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Evaluation of the Radiation Dose Received by Patients diagnostics Article Hybrid Operating Room System for the Treatment of Thoracic and Abdominal Aortic Aneurysms: Evaluation of the Radiation Dose Received by Patients Yoshihiro Haga 1,2, Koichi Chida 1,3,*, Masahiro Sota 1,2, Yuji Kaga 2, Mitsuya Abe 2, Yohei Inaba 1,3 , Masatoshi Suzuki 1,3 , Taiichiro Meguro 4 and Masayuki Zuguchi 1 1 Course of Radiological Technology, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba, Sendai, Miyagi 980-8575, Japan; [email protected] (Y.H.); [email protected] (M.S.); [email protected] (Y.I.); [email protected] (M.S.); [email protected] (M.Z.) 2 Department of Radiology, Sendai Kousei Hospital, 4-15 Hirosemachi, Aoba, Sendai 980-0873, Japan; [email protected] (Y.K.); [email protected] (M.A.) 3 Department of Radiation Disaster Medicine, International Research Institute of Disaster Science, Tohoku University, 468-1 Aramaki Aza-Aoba, Aoba, Sendai, Miyagi 980-0845, Japan 4 Department of Cardiovascular Medicine, Sendai Kousei Hospital, 4-15 Hirose-machi, Aoba, Sendai 980-0873, Japan; [email protected] * Correspondence: [email protected]; Tel.: +81-22-717-7943 Received: 23 September 2020; Accepted: 10 October 2020; Published: 19 October 2020 Abstract: In recent years, endovascular treatment of aortic aneurysms has attracted considerable attention as a promising alternative to traditional surgery. Hybrid operating room systems (HORSs) are increasingly being used to perform endovascular procedures. The clinical benefits of endovascular treatments using HORSs are very clear, and these procedures are increasing in number. In procedures such as thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR), wires and catheters are used to deliver and deploy the stent graft in the thoracic/abdominal aorta under fluoroscopic control, including DSA. Thus, the radiation dose to the patient is an important issue. We determined radiation dose indicators (the dose–area product (DAP) and air karma (AK) parameters) associated with endovascular treatments (EVAR and TEVAR) using a HORS. As a result, the mean ± standard deviation (SD) DAPs of TEVAR and EVAR were 323.7 161.0 and 371.3 186.0 Gy cm2, ± ± × respectively. The mean SD AKs of TEVAR and EVAR were 0.92 0.44 and 1.11 0.54 Gy, respectively. ± ± ± The mean SD fluoroscopy times of TEVAR and EVAR were 13.4 7.1 and 23.2 11.7 min, respectively. ± ± ± Patient radiation dose results in this study of endovascular treatments using HORSs showed no deterministic radiation effects, such as skin injuries. However, radiation exposure during TEVAR and EVAR cannot be ignored. The radiation dose should be evaluated in HORSs during endovascular treatments. Reducing/optimizing the radiation dose to the patient in HORSs is important. Keywords: fluoroscopy; interventional radiology (IVR); stent graft; aneurysm; endovascular treatment; X-ray examination; radiation safety; radiation dose; disaster medicine 1. Introduction In recent years, endovascular treatment of aortic aneurysms has attracted considerable attention as a promising alternative to traditional surgery [1]. Endovascular treatment reduces the risk of complications and shortens hospital stays [2]. In thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR), wires and catheters are used to deliver stent grafts to and deploy the grafts in the Diagnostics 2020, 10, 846; doi:10.3390/diagnostics10100846 www.mdpi.com/journal/diagnostics Diagnostics 2020, 10, 846 2 of 11 Diagnosticscomplications2020, 10 and, 846 shortens hospital stays [2]. In thoracic endovascular aortic repair (TEVAR)2 ofand 11 endovascular aortic repair (EVAR), wires and catheters are used to deliver stent grafts to and deploy the grafts in the thoracic/abdominal aorta under fluoroscopic control (including digital subtraction thoracicangiography/abdominal (DSA)). aorta The under procedures fluoroscopic are often control complex, (including associated digital with subtraction a long fluoroscopy angiography time (DSA)). (FT) Theand many procedures cine acquisitions, are often complex, thus delivering associated highwith radiation a long doses fluoroscopy to both the time interventional (FT) and many radiology cine acquisitions,(IVR) staff [3–5] thus deliveringand patient high [6]. radiation The quality doses toco bothntrol the of interventionalfluoroscopic radiologyX-ray devices (IVR) staff[7,8] [3and–5] andmanagement patient [6]. of The exposure quality doses control are of important fluoroscopic issues X-ray. Appropriate devices [7,8] stent and management graft placement of exposure requires doses very areprecise important manipulation. issues. Appropriate Mobile C-arms stent can graft often placement overheat, requires and exhibit very preciseimage degradation manipulation. [9]. Mobile Thus, C-armsthe X-ray can fluoroscopic often overheat, device and must exhibit feature image both degradation a large capacity [9]. Thus, and the high X-ray X-ray fluoroscopic output. Hybrid device mustoperating feature room both systems a large capacity(HORSs) and are highincreasingly X-ray output. being Hybrid used to operating perform roomendovascular systems (HORSs)procedures. are increasinglyA HORS combines being used state-of-the-art to perform endovascular imaging with procedures. the use of A HORSa high-capacity combines state-of-the-art angiographic imagingsystem, withaffording the use optimal of a high-capacity patient care. angiographicThe fact that system,the operating affording room optimal is sterile patient enables care. vascular The fact surgeons that the operatingto combine room complex is sterile endovascular enables vascular procedures surgeons with tocombine open surgery complex [10]. endovascular Major clinical procedures benefits with are openalready surgery apparent, [10]. and Major HORSs clinical are benefits increasing are already in popularity. apparent, and HORSs are increasing in popularity. The radiation doses delivered to small groups ofof patientspatients undergoingundergoing endovascularendovascular treatment of thoracic and abdominalabdominal aorticaortic aneurysmsaneurysms werewere quantifiedquantified previously.previously. We We here attempted to optimize thethe radiationradiation doses doses delivered delivered during during HORS-mediated HORS-mediated treatment treatment of patientsof patients with with thoracic thoracic and abdominaland abdominal aortic aortic aneurysms. aneurysms. Direct methodsDirect methods of assessing of radiationassessing exposureradiation [11 exposure–14] are cumbersome;[11–14] are thus,cumbersome; we used indirectthus, we methods used indirect (the dose–area methods product (the dose–area (DAP) and product air karma (DAP) (AK) parameters)and air karma to assess (AK) skinparameters) radiation to dosesassess [ 15skin–28 radiation]. We determined doses [15–2 the8]. DAP We anddetermined AK radiation the DAP dose and indicators AK radiation associated dose withindicators EVAR associated and TEVAR with delivered EVAR and via aTEVAR HORS. delivered via a HORS. 2. Materials and Methods The present study was conducted in a HORS at SendaiSendai KouseiKousei HospitalHospital (Japan).(Japan). We evaluated the radiation dose indicators (DAP and AK) and relatedrelated factors (i.e., FT) inin 256256 consecutiveconsecutive patientspatients undergoing endovascular treatment from 20102010 toto 2012.2012. The The study study was approved by the ethics committee of SendaiSendai KouseiKousei HospitalHospital (Permission(Permission code:code: 30-19; 28 May 2018).2018). All procedures were performed usingusing a digitala digital X-ray X-ray system system (INFX-8000H, (INFX-8000H, Toshiba, Toshiba, Otawara, Otawara, Japan; FigureJapan;1). Figure We evaluated 1). We single-plane images obtained using a large field-of-view (12 16 in). Digital cine images were evaluated single-plane images obtained using a large field-of-view× (12 × 16 in). Digital cine images acquiredwere acquired at 10 framesat 10 frames/s/s during during all procedures. all procedur Pulsedes. Pulsed fluoroscopy fluoroscopy (7.5 pulses (7.5 pulses/s)/s) featuring featuring flat panel flat detectionpanel detection (FPD) using(FPD) an using anti-scatter an anti-scatter grid were grid also we performed.re also performed. During the During X-ray the procedures, X-ray procedures, including DSA,including digital DSA, angiography digital angiography (DA), and fluoroscopy,(DA), and fluoroscopy, TEVAR was TEVAR performed was usingperformed a 40–50 using◦ left a anterior 40–50° obliqueleft anterior view, oblique whereas view, EVAR whereas was performed EVAR was using performed various using viewing various angles. viewing The angles. X-ray source The X-ray was placedsource approximatelywas placed approximately 100 cm from 100 the cm FPD. from The the X-ray FPD. details The X-ray and contrast details and conditions contrast used conditions during TEVARused during and EVARTEVAR are and shown EVAR in Tableare shown1. in Table 1. Figure 1. Photograph of the hybrid op operatingerating room system (HORS). The DAP, AK, FT, and number of DA or DSA procedures performed were recorded for all patients. AK was measured at a point 15 cm toward the focal spot commencing at the isocenter of the Diagnostics 2020, 10, 846 3 of 11 Table 1. The standard X-ray and contrast conditions used during endovascular treatment of aortic aneurysms in our hospital. X-ray Conditions Fluoroscopy D A D S A Typical tube voltage (kV) 80 80 80 Typical tube
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