title: Efficacy Analysis of a Script-based Guide for EVAR Execution: is it Possible to Reduce Patient Exposure to Contrast, Operative Time and Blood Loss even when Advanced Technologies are not Available?
abstract: BACKGROUND
  Despite the patient and medical staff exposure to radiation in endovascular aneurysm repair, the benefits of this abdominal aortic aneurysm type of surgical management are justified by minor recovery time and hospitalization, as well as an option for patients not elected to conventional open repair. In this minimally invasive surgical approach, time of procedure and radiation doses can be substantial--and the increasing frequency of these procedures and it's complexity have impelled vascular surgeons to face additional and successive risk to occupational radiation exposure. Meticulous study of the computed tomography angiography during the endovascular aneurysm repair preparation allows reduction of unnecessary radiation exposure, as also reduces consecutive image acquisition and contrast use (that may be related to renal overload in susceptible patients). Some studies have proposed strategies to optimize endovascular intervention to reduce contrast use and X-ray exposure. Although they might prove to be effective, they rely on use of additional specific and advanced equipment, available only in major centers. As an alternative to this expensive and restrict technology, it is presented a simpler technique through image manipulation on software OsiriX, aiming to reduce both exposures.
  
  
  OBJECTIVE
  To analyze the efficacy of the adoption of a study protocol and a script-based guide in preparation for endovascular aneurysm repair through verifying its impact over the surgical procedure--as referred to intravascular contrast infuse, effects over renal function, blood loss and operatory time.
  
  
  METHODS
  A longitudinal prospective study from March 2014 through March 2015, where 30 performed endovascular aneurysm repair were compared to a historic control group. The planning for endovascular aneurysm repair through the patient's tomographic image manipulation in the prospective group was performed with OsiriX MD software. A script-based guide upon gathering detailed computed tomography angiography images was elaborated by the author and distributed to the performing surgical team for appreciation, instruction and pre operatory judgment. Based upon the script, the C-arm gantry angle was specifically corrected in each case of endovascular aneurysm repair, for image optimization and aneurysm's neck visualization. Arteriography was performed under digital subtraction angiography after catheters were positioned according to predicted level description in the referred guide. Statistical analysis were performed with a significance level of 5% (P value<0.05).
  
  
  RESULTS
  There was a statistically significant relationship between the two studied periods and the variables: contrast volume (284.5 vs. 31.8 mL), operative time (207.5 vs. 140.4 min.) and blood loss (798.1 vs. 204.4 mL), revealing that they are considerably larger in the historical control group than in the script guided current group. There was no difference related to the volume of contrast used in the two groups and the occurrence of renal impairment.
  
  
  CONCLUSIONS
  In the present paper it was possible to demonstrate the impact of the ability to manipulate digital formats of medical images without the need of sophisticated equipment, in adoption of a guide based on the compilation of informations collected with assistance of an accessible software performed on a personal computer. Although we could not prove relation to occurrence of renal impairment, there were direct results on reduction of intravascular contrast use, even as surgical time and blood loss, compared to a previous historical period.
authors.affiliation: Universidade Estadual de Campinas, Campinas, SP, Brazil.
authors.forename: Giovani José Dal Poggetto
authors.initials: GJ
authors.lastname: Molinari
authors.affiliation: Universidade Estadual de Campinas, Campinas, SP, Brazil.
authors.forename: Ana Terezinha
authors.initials: AT
authors.lastname: Guillaumon
authors.affiliation: Universidade Estadual de Campinas, Campinas, SP, Brazil.
authors.forename: Andréia Marques de Oliveira
authors.initials: AM
authors.lastname: Dalbem
mesh_terms: D015901:Angiography, Digital Subtraction / Q000379:methods; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D016063:Blood Loss, Surgical / Q000517:prevention & control; D003287:Contrast Media / Q000008:administration & dosage / Q000009:adverse effects; D057510:Endovascular Procedures / Q000379:methods*; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000379:methods; D008137:Longitudinal Studies; D061646:Operative Time; D011446:Prospective Studies; D000069079:Radiation Exposure / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D003287:Contrast Media