A Systematic Review on Occupational Exposure to Ionizing Radiation During Standard and Complex Endovascular Aortic Aneurysm Repair Procedures

Abstract

Purpose:

Occupational radiation exposure remains a critical concern in modern health care due to cumulative health risks for procedural staff, stringent regulatory requirements, and the proliferation of advanced imaging technologies. This systematic review aimed to evaluate occupational radiation exposure among medical personnel during standard and complex endovascular aortic repair (EVAR) procedures, identify key determinants of radiation dose, assess the efficacy of protection strategies, and propose evidence-based recommendations to optimize staff safety in endovascular practice.

Methods:

A systematic review was conducted following PRISMA guidelines, searching MEDLINE, Cochrane Library, and Scopus databases from January 2019 to May 2025. Eligible studies reported quantitative dosimetric data for operating room staff during elective EVAR procedures, excluding ruptured aneurysm cases and non-English publications. Study selection and quality assessment was performed by 2 independent reviewers using ROBINS-I tool.

Results:

From 942 screened studies, 18 met inclusion criteria, revealing significant occupational intraoperative radiation exposure variability. Eligible studies reported dosimetric data in terms of absorbed dose (D), effective dose (ED), personal dose equivalent Hp(10) for whole-body exposure, Hp(3) for eye lens dose, Hp(0.07) for skin and extremities dose, as well as peak skin dose (PSD). The ranges of D, ED, Hp(10), Hp(3), Hp(0.07), and PSD were 0.02 to 0.12 μGy, 0.40 to 4350.00 μSv, 0.00 to 6112.70 μSv, 0.25 to 2500.00 μSv, 0.20 to 971.00 μSv, and 190.00 to 8430.00 μGy, respectively. Operator exposure patterns showed consistent left-sided predominance (left eye 200.00 vs right eye 30.00 μSv; left hand 76.90 vs right hand 46.70 μSv). Advanced imaging technologies demonstrated substantial protective benefits: 3D image fusion reduced operator ED by approximately 55% to 66%, while dual fluoroscopy with digital zooming decreased median doses by 62%. Suspended lead shielding systems eliminated axillary exposure in some cases. Supporting staff received lower but non-negligible exposure, with scrub nurses sustaining higher doses than circulating nurses.

Conclusion:

Complex EVAR procedures continue to pose significant occupational radiation risks despite technological advancements. The findings emphasize the need for optimized protection protocols, particularly for ocular exposure, standardized dosimetric reporting practices across institutions, and continued development of low-radiation or radiation-free navigation technologies. Future research should prioritize multicenter prospective studies with standardized metrics to evaluate long-term health outcomes among surgeons performing complex EVAR operations.

Clinical Impact

This systematic review offers a comprehensive synthesis of current evidence on occupational perioperative radiation exposure during minimally invasive endovascular stent grafting, providing vascular teams with insights to enhance radiation safety protocols. By analyzing dose patterns across different procedure types and technologies, the study highlights effective protective measures, incorporating newfangled imaging systems and shielding solutions. The findings support clinical decision-making by demonstrating how specific interventions can reduce staff exposure while maintaining procedural efficiency. Using an evidence-based approach, this framework guides institutions in optimizing radiation safety programs, improving staff training, and facilitating the integration of dose-reduction technologies in contemporary endovascular practice.