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Patient and Operating Room Staff Radiation Doses during Fenestrated/Branched Endovascular Aneurysm Repair using Premanufactured Devices
Melissa Kirkwood, Khalil Chamseddin, MD, Gary Arbique, PhD, Jeffrey Guild, PhD, David Timaran, MD, Jon Anderson, PhD, Carlos Timaran, MD.
UT Southwestern Medical Center, Dallas, TX, USA.

Introduction: Fenestrated/branched endovascular aneurysm repair(FEVAR) is the highest radiation dose procedure performed by vascular surgeons. We sought to characterize the radiation dose to patients and staff during FEVAR procedures with different premanufactured devices.
Methods: A single center prospective study of FEVARs was performed over 24 months. Three FEVAR devices were included: off-the-shelf (OTS, T branch, P branch), Z-fen, and investigational custom made devices(CMDs). Radiation doses to the surgeon, trainee, anesthesiologist, scrub/circulating nurses were measured using a personal dosimetry system (DoseAware, Philips Healthcare). Procedure type, patient BMI, reference air kerma(RAK) and kerma area product(KAP) were recorded. RAK and KAP were corrected for BMI based on an exponential fit of fluoroscopy dose rate and the dose per radiographic frame. Operator dose was corrected for BMI by the ratio of corrected to actual KAP. A one sided Wilcox rank-sum test was used to compare personnel radiation doses, RAKs and KAPs between procedure types. Statistical significance was p0.05.
Results: 80 FEVARs were performed by a single surgeon on a Philips Allura XperFD 20 fluoroscopy system equipped with Clarity technology. Average BMI was 27. 60 CMDs(36 four, 21 three, and 3 two vessel fenestrations), 11 Zfens(8 three, 3 two vessel fenestrations), and 9 OTS devices(4 P-branch, 5 T-branch) were included. Zfens had significantly lower patient and personnel dose compared to CMDs. OTS devices had significantly lower operator, assistant and circulator doses compared to CMDs. 4-vessel fenestrated devices had significantly higher patient dose compared to 3-vessel and 2-vessel FEVARs and significantly higher operator dose compared to 3-vessel FEVARs.
Table: Mean dose by stent graft device and level of fenestration

CMDZfenOTS4 Vessel3 Vessel2 Vessel
RAK (mGy)295018001*220030202670**1600**
KAP (Gy-cm2)370210*280400320**240**
Operator (μSv)370120*220*440170**420
Assistant (μSv)21060*110*210150140
Anesthesia(μSv)609060705080
Circulator (μSv)30101*41*30107
Scrub (μSv)40101*20403020

* Significantly different than CMD.
** Significantly different than 4 vessel
Discussion:
Patient dose was lowest with Zfens. OR personnel dose was lower with Zfens and OTS devices compared to CMDs. Four vessel fenestrations required significantly more radiation compared to those involving three vessel fenestrations, however the dose increase was only 12% and should not preclude operators from extending coverage, if anatomically required. Overall, patient and personnel radiation doses during FEVAR with all devices were within acceptable limits and lower in our series than previously reported.


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