Three-dimensional fusion computed tomography decreases radiation exposure, procedure time, and contrast use during fenestrated endovascular aortic repair

Abstract

Objectives Endovascular surgery has revolutionized the treatment of aortic aneurysms; however these improvements have come at the cost of increased radiation and contrast exposure, particularly for more complex procedures. Three dimensional (3D) fusion computed tomographic (CT) imaging is a new technology that may facilitate these repairs. The purpose of this analysis was to determine the impact of utilizing intraoperative 3D fusion CT on performance of fenestrated endovascular aortic repair. Methods A review of our institutional database was performed to identify patients undergoing fenestrated/branched endovascular aortic repair (FEVAR). Subjects treated using 3D fusion CT were compared to patients treated in the immediate 12-month period prior to implementation of this technology when procedures were performed in a standard hybrid operating room without CT fusion capabilities. Primary endpoints included patient radiation exposure (air kerma area product: milliGray; mGy*cm2), fluoroscopy time (minutes; min), contrast usage (mL) and procedure time (min). Patients were grouped by number of aortic graft fenestrations revascularized with a stentgraft and operative outcomes were compared. Results A total of 72 patients (N = 41 before vs. N = 31 after 3D fusion CT implementation) underwent FEVAR from September 2012 through March 2014. For 2-vessel fenestrated endografts, there was a significant decrease in radiation exposure (3400±1900 vs. 1380±520 mGy*cm2; P=.001), fluoroscopy time (63±29 vs. 41±11min; P=.02), and contrast usage (69±16 vs. 26±8 mL; P=.0002) with intraoperative 3D fusion CT. Similarly, for combined 3 and 4-vessel FEVAR, significantly decreased radiation exposure (5400±2225 vs. 2700±1400 mGy*cm2; P<.0001), fluoroscopy time (89±36 vs 6±21min; P=.02), contrast usage (90±25 vs. 39±17mL; P<.0001), as well as procedure time (330±100 vs. 230±50min; P=.002) was noted. Estimated blood loss was significantly less (P<.0001) and length of stay had a trend (P=.07) toward being lower for all patients in the 3D CT group. Conclusions These results demonstrate that use of intraoperative 3D fusion CT imaging during FEVAR can significantly decrease radiation exposure and procedure time, as well as contrast usage, which may also decrease the overall physiologic impact of the repair.

Outcomes of surgeon-modified fenestrated-branched endograft repair for acute aortic pathology

“…34 Moreover, F/B-EVAR has a known association with long-term renal function decline in 25% to 33% of subjects, 2,35 which is related to multiple factors including comorbidities, alteration in target vessel perfusion, atheroemboli, and repeated contrast exposure. To reduce this risk, we now routinely employ three-dimensional fusion CT technology 23 to minimize intraoperative contrast exposure in all F/B-EVAR cases and modify surveillance in renal dysfunction patients (eg, noncontrast CT with branch vessel DUS).…”

“…with assistance from other attending surgeons or fellowship trainees. We have previously described in detail our principles of preoperative stabilization, 20 spinal drain use, 21,22 F/B-EVAR planning using centerline reconstruction (Aquarius 3D; Tera Recon, Foster City, Calif), and device modification and implantation, 20,23 as well as use of intraoperative three-dimensional fusion computed tomography (CT) to facilitate visceral vessel cannulation. 23 An example of perioperative planning and device implantation technique is demonstrated in Fig 1, which highlights a patient who presented with a ruptured paravisceral aortic aneurysm after previous infrarenal endovascular aneurysm repair (EVAR).…”

Editor's Choice – Minimizing Radiation Exposure During Endovascular Procedures: Basic Knowledge, Literature Review, and Reporting Standards

“…Indeed, a reduction of up to 70% of the procedure's global radiation has been reported in complex EVAR supported by this technique. 45,70 Shielding…”

The correlation between computed tomography and duplex evaluation of autogenous vein bypass grafts and their relationship to failure

“…CT scanning is increasingly utilized by vascular surgeons and its application continues to expand as three dimensional imaging techniques become more commonly integrated into the management of aortic 24, 25 , carotid 26 , and lower extremity 27 disease. For example, some groups now perform pre-operative vein mapping, once obtained exclusively by ultrasound, using CT scans 27 .…”