Are teams performing complex EVARs at higher radiation risk over their heads?

ref:

Angulation of the C-Arm During Complex Endovascular Aortic Procedures Increases Radiation Exposure to the Head

EJVES Apr 2015
  • Head dose was significantly higher in the PO compared with the AO (median 54 μSv [range 24–130 μSv] vs. 15 μSv [range 7–43 μSv], respectively; p = .022), 
  • as was over-lead body dose (median 80 μSv [range 37–163 μSv] vs. 32 μSv [range 6–48 μSv], respectively; p = .003). 
  • Corresponding under-lead doses were similar between operators (median 4 μSv [range 1–17 μSv] vs. 1 μSv [range 1–3 μSv], respectively;p = .222). 
  • Primary operator height, DSA acquisition time in left anterior oblique (LAO) position, and degrees of LAO angulation were independent predictors of PO head dose (p < .05).

the following diagrams explain it all: 



Cone Beam Computed Tomography and EVAR

ref:

Intra-operative Cone Beam Computed Tomography can Help Avoid Reinterventions and Reduce CT Follow up after Infrarenal EVAR

ref: EJVES Apr 2015
Fifty-one patients (44 men) were enrolled in a prospective trial. Patients underwent completion angiography and CBCT during infrarenal EVAR. 

Twelve endoleaks were detected on completion digital subtraction angiography (CA). CBCT detected 4/5 type 1 endoleaks, but only one type 2 endoleak. CTA identified eight type 2 endoleaks and one residual type I endoleak. Two cases of stent compression were seen on CA. CBCT revealed five stent compressions and one kink, which resulted in four intra-operative adjunctive manoeuvres. CTA identified all cases of kinks or compressions that were left untreated. Two of them were corrected later. No additional kinks/compressions were found on CTA. Groin closure consisted of 78 fascia sutures, nine cut downs, and 11 percutaneous sutures. Seven femoral artery pseudoaneurysms (<1 cm) were detected on CTA, but no intervention was needed.

In 1996, three Italian people invented the Cone Beam CT, which went into the US market in 2001. It has become the ‘norm’ in most dental practices, as a simple means of reconstructing the X-Ray easily into 3D. 
 For Interventional Radiology, the patient is positioned offset to the table so that the region of interest is centered in the field of view for the cone beam. A single 200 degree rotation over the region of interest acquires a volumetric data set. The scanning software collects the data and reconstructs it, producing what is termed a digital volume composed of three-dimensionalvoxels of anatomical data that can then be manipulated and visualized with specialized software



Routine pre-op coronary angio pre- CEA: is it useful?

ref:

Long-term Results of a Randomized Controlled Trial Analyzing the Role of Systematic Pre-operative Coronary Angiography before Elective Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease

EJVES Apr 2015
The group (from Italy) randomised 426 patients who were candidates for CEA, with no history of CAD, a normal electrocardiogram (ECG), and a normal cardiac ultrasound. In group A (n = 216) all patients underwent coronary angiography before CEA. In group B (n = 210) CEA was performed without coronary angiography. Patients were not blinded for relevant assessments during follow-up. Primary end-point was the occurrence of MI at 3.5 years. The secondary end-point was the overall survival rate. Median length of follow-up was 6.2 years.

The outcome is very interesting: short term results are not much different, but long term ones are significantly different and better for coronary patients. This proves the importance of secondary prevention more than anything! 


A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms

Ref.

A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms
EJVES Apr 2015
These figures are shockingly true, and has to be always taken into account when a patient is offered a FEVAR, especially our octogenarians. 
Raux et al.11 compared F-EVAR with open surgery in patients with complex AAA in two large volume centres: In this study, 
  • F-EVAR had higher 30 day mortality rates (9.5% vs. 2%), 
  • higher procedural complications (24% vs. 7%) 
  • and graft related complications (30% vs. 2%) than open surgery.

The authors conceded that “the learning curve of the endovascular technique was likely to be responsible in part for the adverse outcomes observed in the F-EVAR cohort”

The WINDOWS multicentre French Registry reported outcomes in 268 patients who received F-EVAR or B-EVAR for juxtarenal AAA (group 1), suprarenal AAA and TAAA Type IV (group 2), and TAAA Type I, II, III (group 3).15 In hospital mortality was 6.5% for group 1 patients, 14.3% for group 2, and 21.4% for group 3.

This paper suggests that more complex aortic endovascular procedures (especially branched repair of TAAAs) should be focused within higher volume institutions that can provide all treatment options, have experience in dealing with technically challenging intra-operative problems and where multidisciplinary cooperation is such that the choice of treatment is not influenced by specialty, political, or financial aspects.

personally fully agree .. the amount of complex parameters involved in the treatment of those patients is huge … and require a lot of experience and high level thinking/planning… as well as a relaxed time in the sub-sub-sub specialty in vascular surgery …. for best outcome to be achieved,.