Invited commentary

Article Outline

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Endovascular repair of abdominal aortic aneurysm (AAA) has afforded patients significant benefit over open repair of AAA by measures of standard risks associated with aneurysm repair. However, the adoption of this form of repair for most AAAs has brought with it new risks that remain yet to be fully defined. These additional risks include endoleaks, endotension, and the potential of device failure. Importantly, these risks can be identified with careful follow-up and quantified when describing the performance of the procedure to patients.

The procedure also brings with it, however, the risk of the radiation burden imposed by the preoperative assessment, the intraoperative use of fluoroscopy, and the continuing radiation burden related to radiographic imaging to assess the graft and its function over time. The intraoperative radiation risks are not exclusive to the patient, but affect the surgeon and the operative team as well. Identifying the radiation burden, the related clinical variables, and the timing of this radiation burden is important in any attempt to reduce these risks for both patient and staff.

Kalef-Ezra et al, in the current study, have evaluated the radiation burden incurred by patients undergoing endovascular aneurysm repair. Although their main focus was the radiation burden during the performance of the procedure, the study also assessed the additional risk from the continued assessment in follow-up. This overall risk is not insignificant: in the first year alone, the patients undergoing endovascular aneurysm repair averaged a dose close to 30 times the average annual background radiation to which individuals are normally exposed, and this assumes only single-phase computed tomography scans (CT) obtained three times in the first year. The amount of exposure during the procedure itself averaged less than half the presumed necessary amount for radiation to induce erythematous skin changes and appears to be significantly less than that accumulated during the routine follow-up with CT scan. However, this intraoperative amount coupled with the dosing obtained from preoperative and long-term follow-up leads to a considerable radiation exposure. The authors noted two direct correlates to increased radiation dose: body-mass index and fluoroscopy time.

As the complexity of endovascular repair and the proportion of vascular surgical procedures performed with fluoroscopy increases, we need to be cognizant of the increasing radiation exposure to our patients, our staff, and ourselves. The current study highlights the importance of fluoroscopy time in relation to radiation exposure. All surgeons performing these procedures need to devote their efforts to minimizing fluoroscopy time, thereby reducing exposure to all present in the room. Increased size of the patient and increased complexity and time for the repair, in particular, pose intraoperative risk for high-dose radiation exposure and potentially for radiation-induced skin changes.

In addition, the total radiation burden borne by the patient determines his or her overall risk, and methods to reduce this burden need to be developed to ensure that we are not exposing our patients to unnecessary risks. Evaluation of methods to reduce the overall radiation burden should involve reducing the doses achieved during the preoperative assessment study, operative procedure, and the long-term follow-up evaluation to minimize radiation exposure.