Dose Reduction Using Digital Fluoroscopy Versus Digital Subtraction Angiography in EVAR: A Prospective Randomized Trial.

Abstract Purpose Endovascular aneurysm repair (EVAR) can result in high radiation dose to patients and operators. This prospective randomized study aimed to assess whether patient radiation dose sustained during EVAR could be decreased by predominantly using digital fluoroscopy (DF) versus the standard technique using digital subtraction angiography (DSA). Materials and Methods Between February 2011 and June 2017, patients with EVAR of infrarenal abdominal aortic aneurysms were prospectively enrolled and randomly assigned to a standard-treatment DSA cohort or a DF cohort in which 2 or fewer DSA acquisitions were allowed for confirmatory imaging. Primary end points included dose area product (DAP) and cumulative air kerma (CAK). Secondary end points included technical success and conversion to DSA standard treatment (if DF was inadequate for visualization). Results For all 43 patients enrolled (26 in the DF cohort, 17 in the DSA cohort), technical success was 100%. Five of 26 DF patients (19%) required conversion to the DSA cohort. In an intention-to-treat analysis, mean DAP was significantly lower in the DF cohort than the DSA cohort (132 vs 174 Gy·cm2; P=.04). When separating patients by number of DSA acquisitions (≤2 vs ≥3), mean DAP decreased 41% (109 vs 185 Gy·cm2; P=.005) and CAK decreased 40% (578 vs 964 mGy; P=.004). Conclusion In most patients (81%), DF or limited DSA was adequate for visualization during EVAR. In both intention-to-treat DF and limited-DSA cohorts, mean DAP was significantly decreased. If image quality allows, a DF-only or limited-DSA approach to EVAR decreases radiation dose.