title: Patterns of procedure-specific radiation exposure in the endovascular era: impetus for further innovation.
abstract: OBJECTIVE
  Although patient preference and outcome data support continued development and use of minimally invasive endovascular therapies, only a few studies have documented radiation exposure to the patient. This report summarizes patient radiation exposure by endovascular procedure at Cleveland Clinic.
  
  
  METHODS
  A retrospective review was undertaken of all endovascular procedures during a 30-month period. Procedures were categorized as infrarenal aortic aneurysm (IAA), isolated thoracic aneurysm (TA), visceral occlusive intervention, renal artery intervention, cerebrovascular intervention, cerebrovascular and lower extremity diagnostic, atherectomy, and lower extremity intervention. Radiation exposure was categorized by procedure. The estimated skin dose (ESD, mGy) and effective dose (ED, mSv) were calculated. Total computed tomography (CT) scans were tabulated for patients undergoing aneurysm stent grafting, and the cumulative ED was estimated. Statistical analyses were done with Kruskal-Wallis tests to detect overall differences, Wilcoxon rank sum exact tests for paired comparisons, and the Bonferroni post hoc test for group comparison.
  
  
  RESULTS
  Fluoroscopy times were recorded in 2103 endovascular procedures. The more complex the procedure, the longer the fluoroscopy time and ESD. Patients undergoing atherectomy had significantly higher ESD, at 1260 mGy (900, 1542; P < .001) than all groups. When converting to ED, however, cerebrovascular intervention and IAA received the highest ED, at 120 mSV (100, 150 mSV) and 109 mSV (85, 151 mSV; respectively, P < .001) among other groups. TAA patients underwent a greater number of CT scans than IAA patients (7.4 +/- 0.3 vs 5.8 +/- 0.2; P < .004). Tabulating the cumulative ED, including procedure and CT scans, showed IAA patients had significantly higher doses of radiation exposure than TAA patients (217 +/- 5 vs 191 +/- 6; P < .004).
  
  
  CONCLUSIONS
  The increasing complexity of endovascular interventions has resulted in increased radiation exposure to all involved, with the highest doses occurring in aneurysm repairs. Future innovations should concentrate on reducing the risk of radiation exposure to all personnel and developing newer imaging techniques.
authors.affiliation: Department of Vascular Surgery, The Cleveland Clinic, Cleveland, Ohio 44195, USA.
authors.forename: Mohsen
authors.initials: M
authors.lastname: Bannazadeh
authors.forename: Ozcan
authors.initials: O
authors.lastname: Altinel
authors.forename: Vikram S
authors.initials: VS
authors.lastname: Kashyap
authors.forename: Zhiyuan
authors.initials: Z
authors.lastname: Sun
authors.forename: Daniel
authors.initials: D
authors.lastname: Clair
authors.forename: Timur P
authors.initials: TP
authors.lastname: Sarac
mesh_terms: D000792:Angiography / Q000009:adverse effects; D004307:Dose-Response Relationship, Radiation; D005471:Fluoroscopy / Q000009:adverse effects; D006801:Humans; D019060:Minimally Invasive Surgical Procedures; D009381:Neoplasms, Radiation-Induced / Q000209:etiology* / Q000517:prevention & control; D011829:Radiation Dosage; D011834:Radiation Monitoring; D011835:Radiation Protection; D011855:Radiodermatitis / Q000209:etiology* / Q000517:prevention & control; D015641:Radiography, Interventional / Q000009:adverse effects*; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000009:adverse effects; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000000981:diagnostic imaging* / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000009:adverse effects*