National Diagnostic Reference Levels for Standard Descending Thoracic Endovascular Aortic Repair and Optimisation Strategies

Maria L Del Río-Solá; Rodrigo Rial; Cristina Lopez-Espada; Alejandro Rodríguez-Morata; Eliseo Vañó; Spanish DRLs Vascular Collaborators Group

doi:10.1016/j.ejvs.2024.05.012

National Diagnostic Reference Levels for Standard Descending Thoracic Endovascular Aortic Repair and Optimisation Strategies

Eur J Vasc Endovasc Surg. 2024 May 14:S1078-5884(24)00390-3. doi: 10.1016/j.ejvs.2024.05.012. Online ahead of print.

Authors

Maria L Del Río-Solá¹, Rodrigo Rial², Cristina Lopez-Espada³, Alejandro Rodríguez-Morata⁴, Eliseo Vañó⁵; Spanish DRLs Vascular Collaborators Group

Collaborators

Spanish DRLs Vascular Collaborators Group:
Mercedes Guerra Requena⁶, Elena Iborra Ortega⁷, Rosa Lopez-Perez⁸, Luis Miguel Salmerón Febres⁹, Caridad Morata Barrado⁶, Luis Estallo Liena¹⁰, Sergi Bellmunt¹¹, Elena Gonzalez Cañas¹², Claudia Aramendi¹³, Pascual Lozano Vilardell¹⁴, Francisco Jose Gomez Palones¹⁵, Lucia Martínez Carnovale¹⁶, Enrique Gonzalez Tabares¹⁷, Lino Antonio Camblor Santervas¹⁸, Mehdi El Amrani¹⁹, Francisco Rielo Arias²⁰, Vicent Riambau²¹

Affiliations

¹ Department of Surgery, Ophthalmology, Otorhinolaryngology, and Physiotherapy, University Clinical Hospital of Valladolid, University of Valladolid, Valladolid, Spain.
² Vascular and Endovascular Surgery Department, University Hospital HM Madrid-Torrelodones, Madrid, Spain.
³ Vascular Surgery Unit, University Hospital Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria - ibs.GRANADA, Granada, Spain; Department of Surgery, Faculty of Medicine, University of Granada, Granada, Spain. Electronic address: clegra3@hotmail.com.
⁴ Department of Vascular Surgery, Quironsalud Hospital, Málaga, Spain.
⁵ Radiology Department, Complutense University, Madrid, Spain.
⁶ Vascular Surgery Unit, University Hospital Guadalajara, Guadalajara, Spain.
⁷ Vascular Surgery Department, University Hospital Bellvitge, Barcelona, Spain.
⁸ Vascular Surgery Department, University Hospital Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain.
⁹ Vascular Surgery Department, University Hospital San Cecilio, Granada, Spain.
¹⁰ Vascular Surgery Department, University Hospital Galdakao, Bilbao, Spain.
¹¹ Vascular Surgery Department, University Hospital Vall D'Hebron, Barcelona, Spain.
¹² Vascular Surgery Department, Consorci Corporacio Sanitaria Parc Tauli, Sabadell, Barcelona, Spain.
¹³ Vascular Surgery Department, Basurto Hospital, Bilbao, Spain.
¹⁴ Vascular Surgery Department, University Hospital Son Espases, Palma de Mallorca, Spain.
¹⁵ Vascular Surgery Department, University Hospital Dr. Peset, Valencia, Spain.
¹⁶ Vascular Surgery Department, University Hospital German Trias i Pujol, Badalona, Barcelona, Spain.
¹⁷ Vascular Surgery Department, University Hospital de Canarias, Tenerife, Spain.
¹⁸ Vascular Surgery Department, University Hospital Central de Asturias, Oviedo, Spain.
¹⁹ Vascular Surgery Department, University Hospital Ramon y Cajal, Madrid, Spain.
²⁰ Vascular Surgery Department, University Hospital Lucus Augusti, Lugo, Spain.
²¹ Vascular Surgery Department, University Hospital Clinic de Barcelona, Barcelona, Spain.

PMID: 38754725
DOI: 10.1016/j.ejvs.2024.05.012

Abstract

Objective: The International Commission on Radiological Protection has highlighted the large number of medical specialties that use fluoroscopy outside diagnostic imaging departments without radiation protection programmes for patients and staff. Vascular surgery is one of these specialties. Thoracic endovascular aortic repair (TEVAR) is a complicated procedure requiring radiation protection guidance and optimisation. The recent EU Basic Safety Standards Directive requires the use and periodic updating of diagnostic reference levels (DRLs) for interventional procedures. The aim of this study was to determine doses for patients undergoing TEVAR with mobile X-ray systems and hybrid rooms (fixed X-ray systems) to obtain national DRLs and to suggest optimisation actions.

Methods: This was a retrospective cross-sectional study. The Spanish Chapter of Endovascular Surgery conducted a national survey in 11 autonomous communities representing around 77.6% of the Spanish population (47.33 million inhabitants). A total of 266 TEVAR procedures from 17 Spanish centres were analysed, of which 50.2% were performed in hybrid operating rooms. National DRLs were obtained and defined as the third quartile of the median values from the different participating centres.

Results: The proposed national DRLs are: for kerma area product (KAP), 113.81 Gy·cm² for mobile X-ray systems and 282.59 Gy·cm² for hybrid rooms; and for cumulative air kerma (CAK) at the patient entry reference point, 228.38 mGy for mobile systems and 910.64 mGy for hybrid rooms.

Conclusion: Based on the requirement to know radiation doses for standard endovascular procedures, this study of TEVARs demonstrated that there is an increased factor of 2.48 in DRLs for KAP when the procedure is performed in a hybrid room compared with mobile C-arm systems, and an increased factor of 3.98 in DRLs for CAK when the procedure is performed with hybrid equipment. These results will help to optimise strategies to reduce radiation doses during TEVAR procedures.

Keywords: DRL; Diagnostic reference level; European Directive; Optimisation; Patient dose; TEVAR.