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Surgeon-led Initiatives to Enhance Imaging and Reduce Radiation during Complex Endovascular Aortic Aneurysm Repair
Andres V. Figueroa,
Jesus H. Porras-Colon, Natalia I. Coronel, Marilisa Soto-Gonzalez, Mirza S. Baig, Melissa L. Kirkwood, Carlos H. Timaran
University of Texas Southwestern Dallas, Dallas, TX
Background: Endovascular aortic aneurysm repair (EVAR) has become the preferred treatment option for complex aortic aneurysms. Substantial radiation exposure during these procedures remains a safety concern. Intraoperative imaging adjuncts such as dual fluoroscopy with live-image digital zooming (DZ) and Fiber Optic RealShape (FORS) technology improve imaging guidance and may reduce radiation. FORS, in particular, allows three-dimensional multiplanar navigation of devices without x-rays using optic fibers embedded in wires, artificial intelligence semi-automatic registration, and a light source (Fig). This study aims to assess the impact of DZ and FORS on imaging and radiation exposure during complex EVAR.
Methods: An observational prospective study of consecutive patients undergoing complex EVAR between 2015 and 2024 was performed. During the study period and as enhanced imaging techniques were introduced, live-image processing was performed with standard fluoroscopy, dual fluoroscopy with live-image DZ and DZ+FORS. All procedures were performed as part of a surgeon-sponsored investigational device exemption study designed in part to assess patient and operating staff radiation safety. Endpoints included patient dose area product (DAP), reference air kerma (RAK), fluoroscopy time, contrast load and operating staff dosimetry.
Results: A total of 494 patients (mean age 73±9 years; 71% male) underwent complex EVAR using 420 (85%) patient-specific company-manufactured and 74 (15%) off-the-shelf devices. Standard fluoroscopy was used in the initial 123 (25%) procedures, DZ in the following 277 (56%), and DZ+FORS in the latter 94 (19%) (Table). Type I-III thoracoabdominal aortic aneurysms were more frequent in procedures with DZ (35%) compared with standard fluoroscopy (26%) and DZ+FORS (22%) (
P=.03). Upper extremity access was more frequent in procedures with DZ (60%) and standard fluoroscopy (82%) than in those with DZ+FORS (46%) (P=.<.001). BMI was slightly higher in the DZ group. Patient radiation doses were significantly higher with standard fluoroscopy (RAK, 2453±1556 mGy; DAP, 321±199 Gy*cm
2) than with DZ (RAK, 1304±848 mGy; DAP, 159±123 Gy*cm
2) and DZ+FORS (RAK, 1479±1044 mGy; DAP, 181±131 Gy*cm
2) (
P<.001). Contrast load was significantly lower with standard fluoroscopy than with DZ and DZ+FORS (90
vs. 120
vs. 130 ml;
P=.<.001). There was no significant difference in fluoroscopy time between imaging modalities. Compared to standard fluoroscopy, staff radiation doses were significantly reduced once DZ and DZ+FORS were adopted (Table).
Conclusions: Digital zooming and Fiber Optic RealShape technology reduce patient and operating staff radiation exposure during complex endovascular aortic aneurysm repair. Surgeon-led initiatives have played an important role in adopting adjuncts to improve imaging and reduce radiation exposure.
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