Journal Article Ahead of print
PubMed: 42011971 DOI: 10.1177/15266028261440717
Inter-Center Radiation Variability in CO 2-Guided EVAR: Lessons From the Zero Iodine Contrast Multicenter Prospective Study.
J Endovasc Ther
Authors: Emiliano Chisci, Emanuele Ferrero, Michele Antonello, Luca Mezzetto, Raffaele Pulli, Gioele Simonte, Mauro Gargiulo, Giovanni Pratesi, Luca Bertoglio, Tommaso Lazzarotto
Affiliations
- Department of Surgery, Vascular and Endovascular Surgery Unit, USL Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy.
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy.
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, University of Padua, Padua, Italy.
- Department of Vascular Surgery, University and Hospital Trust of Verona, University of Verona - School of Medicine, Verona, Italy.
- Section of Vascular Surgery, Department of Excellence of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy.
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy.
- Clinic of Vascular and Vascular Surgery, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy.
- Division of Vascular Surgery, Department of Experimental and Clinical Sciences, University of Brescia School of Medicine, Spedali Civili di Brescia, Brescia, Italy.
Abstract
INTRODUCTION
Current diagnostic reference levels (DRLs) for endovascular aortic repair (EVAR), based on iodinated contrast media (ICM) protocols, range from 100 to 200 Gy·cm 2. As CO 2 is a negative contrast agent requiring digital subtraction angiography (DSA) for visualization, it may be associated with increased radiation exposure. This multicenter study presents the largest prospective data set to date evaluating radiation dose during EVAR using CO 2 angiography alone with an automated injector.
METHODS
A prospective, multicenter, nationwide, nonrandomized, investigator-initiated observational study of dosimetry recorded during EVAR procedures with CO 2 as exclusive contrast medium was conducted. Primary endpoints included dose-area product (DAP) and reference air kerma (K ar) measurements across all participating centers. Secondary objectives focused on evaluating optimization strategies to reduce radiation exposure for both patients and operators at a single investigational site.
RESULTS
A total of 293 patients were enrolled across 10 centers, between January 2023 and January 2024, median DAP and K ar were 189 Gy·cm 2 (interquartile range [IQR] 107-285) and 626.5 mGy (IQR 145.5-1373.5), respectively, with significant inter-center variability (all p<0.001). Newer angiographic systems demonstrated markedly lower DAP (median: 90 Gy·cm 2, IQR 71-153) vs older systems (191 Gy·cm 2, IQR 111-409; p<0.001). Through sequential optimization, we achieved progressive dose reductions: 38.5% via low-dose protocols, 52.3% with modern equipment, culminating in a 56% overall reduction (p<0.001) with synchronized CO 2-DSA-yielding a final median DAP of 28.5 Gy·cm 2.
CONCLUSIONS
CO 2-guided EVAR exhibits substantial radiation dose variability, driven by angiographic system generation, software, and synchronization protocols. Modern systems with optimized low-dose protocols and CO 2-DSA synchronization reduce radiation exposure to levels comparable to ICM-based EVAR.Clinical ImpactThis large multicenter prospective study establishes a reliable radiation dose benchmarks for CO2-guided endovascular aortic repair (EVAR), showing that modern angiographic systems with optimized low-dose protocols and synchronized CO 2-digital subtraction angiography achieve median dose-area product values comparable with conventional iodinated contrast media EVAR, thereby dispelling concerns about excessive radiation exposure with CO 2-guided EVAR.
MeSH
Contrast Media, Angiography, Digital Subtraction, Angiography, Air, Vascular Surgical Procedures, Radiation Exposure, Prospective Studies, Endovascular Aneurysm Repair