The Risk of Elevated Radiation Dose in Complex Endovascular Procedures: Surgeon Education Improves Patient Safety

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Complex endovascular procedures (CEP), such as fenestrated endovascular aneurysm repair (FEVAR), are associated with higher radiation doses compared with other fluoroscopically guided interventions (FGI). The purpose of this study was to determine whether surgeon education on radiation dose control can lead to lower reference air kerma (RAK) and peak skin dose (PSD) levels in high-dose procedures. Radiation dose and operating factors were recorded for FGI performed in a hybrid room over a 17-month period. Cases exceeding 6 Gy RAK were investigated according to institutional policy. Information obtained from these investigations led to surgeon education consisting of personalized instruction and a 1-hour lecture focused on reducing patient dose. Points addressed included increasing table height, using collimation and angulation, decreasing magnification modes, and maintaining minimal patient-to-detector distance. Procedural RAK doses and operating factors were compared 8 months before and 8 months after the educational intervention using analysis of variance with Tukey pairwise comparisons and t tests. Peak skin dose (PSD) distributions were calculated using custom software using input data from fluoroscopic machine logs. Of 447 procedures performed, 300 FGI had sufficient data to be included in the analysis (54% lower extremity, 11% TEVAR, 10% cerebral, 8% FEVAR, 7% EVAR, 5% visceral, and 5% embolization). Twenty cases were further investigated for exceeding 6 Gy RAK (14 FEVAR, 3 embolization, 1 EVAR, 1 TEVAR, 1 visceral). FEVAR represented only 8% of cases performed; however, FEVAR comprised 70% of the cases investigated for reaching 6 Gy RAK and had five times the average RAK dose compared with all other FGI performed (P < .0001). Degree of fenestration ranged from one to four vessels, and there was no difference in RAK dose based on number of vessels fenestrated. The effect of surgeon education on radiation dose was seen in all cases, regardless of complexity. Compared with the pre-education data set, the posteducation table height was 10 cm higher on average (P < .0001) per case, resulting in an estimated 15% reduction in PSD. Additionally, the use of collimation also increased from 25% to 40% (P < .001) for all cases, further reducing PSD. There was no observable change in other operating factors, including the use of magnification or angulation. The number of cases that exceeded 6 Gy RAK did not change after education; however, the proportion of non-FEVAR cases that exceeded 6 Gy decreased from 40% to 20%. These data show that radiation doses associated with FEVAR are significantly greater than doses associated with all other FGI. Surgeon education focused on good fluoroscopic operating factors can lower patient PSD; therefore, vascular surgeons must not only be aware of the potential for high radiation dose in CEP but also be vigilant in efforts to reduce exposure to themselves and the patient.