Dual fluoroscopy with live-image digital zooming significantly reduces patient and operating staff radiation during fenestrated-branched endovascular aortic aneurysm repair.

OBJECTIVE: Fenestrated-branched endovascular aneurysm repair (F/B-EVAR) is a complex procedure that generates high radiation doses. Magnification aids in vessel cannulation but increases radiation. The aim of the study was to compare radiation doses to patients and operating room staff from two fluoroscopy techniques, standard magnification vs dual fluoroscopy with live-image digital zooming during F/B-EVAR. METHODS: An observational, prospective, single-center study of F/B-EVAR procedures using Philips Allura XperFD20 equipment (Philips Healthcare, Amsterdam, The Netherlands) was performed during a 42-month period. Intravascular ultrasound, three-dimensional fusion, and extreme collimation were used in all procedures. Intraoperative live-image processing was performed with two imaging systems: standard magnification in 123 patients (81%) and dual fluoroscopy with live-image digital zooming in 28 patients (18%). In the latter, the live "processed" zoomed images are displayed on examination displays and live images are displayed on reference displays. The reference air kerma was collected for each case and represents patient dose. Operating staff personal dosimetry was collected using the DoseAware system (Philips Healthcare). Patient and staff radiation doses were compared using nonparametric tests. RESULTS: Mean age was 71.6 ± 11.4 years. The median body mass index was 27 kg/m2 (interquartile range [IQR], 24.4-30.6 kg/m2) and was the same for both groups. Procedures performed with dual fluoroscopy with digital zooming demonstrated significantly lower median patient (1382 mGy [IQR, 999-2045 mGy] vs 2458 mGy [IQR, 1706-3767 mGy]; P < .01) and primary operator radiation doses (101 µSv [IQR, 34-235 µSv] vs 266 µSv [IQR, 104-583 µSv]; P < .01) compared with standard magnification. Similar significantly reduced radiation doses were recorded for first assistant, scrub nurse, and anesthesia staff in procedures performed with dual fluoroscopy. According to device design, procedures performed with four-fenestration/branch devices generated higher operator radiation doses (262 µSv [IQR, 116.5-572 µSv] vs 171 µSv [IQR, 44-325 µSv]; P < .01) compared with procedures with three or fewer fenestration/branches. Among the most complex design (four-vessel), operator radiation dose was significantly lower with digital zooming compared with standard magnification (128.5 µSv [IQR, 70.5-296 µSv] vs 309 µSv [IQR, 150-611 µSv]; P = .01). CONCLUSIONS: Current radiation doses to patients and operating personnel are within acceptable limits; however, dual fluoroscopy with live-image digital zooming results in dramatically lower radiation doses compared with the standard image processing with dose-dependent magnification. Operator radiation doses were reduced in half during procedures performed with more complex device designs when digital zooming was used.

Colocación de stents vs. endarterectomía para enfermedades carotídeas. Resultados del Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) / Stenting vs. endarterectomy for carotid disease. Results of the carotid revascularization endarterectomy vs. stenting trial (CREST) / Colocação de stent vs. Endarterectomia para doença arterial carotídea. Resultados do carotid revascularization endarterectomy vs. Stenting trial (crest)

Antecedentes y objetivos: La estenosis de la arteria carótida causa hasta el 10% de todos los ataques cerebrovasculares isquémicos. La endarterectomía carotídea (CEA) se presentó como tratamiento para prevenir los ataques cerebrovasculares en los comienzos de 1950. La colocación del stent carotídeo (CAS) fue presentada como tratamiento para prevenir el ataque cerebrovascularen 1994. Métodos: CREST es un estudio randomizado con adjudicación completamente ciega. Tanto los pacientes sintomáticos como los asintomáticos fueron randomizados a CAS o CEA. El objetivo final primario fue la combinación de cualquier accidente cerebrovascular, de infarto de miocardioo bien de fallecimiento durante el período periprocedimiento y de accidente cerebrovascular ipsilateral después de 4 años. Resultados: No existió una diferencia significativa en los promedios del objetivo final entre CASy CEA (7.2% vs. 6.8%; HR=1.11; 95% CI, 0.81-1.51; P=0.51). Tanto el estado sintomático como el sexo de los pacientes no modificaron el efecto del tratamiento, pero si se detectó una interacción entre la edad y el tratamiento. Los resultados fueron levemente mejores con CAS, en aquellos pacientes menores de 70 años, mientras que para los pacientes mayores a 70 años fue mejor para aquellos pacientes con CEA. El objetivo final periprocedimiento no difería entre CAS y CEA, pero existían diferencias en los componentes CAS vs. CEA (ataques cerebrovasculares 4.1% vs. 2.3%, P=0.012; y el infarto de miocardio 1.1% vs. 2.3%, P=0.032). Conclusiones: En el CREST, el objetivo final primario tanto en CAS como en CREST, tuvo similares síntomas a corto como a largo plazo. Durante el período periprocedimiento, existía mayor riesgo de ataque cerebrovascular con CAS mientras que con CEA existía un riesgo mayor de infarto de miocardio.

Antecedentes e objetivos: A estenose arterial carotídea é causa de aproximadamente 10% de todos os acidentes cerebrovasculares isquêmicos. A endarterectomia carotídea (CEA) se apresentou como tratamento para prevenir os acidentes cerebrovasculares no início dos anos 50. A colocação do stent carotídeo (CAS) foi apresentada como um tratamento para prevenir o acidente cerebrovascular em 1994. Métodos: O estudo CREST foi um ensaio clínico randomizado completamente cego. Tantoos pacientes sintomáticos quanto os assintomáticos foram randomizados CAS ou randomizados CEA. O objetivo final primário foi a combinação de qualquer acidente cerebrovascular, de infarto do miocárdio ou inclusive de óbito durante o período periprocedimento e de acidente cerebrovascular ipsilateral depois de 4 anos. Resultados: Não foi demonstrada uma diferença significativa nas médias do objetivo final entre CAS e CEA (7.2% vs. 6.8%; HR=1.11; 95% CI, 0.81-1.51; P=0.51). Tanto o estado sintomático quanto o sexo dos pacientes não modificaram o efeito do tratamento, porém, detectou-se uma interação entre a idade e o tratamento. Os resultados foram levemente melhores com CAS nos pacientes menores de 70 anos, enquanto que para os pacientes maiores de 70 anos foi melhor com CEA. O objetivo final periprocedimento não diferia entre CAS e CEA, mas existiam diferenças nos componentes CAS vs. CEA (acidentes cerebrovasculares 4.1% vs. 2.3%, P=0.012; e o infarto do miocárdio 1.1% vs. 2.3%, P=0.032). Conclusões: No estudo CREST, o objetivo final primário tanto em CAS quanto em CREST, apresentou similares sintomas tanto a curto como a longo prazo. Durante o período periprocedimento, existia maior risco de acidente cerebrovascular com CAS enquanto que com CEA existia um risco maior de infarto do miocárdio.

Background and purpose: Carotid artery stenosis causes 10% of all ischemic cerebrovascular attacks. Carotid endarterectomy (CEA) was introduced as the treatment to prevent strokes in the beginning of the 50´s. The placement of a carotid stents (CAS) was introduced as a treatment to prevent strokes in 1994. Method: CREST is a randomized study with complete blind randomization. Both symptomatic and asymptomatic patients were randomized to CAS or CEA. The primary outcome was the combination of the prevention of stroke, myocardial infarction or death during the periprocedural period or ipsilateral stroke after 4 years. Results: There were no significant differences in the mean final outcome between CAS andCEA (7.2% vs. 6.8%; HR=1.11; 95% CI, 0.81-1.51; P=0.51). Both being symptomatic as well as the gender of the patients did not modify the treatment effect, but there was a relationship between age and treatment. The results were slightly better with CAS in patients under 70 years old, while in patients over 70 years old the results were better with CEA. The final peri-procedural outcome did not differ between CAS and CEA but there were differences in the CAS vs CEA components (stroke 4.1% vs. 2.3%, P=0.012; and myocardial infarction 1.1% vs. 2.3%, P=0.032). Conclusions: In the CREST study, with regards to the primary end point both CAS and CEA had similar short-term symptoms. During the peri-procedural period in patients undergoing CAS there was a higher risk of stroke while patients undergoing CEA presented a higher risk of myocardial infarction.