title: Surgeon education decreases radiation dose in complex endovascular procedures and improves patient safety.
abstract: OBJECTIVE
  Complex endovascular procedures such as fenestrated endovascular aneurysm repair (FEVAR) are associated with higher radiation doses compared with other fluoroscopically guided interventions (FGIs). The purpose of this study was to determine whether surgeon education on radiation dose control can lead to lower reference air kerma (RAK) and peak skin dose (PSD) levels in high-dose procedures.
  
  
  METHODS
  Radiation dose and operating factors were recorded for FGI performed in a hybrid room over a 16-month period. Cases exceeding 6 Gy RAK were investigated according to institutional policy. Information obtained from these investigations led to surgeon education focused on reducing patient dose. Points addressed included increasing table height, utilizing collimation and angulation, decreasing magnification modes, and maintaining minimal patient-to-detector distance. Procedural RAK doses and operating factors were compared 8 months pre- (group A) and 8 months post- (group B) educational intervention using analysis of variance with Tukey pairwise comparisons and t-tests. PSD distributions were calculated using custom software employing input data from fluoroscopic machine logs.
  
  
  RESULTS
  Of 447 procedures performed, 300 FGIs had sufficient data to be included in the analysis (54% lower extremity, 11% thoracic endovascular aneurysm repair, 10% cerebral, 8% FEVAR, 7% endovascular aneurysm repair, 5% visceral, and 5% embolization). Twenty-one cases were investigated for exceeding 6 Gy RAK. FEVAR comprised 70% of the investigated cases and had a significantly higher median RAK dose compared with all other FGIs (P < .0001). There was no difference in body mass index between groups A and B; however, increasing body mass index was an indicator for increased RAK. PSD calculations were performed for the 122 procedures that focused on the thorax and abdomen (group A, 80 patients; group B, 42 patients). Surgeon education most strongly affected table height, with an average table height elevation of 10 cm per case after education (P < .0001). The dose index (PSD/RAK ratio) was used to track changes in operating practices, and it decreased from 1.14 to 0.79 after education (P < .0001). These changes resulted in an estimated 16% reduction in PSD. There was a trend toward a decrease in patient to detector distance, and the use of collimation increased from 25% to 40% (P < .001) for all cases; however, these did not result in a decrease in PSD. The number of cases that exceeded 6 Gy RAK did not change after education; however, the proportion of non-FEVAR cases that exceeded 6 Gy decreased from 40% to 20%.
  
  
  CONCLUSIONS
  Surgeon education on the appropriate use of technical factors during FGIs improved operating practice, reduced patient radiation dose, and decreased the number of non-FEVAR cases that exceeded 6 Gy. It is essential that vascular surgeons be educated in best operating practices to lower PSD; nonetheless, FEVAR remains a high-dose procedure.
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390-9157, USA. melissa.kirkwood@utsouthwestern.edu
authors.forename: Melissa L
authors.initials: ML
authors.lastname: Kirkwood
authors.forename: Gary M
authors.initials: GM
authors.lastname: Arbique
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Guild
authors.forename: Carlos
authors.initials: C
authors.lastname: Timaran
authors.forename: Jayer
authors.initials: J
authors.lastname: Chung
authors.forename: Jon A
authors.initials: JA
authors.lastname: Anderson
authors.forename: R James
authors.initials: RJ
authors.lastname: Valentine
mesh_terms: D002983:Clinical Competence; D004502:Education, Medical, Continuing; D057510:Endovascular Procedures / Q000009:adverse effects / Q000193:education*; D005471:Fluoroscopy; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D009873:Operating Rooms; D061214:Patient Safety; D011829:Radiation Dosage; D011832:Radiation Injuries / Q000517:prevention & control; D015641:Radiography, Interventional / Q000009:adverse effects; D015642:Radiology, Interventional / Q000193:education*; D012189:Retrospective Studies; D016896:Treatment Outcome