Overhead arm support reduces radiation exposure during complex endovascular aortic repair

Mid-term outcomes of endovascular repair for abdominal aortic aneurysm using the cuff-first technique to prevent type II endoleaks

OBJECTIVE

To evaluate the initial and mid-term outcomes of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) using the cuff-first technique (CFT) to prevent type II endoleak (T2EL).

METHODS

CFT involves deploying an aortic cuff inside the AAA to cover the ostium of the aortic side branch vessels before deploying the main body. We performed a retrospective review of all patients undergoing EVAR with CFT or side branch embolization (SBE) for AAAs at The Jikei University Hospital between 2016 and 2022. Primary endpoint was the rate of aneurysm sac shrinkage. Secondary endpoints were procedure time, radiation exposure, technical and clinical success rates, occurrence of T2EL, and freedom from reintervention or aneurysm-related death (ARD).

RESULTS

Out of 406 patients who underwent EVAR for AAAs, CFT was utilized in 56 (CFT group) and SBE in 35 (SBE group); all 91 patients were included in this study. There were no differences in patient demographics between groups but there were differences in patency rate of the inferior mesenteric artery (IMA) and absent intraluminal thrombus. The technical success rate per target vessel in the CFT and SBE group was 97.8% and 91.8%, and the clinical success rate was 91.0% and 100%, respectively. The procedure time was shorter for CFT than for SBE (median [IQR, interquartile range]; CFT: 10 [6-14] min vs. SBE: 25 [18.5-45] min; P < 0.05), and radiation exposure was lower for CFT than for SBE (median [IQR]; CFT: 1455 [840-2634] mGy vs. SBE: 2353 [1552-3586] mGy, P < 0.05). During the median follow-up of 25 (12.5-47) months, sac shrinkage occurred at similar rates in both groups (CFT: 37.5% vs. SBE: 40.0%; P = 0.812), and there were no differences in freedom from reintervention (CFT: 96.2% and 91.4% at 12 and 36 months vs. SBE: 100% and 89.5% at 12 and 36 months; log-rank, P = 0.761) and freedom from ARD (100% at 36 months in both groups; log-rank, P = 0.440). The odds ratio (OR) of CFT vs. SBE for sac regression was calculated by adjusting for IMA patency and absent intraluminal thrombus, resulting in no statistical significance (OR, 1.231, 95% confidence interval, 0.486-3.122).

CONCLUSIONS

CFT is feasible with a shorter procedure time and lower radiation exposure than SBE and comparable mid-term outcomes, including sac shrinkage rate, compared with SBE. We believe that CFT, if anatomically suitable, is an alternative to SBT for the prevention of T2EL during EVAR.

A procedural step analysis of radiation exposure in fenestrated endovascular aortic repair

OBJECTIVE

Radiation exposure during complex endovascular aortic repair may be associated with tangible adverse effects in patients and operators. This study aimed to identify the steps of highest radiation exposure during fenestrated endovascular aortic repair (FEVAR) and to investigate potential intraoperative factors affecting radiation exposure.

METHODS

Prospective data of 31 consecutive patients managed exclusively with four-fenestration endografts between March 1, 2020, and July 1, 2022 were retrospectively analyzed. Leveraging the conformity of the applied technique, every FEVAR operation was considered a combination of six overall stages composed of 28 standardized steps. Intraoperative parameters, including air kerma, dose area product, fluoroscopy time, and number of digital subtraction angiographies (DSAs) and average angulations were collected and analyzed for each step.

RESULTS

The mean procedure duration and fluoroscopy time was 140 minutes (standard deviation [SD], 32 minutes), and 40 minutes (SD, 9.1 minutes), respectively. The mean air kerma was 814 mGy (SD, 498 mGy), and the mean dose area product was 66.8 Gy cm2 (SD, 33 Gy cm2). The percentage of air kerma of the entire procedure was distributed throughout the following procedure stages: preparation (13.9%), main body (9.6%), target vessel cannulation (27.8%), stent deployment (29.1%), distal aortoiliac grafting (14.3%), and completion (5.3%). DSAs represented 23.0% of the total air kerma. Target vessel cannulation and stent deployment presented the highest mean lateral angulation (67 and 63 degrees, respectively). Using linear regression, each minute of continuous fluoroscopy added 18.9 mGy of air kerma (95% confidence interval, 17.6-20.2 mGy), and each DSA series added 21.1 mGy of air kerma (95% confidence interval, 17.9-24.3 mGy). Body mass index and lateral angulation were significantly associated with increased air kerma (P < .001).

CONCLUSIONS

Cannulation of target vessels and bridging stent deployment are the steps requiring the highest radiation exposure during FEVAR cases. Optimized operator protection during these steps is mandatory.