Modern Fixed Imaging Systems Reduce Radiation Exposure to Patients and Providers

Abstract

High-definition fluoroscopic imaging is required to perform endovascular procedures safely and precisely, especially in complex cases, resulting in longer procedures and increased radiation exposure. This is of importance for training institutions as trainees, even with sound instruction in as low as reasonably achievable (ALARA) principles, tend to have high radiation exposures. Recently, there was an upgrade in the imaging system allowing for comparison of radiation exposure to patients and providers. We performed an analysis of consecutive endovascular aneurysm repair (EVAR) and superficial femoral artery (SFA) interventions in the years 2013 to 2014. We recorded body mass index (BMI) and fluoroscopy time (FT) and subsequently matched 1:1 based on BMI, FT, or both. We determined radiation dose using air kerma (AK) and also recorded individual surgeons’ badge readings. Allura Xper FD20 was upgraded to AlluraClarity with ClarityIQ. We identified a total of 77 EVARs (52 pre and 25 post) and 134 SFA interventions (99 pre and 35 post). Unmatched results for EVAR were BMI pre 26.2 versus post 25.8 (kg/m², P = .325), FT 28.1 versus 21.2 (minutes, P = .051), and AK 1178.5 versus 581 (mGy, P < .001), respectively. After matching, there was a 53.2% reduction in AK (846.1 vs 395.9 mGy; P = .004) for EVAR. Unmatched results for SFA interventions were BMI pre 28.1 versus post 26.6 (P = .327), FT 18.7 versus 16.2 (P = .282), and AK 285.6 versus 106.0 (P < .001), respectively. After matching, there was a 57.0% reduction in AK (305.0 vs 131.3, P < .001). The total deep dose equivalent from surgeons’ badge readings decreased from 39.5 to 17 mrem (P = .029). Aortic and peripheral endovascular interventions can be performed with reduced radiation exposure to patients and providers, employing modern fixed imaging systems with advanced dose reduction technology. This is of particular importance in the light of the increasing volume and complexity of endovascular and hybrid procedures as well as the prospect of decades of radiation exposure during training and practice.

Keywords

radiation safety exposure fixed imaging system endovascular

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References

Sachs

Schermerhorn

Pomposelli

Cotterill

O’Malley

Landon

. Resident and fellow experiences after the introduction of endovascular aneurysm repair for abdominal aortic aneurysm. J Vasc Surg. 2011;54(3):881–888.

Ultee

KHJ

Hurks

Buck

. The impact of endovascular repair on specialties performing abdominal aortic aneurysm repair. J Vasc Surg. 2015;62(3):562–563.

Siracuse

Menard

Eslami

. Comparison of open and endovascular treatment of patients with critical limb ischemia in the Vascular Quality Initiative. J Vasc Surg. 2016;63(4):958–965.e1.

Sachs

Pomposelli

Hamdan

Wyers

Schermerhorn

. Trends in the national outcomes and costs for claudication and limb threatening ischemia: angioplasty vs bypass graft. J Vasc Surg. 2011;54(4):1021–1021.

Rowe

Lee

Weaver

Etzioni

. Patterns of treatment for peripheral arterial disease in the United States: 1996-2005. J Vasc Surg. 2009;49(4):910–917.

Kendrick

Miller

Moorehead

. Comparative occupational radiation exposure between fixed and mobile imaging systems. J Vasc Surg. 2016;63(1):190–197.

Fossaceca

Brambilla

Guzzardi

. The impact of radiological equipment on patient radiation exposure during endovascular aortic aneurysm repair. Eur Radiol. 2012;22(11):2424–2431.

de Ruiter

QMB

Reitsma

Moll

van Herwaarden

. Meta-analysis of cumulative radiation duration and dose during EVAR using mobile, fixed, or fixed/3D fusion C-arms. J Endovasc Ther. 2016;23(6):944–956.

Kirkwood

Arbique

Guild

. Surgeon education decreases radiation dose in complex endovascular procedures and improves patient safety. J Vasc Surg. 2013;58(3):715–721.

10.

Stangenberg

Shuja

Carelsen

Elenbaas

Wyers

Schermerhorn

. A novel tool for three-dimensional roadmapping reduces radiation exposure and contrast agent dose in complex endovascular interventions. J Vasc Surg. 2015;62(2):448–455.

11.

Söderman

Mauti

Boon

. Radiation dose in neuroangiography using image noise reduction technology: a population study based on 614 patients. Neuroradiology. 2013;55(11):1365–1372.

12.

Söderman

Holmin

Andersson

Palmgren

Babic

Hoornaert

. Image noise reduction algorithm for digital subtraction angiography: clinical results. Radiology. 2013;269(2):553–560.

13.

Schermerhorn

Giles

Hamdan

Wyers

Pomposelli

. Mesenteric revascularization: management and outcomes in the United States, 1988-2006. J Vasc Surg. 2009;50(2):341–341.

14.

Schermerhorn

Buck

O’Malley

. Long-term outcomes of abdominal aortic aneurysm in the medicare population. N Engl J Med. 2015;373(4):328–338.

15.

Flegal

Kruszon-Moran

Carroll

Fryar

Ogden

. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284–2291.

16.

Ector

Dragusin

Adriaenssens

. Obesity is a major determinant of radiation dose in patients undergoing pulmonary vein isolation for atrial fibrillation. J Am Coll Cardiol. 2007;50(3):234–242.

17.

Shah

Das

Subkovas

Buch

Rees

Bellamy

. Radiation dose during coronary angiogram: relation to body mass index. Heart Lung Circ. 2015;24(1):21–25.

18.

Bernardi

Padovani

Trianni

. The effect of fellows’ training in invasive cardiology on radiological exposure of patients. Radiat Prot Dosimetry. 2008;128(1):72–76.

19.

de Ruiter

QMB

Moll

Gijsberts

van Herwaarden

. AlluraClarity radiation dose–reduction technology in the hybrid operating room during endovascular aneurysm repair. J Endovasc Ther. 2016;23(1):130–138.

20.

Nakamura

Kobayashi

Funatsu

. Patient radiation dose reduction using an X-ray imaging noise reduction technology for cardiac angiography and intervention. Heart Vessels. 2015;31(5):1–9.

21.

van den Haak

RFF

Hamans

Zuurmond

Verhoeven

BAN

Koning

OHJ

. Significant radiation dose reduction in the hybrid operating room using a novel X-ray imaging technology. Eur J Vasc Endovasc Surg. 2015;50(4):480–486.

22.

Kirkwood

Guild

Arbique

. New image-processing and noise-reduction software reduces radiation dose during complex endovascular procedures. J Vasc Surg. 2016;64(5):1357–1365.

23.

van Strijen

Grünhagen

Mauti

. Evaluation of a noise reduction imaging technology in iliac digital subtraction angiography: noninferior clinical image quality with lower patient and scatter dose. J Vasc Interv Radiol. 2015;26(5):642–650.e1.

24.

McCarney

Warner

Iliffe

van Haselen

Griffin

Fisher

. The Hawthorne Effect: a randomised, controlled trial. BMC Med Res Methodol. 2007;7(1):30.

25.

Fazel

Gerber

Balter

. Approaches to enhancing radiation safety in cardiovascular imaging: a scientific statement from the American Heart Association. Circulation. 2014;130(19):1730–1748.

26.

Kim

Miller

de Gonzalez

. Occupational radiation doses to operators performing fluoroscopically-guided procedures. Health Physics. 2012;103(1):80–99.