular surgeons (VS), interventional radiologists, and interventional cardiologists. Initial items and anchors were drafted a priori and rated using five-point Likert scales. Participants could suggest additional items or adjustments. Consensus was defined as ≥ 80% agreement (rating ≥ 4) with Cronbach's alpha ≥ .80. Two VS with expertise in radiation safety evaluated 15 video-recorded endovascular repairs of infrarenal aortic aneurysms (EVAR) to assess usability, inter and intrarater reliability. RESULTS Thirty-one of 46 invited specialists completed three rating rounds to generate the final rating scale. Five items underwent major adjustments. In the final round, consensus was achieved for all items (alpha = .804; agreement > 87%): 'Pre-procedural planning', 'Preparation in angiosuite/operating room', 'Shielding equipment', 'Personal protective equipment', 'Position of operator/team', 'Radiation usage awareness', 'C-arm handling', 'Adjusting image quality', 'Additional dose reducing functions', 'Communication/leadership', and 'Overall radiation performance and ALARA principle'. All EVARs were rated, yielding excellent Cronbach's alpha (.877) with acceptable interrater and excellent intrarater reliability (ICC = .782; ICC = .963, respectively). CONCLUSION A reliable framework was developed to assess radiation safety behaviors in endovascular practice and provide teams with formative feedback. The final scale is provided in this publication.
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Affiliation(s)
- Bart Doyen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, 2K12D, Route 1024, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Blandine Maurel
- Department of Vascular Surgery, University Hospital Centre of Nantes, Nantes, France
| | - Adrien Hertault
- Department of Vascular Surgery, Valenciennes General Hospital, Valenciennes, France
| | - Peter Vlerick
- Department of Work, Organisation and Society, Ghent University, Ghent, Belgium
| | - Tara Mastracci
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, 2K12D, Route 1024, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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Bisdas T, Koutsias S. Carbon Dioxide As a Standard of Care for Zero Contrast Interventions: When, Why and How? Curr Pharm Des 2020; 25:4662-4666. [PMID: 31782359 DOI: 10.2174/1381612825666191129093823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Traditional contrast media containing iodine remain the gold standard for vessel visualization during endovascular procedures. On the other hand, their use has several side effects and implications and may cause contrast medium-induced nephropathy. Carbon dioxide (CO2) angiography is an old alternative technique used only for critical patients in order to prevent kidney damages or allergic reactions. Zero contrast procedure: The availability of automated CO2 injectors has led to an increase in the use of CO2 angiography, providing an option for zero contrast interventions, preserving patient renal function and saving costs for the hospital facility. Taking advantage of the properties of CO2 gas, it is possible to improve the performance of some complex procedures such as atherectomy and the detection of type II endoleaks after EVARs. However, a learning curve is needed to get good imaging, and learn about the qualities and limitations of the technique. CONCLUSIONS The use of automatic delivery systems for CO2 angiography appears to be a good choice for the use of CO2 as the first imaging option. The standardization of injection protocols and the extensive use of this technique could lead to significant benefits both for the patient's prospects and health facilities.
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Affiliation(s)
- Theodosios Bisdas
- Clinic of Advanced Endovascular Services, Athens Medical Centre, Athens, Greece
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13
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Jäckle S, García-Vázquez V, Eixmann T, Matysiak F, von Haxthausen F, Sieren MM, Schulz-Hildebrandt H, Hüttmann G, Ernst F, Kleemann M, Pätz T. Three-dimensional guidance including shape sensing of a stentgraft system for endovascular aneurysm repair. Int J Comput Assist Radiol Surg 2020; 15:1033-1042. [PMID: 32383105 PMCID: PMC7303070 DOI: 10.1007/s11548-020-02167-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/06/2020] [Indexed: 11/04/2022]
Abstract
PURPOSE During endovascular aneurysm repair (EVAR) procedures, medical instruments are guided with two-dimensional (2D) fluoroscopy and conventional digital subtraction angiography. However, this requires X-ray exposure and contrast agent is used, and the depth information is missing. To overcome these drawbacks, a three-dimensional (3D) guidance approach based on tracking systems is introduced and evaluated. METHODS A multicore fiber with fiber Bragg gratings for shape sensing and three electromagnetic (EM) sensors for locating the shape were integrated into a stentgraft system. A model for obtaining the located shape of the first 38 cm of the stentgraft system with two EM sensors is introduced and compared with a method based on three EM sensors. Both methods were evaluated with a vessel phantom containing a 3D-printed vessel made of silicone and agar-agar simulating the surrounding tissue. RESULTS The evaluation of the guidance methods resulted in average errors from 1.35 to 2.43 mm and maximum errors from 3.04 to 6.30 mm using three EM sensors, and average errors from 1.57 to 2.64 mm and maximum errors from 2.79 to 6.27 mm using two EM sensors. Moreover, the videos made from the continuous measurements showed that a real-time guidance is possible with both approaches. CONCLUSION The results showed that an accurate real-time guidance with two and three EM sensors is possible and that two EM sensors are already sufficient. Thus, the introduced 3D guidance method is promising to use it as navigation tool in EVAR procedures. Future work will focus on developing a method with less EM sensors and a detailed latency evaluation of the guidance method.
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Affiliation(s)
- Sonja Jäckle
- Fraunhofer MEVIS, Institute for Digital Medicine, Maria-Goeppert-Straße 3, 23562, Lübeck, Germany.
| | - Verónica García-Vázquez
- Institute for Robotics and Cognitive Systems, Universität zu Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Tim Eixmann
- Institute of Biomedical Optics, Universität zu Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Florian Matysiak
- Division of Vascular- and Endovascular Surgery, Department of Surgery, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Felix von Haxthausen
- Institute for Robotics and Cognitive Systems, Universität zu Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Malte Maria Sieren
- Department for Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Hinnerk Schulz-Hildebrandt
- Institute of Biomedical Optics, Universität zu Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
- Medical Laser Center Lübeck GmbH, Peter-Monnik-Weg 4, 23562, Lübeck, Germany
- German Center for Lung Research (DZL) , Airway Research Center North, Wöhrendamm 80, 22927, Großhansdorf, Germany
| | - Gereon Hüttmann
- Institute of Biomedical Optics, Universität zu Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
- Medical Laser Center Lübeck GmbH, Peter-Monnik-Weg 4, 23562, Lübeck, Germany
- German Center for Lung Research (DZL) , Airway Research Center North, Wöhrendamm 80, 22927, Großhansdorf, Germany
| | - Floris Ernst
- Institute for Robotics and Cognitive Systems, Universität zu Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Markus Kleemann
- Division of Vascular- and Endovascular Surgery, Department of Surgery, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Torben Pätz
- Fraunhofer MEVIS, Institute for Digital Medicine, Am Fallturm 1, 28359, Bremen, Germany
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14
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Zurcher KS, Naidu SG, Money SR, Stone WM, Fowl RJ, Knuttinen G, Oklu R, Rotellini Coltvet LA, Crawford D, Buras MR, Pavlicek W. Dose reduction using digital fluoroscopy versus digital subtraction angiography in endovascular aneurysm repair: A prospective randomized trial. J Vasc Surg 2020; 72:1938-1945. [PMID: 32276019 DOI: 10.1016/j.jvs.2020.02.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/29/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Endovascular aneurysm repair (EVAR) can result in high radiation dose to patients and operators. This prospective randomized study aimed to assess whether patient radiation dose sustained during EVAR could be decreased by predominantly using digital fluoroscopy (DF) vs the standard technique using digital subtraction angiography (DSA). METHODS Between February 2011 and June 2017, patients with EVAR of infrarenal abdominal aortic aneurysms were prospectively enrolled and randomly assigned to a standard treatment DSA cohort or a DF cohort in which two or fewer DSA acquisitions were allowed for confirmatory imaging. Primary end points included dose-area product (DAP) and cumulative air kerma. Secondary end points included technical success and conversion to DSA standard treatment (if DF was inadequate for visualization). RESULTS For all 43 patients enrolled (26 in the DF cohort, 17 in the DSA cohort), technical success was 100%. Of the 26 DF patients, 5 (19%) required conversion to the DSA cohort. In an intention-to-treat analysis, mean DAP was significantly lower in the DF cohort than in the DSA cohort (132 vs 174 Gy·cm2; P = .04). When patients were separated by number of DSA acquisitions (two or fewer vs three or more), mean DAP decreased 41% (109 vs 185 Gy·cm2; P = .005) and cumulative air kerma decreased 40% (578 vs 964 mGy; P = .004). CONCLUSIONS In most patients (81%), DF or limited DSA was adequate for visualization during EVAR. In both intention-to-treat DF and limited-DSA cohorts, mean DAP was significantly decreased. If image quality allows, a DF-only or limited-DSA approach to EVAR decreases radiation dose.
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Affiliation(s)
- Kenneth S Zurcher
- Division of Interventional Radiology, Mayo Clinic Hospital, Phoenix, Ariz
| | - Sailendra G Naidu
- Division of Interventional Radiology, Mayo Clinic Hospital, Phoenix, Ariz.
| | - Samuel R Money
- Division of Vascular and Endovascular Surgery, Mayo Clinic Hospital, Phoenix, Ariz
| | - William M Stone
- Division of Vascular and Endovascular Surgery, Mayo Clinic Hospital, Phoenix, Ariz
| | - Richard J Fowl
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Scottsdale, Ariz
| | - Grace Knuttinen
- Division of Interventional Radiology, Mayo Clinic Hospital, Phoenix, Ariz
| | - Rahmi Oklu
- Division of Interventional Radiology, Mayo Clinic Hospital, Phoenix, Ariz
| | | | - Daniel Crawford
- Department of General Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Ariz
| | - Matthew R Buras
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, Ariz
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15
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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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Abstract
A hybrid suite is an operating theater with imaging equipment equivalent to that used in an angiography suite with computed tomography (CT) and magnetic resonance imaging (MRI). They are often situated outside the operating room area and typically serve as multifunctional rooms designed to support a variety of catheter-based endovascular procedures and open surgery to be performed in the same location. The possibility to perform these in the same location facilitates the combination of both approaches to so-called hybrid procedures. Typical clinical applications of hybrid suites are cardiac, thoracic and vascular surgery, neurosurgery and neuroradiology, as well as orthopedics and traumatology. Transcatheter aortic valve implantation (TAVI) is significantly less invasive than a classical approach by open surgery. Patients older than 75 years with relevant comorbidities benefit most from the minimally invasive interventional approach. There has been a paradigm shift in the management of vascular diseases from open surgical repair to new percutaneous endovascular interventions with good early outcomes. Of particular interest in this context is the ability to block the part of the aorta proximal to the aneurysm with a catheter-based dilatation balloon. Progress in image fusion technology and intraoperative navigation has led to an increased acceptance of hybrid suites in orthopedics and traumatology. The complex care of high-risk patients most often outside the operating theater area is a challenge for the anesthesia team. This demands meticulous planning on behalf of the anesthesiologist to ensure an appropriate and safe strategy for anesthesia, intraoperative monitoring, vascular access and the need for additional equipment. A thorough understanding of the complexity of procedures is vital and a series of questions must be addressed: what is needed to safely administer anesthesia in this environment? What additional resources would be needed for an emergency situation? Is the patient being kept safe from radiation hazards? Moreover, logistics may become an issue as the hybrid suite is most often delocalized. In addition, many procedures realized in a hybrid suite require a multidisciplinary approach and therefore teamwork and professional communication are mandatory. Anesthesiologists need to have an integral role in the hybrid suite team, understanding and anticipating the risks for patients and leading the organization of workflow. The challenge in anesthesia is to ensure that when patients are taken to these complex environments the resources available enable high standards of care to be provided. With future developments in imaging technology combined with more powerful hardware and software, a far greater integration of all these imaging and navigation technologies will be seen in future operating rooms. Finally, patients are becoming more aware of medical developments via the world wide web and increasingly request what they consider to be state of the art treatment.
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Affiliation(s)
- T Fuchs-Buder
- Klinik für Anästhesie und Intensivmedizin, Universitätsklinikum Nancy, Nancy, Frankreich. .,Département d'Anesthésie-Réanimation, Rue du Morvan, 54511, Vandoeuvre-les-Nancy, Frankreich.
| | - N Settembre
- Klinik für Gefäßchirurgie, Universitätsklinikum Nancy, Nancy, Frankreich
| | - D Schmartz
- Klinik für Anästhesie, Universitätsklinikum Brugmann, Brüssel, Belgien
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Ribeiro A, Husson O, Drey N, Murray I, May K, Thurston J, Oyen W. Ionising radiation exposure from medical imaging - A review of Patient's (un) awareness. Radiography (Lond) 2019; 26:e25-e30. [PMID: 32052780 DOI: 10.1016/j.radi.2019.10.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Medical imaging is the main source of artificial radiation exposure. Evidence, however, suggests that patients are poorly informed about radiation exposure when attending diagnostic scans. This review provides an overview of published literature with a focus on nuclear medicine patients on the level of awareness of radiation exposure from diagnostic imaging. METHODS A review of available literature on awareness, knowledge and perception of ionising radiation in medical imaging was conducted. Articles that met the inclusion criteria were subjected to critical appraisal using the Mixed Methods Appraisal Tool. RESULTS 140 articles identified and screened for eligibility, 24 critically assessed and 4 studies included in synthesis. All studies demonstrated that patients were generally lacking awareness about radiation exposure and highlighted a lack of communication between healthcare professionals and patients with respect to radiation exposure. CONCLUSION Studies demonstrate a need to better inform patients about their radiation exposure, and further studies focusing on nuclear medicine patients are particularly warranted. IMPLICATIONS FOR PRACTICE Adequate and accurate information is crucial to ensure the principle of informed consent is present.
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Affiliation(s)
- A Ribeiro
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom.
| | - O Husson
- Institute of Cancer Research, Sutton, United Kingdom
| | - N Drey
- City University of London, London, United Kingdom
| | - I Murray
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - K May
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - J Thurston
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom
| | - W Oyen
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, United Kingdom; Institute of Cancer Research, Sutton, United Kingdom
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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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Peters AS, Hatzl J, Bischoff MS, Böckler D. Comparison of endovascular aneurysm sealing and repair with respect to contrast use and radiation in comparable patient cohorts. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 61:67-72. [PMID: 29616520 DOI: 10.23736/s0021-9509.18.10206-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Due to recent advances in endograft design and percutaneous access, technical success could be increased during endovascular aneurysm repair (EVAR). Beside EVAR, endovascular aneurysm sealing (EVAS) provides an alternative procedure to treat aneurysms. To compare the two methods, additional benchmark criteria should be evaluated: Screening time, dose area product (DAP), procedure time and contrast use. In this study these technical variables are analyzed for EVAS vs. EVAR in comparable patient cohorts. METHODS It is a retrospective, single-center study. Only elective cases of infrarenal aortic aneurysms were included, all treated by the same surgeon (D.B.). Procedures were performed within the instructions for use without additional procedures. All operations were undertaken in a hybrid operating theatre. For EVAR, only the Medtronic Endurant® and the Gore C3 Excluder® were included. For EVAS the Nellix® from Endologix was used. RESULTS Between 2012 and 2016, 67 patients were treated with EVAS and 40 with EVAR; of these 20 and 16 could be introduced into the study respectively. Median age was 73 and 72 years respectively (only men). The two groups were comparable in terms of BMI, GFR and ASA-status. Screening time was reduced for EVAS (10.6 vs. 14.5 min., P<0.01), while the DAP was not significantly different. Procedural time and contrast use were increased for EVAS (120 vs. 96 min., 120 vs. 79 mL, P<0.01). CONCLUSIONS Especially the younger EVAS-procedure requires ongoing review in order to further reduce contrast agent. Reduced screening time for EVAS does not have a significant impact on radiation dose.
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Affiliation(s)
- Andreas S Peters
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Hatzl
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany -
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[Ablative therapy in urology: Good practice and perspective]. Prog Urol 2017; 27:994-1014. [PMID: 28958771 DOI: 10.1016/j.purol.2017.08.008] [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: 07/26/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION To expose the main point of discussion from present ablative therapies' guidelines and propose global perspectives. MATERIALS AND METHODS A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com/) using different associations of keywords "ablative therapy" ; "prostate cancer"; "kidney cancer"; "guidelines"; "hybrid operating room". Publications obtained were selected based on methodology, language and relevance. RESULTS Present guidelines on ablative therapies in urology are, considering authors and organs, either particularly prudent (EAU guidelines for prostate and kidney) or relatively optimistic (CIRSE guidelines). This discrepancy is related to a low level of proof. So, a new approach is mandatory: more homogeneous in methodology, and especially more open to a new organization sparing economic efficiency. The objective will be to get multifunctional and multidisciplinaries platforms, in facts and in minds. It will induce, in the future, a deep reflection about training and boundaries' specialties. CONCLUSION Ablative therapies represent a crucial stake for urology and a clear example of medicosurgical evolution in future, based on new technologies (energy, robotic, imaging). A serious and deep reflection is necessary to prepare it and be deeply involved in.
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