A Systematic Review and Meta-analysis of Intraoperative Patient Dosimetric Data in Standard Endovascular Repair for Infrarenal Abdominal Aortic Aneurysms Versus Fenestrated and Branched Endovascular Procedures for Thoracoabdominal Aortic Aneurysms

Abstract

Purpose:

The complexity of fenestrated and branched endovascular aneurysm repair (F/BEVAR) has been linked to substantially longer procedural duration compared with standard endovascular aneurysm repair (EVAR). These complex procedures rely heavily on fluoroscopic guidance, leading to prolonged radiation exposure for both patients and operators. Given the potential risks associated with high radiation doses, this meta-analysis aimed to assess and compare patient radiation exposure between EVAR and F/BEVAR and evaluate time trends.

Methods:

Mendeley reference manager was used by 2 independent reviewers to evaluate articles identified in the MEDLINE, Cochrane Library, and Scopus databases over a 7-year period. A meta-analysis was conducted under Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria using the medical subject headings (MeSH) terms “AAA,” “aortic aneurysm,” and “radiation” to search and index journal articles systematically. Only full-text, English-language publications reporting radiation data on humans treated with standard EVAR or F/BEVAR were included. The SPSS statistical package was employed to generate fluoroscopy time (FT), kerma-area product (KAP), and cumulative air kerma (CAK) regression lines. The STATA statistical software was used to perform the meta-analysis and present the forest plots.

Results:

Seventy-two articles, encompassing 92 EVAR and F/BEVAR studies, were eligible for inclusion in this meta-analysis. The pooled mean values were lower in standard EVAR compared with the more complex F/BEVAR cases for FT (26.05 vs 77.51 minutes; p<0.001), KAP (131.34 vs 209.50 Gycm²; p=0.010), and CAK (806.76 vs 2798.61 mGy; p<0.001). This translates to a 197.5% increase in FT, a 59.5% increase in KAP, and a 246.9% increase in CAK for F/BEVAR compared with EVAR. Except for the increase in KAP during F/BEVAR procedures (r=0.531, p=0.028), all investigated parameters showed a decreasing trend over time for both EVAR (FT: r=–0.037, p=0.810; KAP: r=–0.098, p=0.540; CAK: r=–0.115, p=0.740) and F/BEVAR (FT: r=–0.387, p=0.034; CAK: r=–0.377, p=0.037).

Conclusion:

This meta-analysis highlights the substantial increase in radiation exposure associated with F/BEVAR compared with standard EVAR. Even though there is a clear paucity of rigorous, high-quality studies, the considerable radiation burden associated with F/BEVAR underscores the need for optimization efforts that minimize patient exposure without compromising procedural success.

Clinical Impact

This article provides information for better understanding of how patient intraoperative radiation exposure varies between the standard and the more complex endovascular aneurysm repair procedures using fenestrated and branched devices. This meta-analysis identified trends and heterogeneities in the fluoroscopy time, kerma-area product, and cumulative air kerma values among the studies. The regression lines deliver a clearer picture of the radiation exposure trends over the last years, offering insights into improving surgical techniques and patient safety by providing guidance on how to balance between the technical demands of complex devices and technology of the C-arm systems with the need to minimize patients’ radiation doses.