Poster No.: R Page 1 of 12

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1 Abdominal endovascular aortic repair (EVAR): Comparison of image fusion (IF3D) angiography versus conventional (2D) angiography with respect to intravenous contrast dose, radiation dose and total fluoroscopy time Poster No.: R-0025 Congress: Type: Authors: Keywords: DOI: 2014 CSM Scientific Exhibit N. Bajic, T. Kurmis, K. Doan, R. Sebben, R. Fitridge, J. Dawson; ADELAIDE/AU Interventional vascular, Vascular, Arteries / Aorta, Catheter arteriography, CT-Angiography, Fluoroscopy, Catheters, Computer Applications-3D, Contrast agent-intravenous, Aneurysms, Grafts /ranzcr2014/R-0025 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR/AIR/ACPSEM's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR/AIR/ ACPSEM is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR/AIR/ACPSEM harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Aim Endovascular aneurysm repair (EVAR) has evolved to become the standard of care for abdominal aortic aneurysms (AAA) that are not amenable to traditional open surgical repair (1). EVAR operator techniques, devices and radiological equipment continue to evolve enabling more ambitious repairs of increasingly complex AAAs (1,2). EVARs were initially treated in angiographic suites with 2D fluoroscopy which are being superseded by sophisticated angiographic suites with the ability to perform 3D fluoroscopy with cone beam CT (CBCT) (3-5). Vendors offer the capability to perform image fusion (IF) within 2D or 3D fluoroscopy angiography suites. IF is the ability to summate multiple imaging data sets into a single displayed image set (1,2). The 3D volume rendered (VR) images of the aneurysmal aorta obtained from pre-operative planning CT angiogram (CTA) may be fused with live fluoroscopy (1-5). Alternatively, intra-procedural CBCT data set may also be fused with live fluoroscopy (2,3,5). IF live fluoroscopy may therefore be used as a virtual roadmap for manipulation of catheters and wires during EVAR deployment with the potential advantage of reduced intravenous contrast dose and radiation exposure. The authors aim to evaluate the replacement of a conventional digital subtraction angiography (DSA) intra-procedural roadmap (2D angiography) angiography suite with the introduction of IF and 3D fluoroscopic capabilities. The authors aim to compare multiple parameters between 2D and IF3D EVAR cohorts including intravenous contrast dose (ml); total radiation dose (dose area product [DAP])(Gy/cm 2 ); total skin dose (mgy) and total fluoroscopy time during examination (minutes). Methods and materials 46 consecutive patients that underwent EVAR utilising conventional fluoroscopy in an angiography suite without IF capabilities (2D) were retrospectively compared to 50 consecutive patients that underwent EVAR after the introduction of IF capable angiography (IF3D). All procedures were performed at the same institution with the same operators. Exclusion criteria included thoracic or thoraco-abdominal EVAR, fenestrated EVARs and EVAR with a secondary procedure, e.g. Iliac Branch Device (IBD). Page 2 of 12

3 Parameters compared between the 2D and IF3D groups included contrast dose used (ml); total radiation dose (dose area product [DAP])(Gy/cm 2 ); total skin dose (mgy) and total fluoroscopy time during examination (minutes). Data distribution was non-parametric according to visual analysis and formal normality testing (D'Agostino & Pearson, Shapiro- Wilk and Kolmogorov-Smirnov test) and therefore a Mann-Whitney test was utilised for all continuous data. Images for this section: Fig. 1: Infra-renal abdominal aortic aneurysm EVAR using image fusion (IF); preprocedural CTA overlaid on real-time fluoroscopy. Video 1 - Catheter manipulation. IF image adjusts to alterations in table motion, gantry movements, field of view and source to image distance. Page 3 of 12

4 Fig. 2: Infra-renal abdominal aortic aneurysm EVAR using image fusion (IF); preprocedural CTA overlaid on real-time fluoroscopy. Video 2 - EVAR pre-deployment Digital Subtraction Angiography (DSA) to check for position of stent markers with respect to the renal ostia and the aneurysm neck. Page 4 of 12

5 Fig. 3: Infra-renal abdominal aortic aneurysm EVAR using image fusion (IF); preprocedural CTA overlaid on real-time fluoroscopy. Video 3 - EVAR Partial Deployment under IF. Fig. 4: Infra-renal abdominal aortic aneurysm EVAR using image fusion (IF); preprocedural CTA overlaid on real-time fluoroscopy. Video 4 - EVAR Partial Deployment DSA. Page 5 of 12

6 Results There were no significant differences in procedure success rates between the two groups. The IF3D group displayed a significant reduction in contrast volume administered (115 ml (95-140) vs 163 ml ( ), p=0.0002). (Fig 5) IF3D was associated with significant reduction in overall fluoroscopy time per procedure (20.4 minutes ( ) vs 31.6 minutes ( ), p<0.0001). (Fig 6) The IF3D cohort tended towards lower radiation dose as measured by total skin dose (855 mgy, ( ) versus 1303 mgy ( ), p=0.07), however, this was not statistically significant. (Fig 7) IF3D was associated with a similar radiation doses as measured as dose area produce (DAP) (22654 ( ) vs ( ), p=0.53) (Fig 8) Images for this section: Page 6 of 12

7 Fig. 5: The IF3D group displayed a significant reduction in contrast volume administered (115 ml (95-140) vs 163 ml ( ), p=0.0002) Page 7 of 12

8 Fig. 6: IF3D was associated with a significant reduction in overall fluoroscopy time per procedure (20.4 minutes ( ) vs 31.6 minutes ( ), p<0.0001) Page 8 of 12

9 Fig. 7: The IF3D cohort tended towards lower radiation dose as measured by total skin dose (855 mgy, ( ) versus 1303 mgy ( ), p=0.07), however, this was not statistically significant Page 9 of 12

10 Fig. 8: IF3D was associated with similar radiation doses as measured as dose area product (DAP) (22654 ( ) vs ( ), p=0.53) Page 10 of 12

11 Conclusion This study has demonstrated that the use of Image Fusion 3D angiography during EVAR within our institution is associated with a reduction in contrast volume dose, total fluoroscopy time, a trend towards decreased total radiation skin exposure, with similar total radiation dose (DAP) imparted to the patient and operators. The reduced contrast volume may decrease the incidence of contrast induced nephropathy (CIN) in vascular patients who often have impaired baseline renal function. In addition, if lower volumes of contrast have been used during the primary procedure, any secondary procedures do not need to be delayed due to concerns regarding CIN. Decreased fluoroscopy times may lead to overall procedure time reduction, which in turn may reduce the costs of performing EVAR. IF3D angiography would be even more beneficial to the patient and the operators if further efforts and research were aimed at reducing radiation dose. Personal information References 1. Gailloud P, Oishi S, Carpenter J, Murphy KJ. Three-dimensional fusion digital subtraction angiography: New reconstruction algorithm for simultaneous three-dimensional rendering of osseous and vascular information obtained during rotational angiography. Am J Neuroradiol 2005 Apr 26: Abi-Jaoudeh N, Kruecker J, Kadoury S, et al. Multimodality image fushionguided procedures: technique, accuracy, and applications. Cardiovasc Intervent Radiol 2012; 35: Haulon S, Hertault A, Maurel B, et al. Using Image Fusion During EVAR. Endovascular Today 2014 Feb, in press. 4. Taher V, Lin M, Desgrages P, e al. Image guidance for endovascular repair of complex thoracoabdominal aortic aneurysms: Comparison of two - dimensional and three-dimensional angiography and image fusion. J Vasc Interv Radiol Nov; 24(11): Kobeiter H, Nahum J, Becquemin JP. Zero-contrast thoracic endovascular aortic repair using image fusion. Circulation Sep 13; 124(11):e Page 11 of 12

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