Significant Radiation Reduction Using Cloud-Based AI Imaging in Manually Matched Cohort of Complex Aneurysm Repair

Cloud-based, surgical augmented intelligence (Cydar Medical, Cambridge, United Kingdom) can be used for surgical planning and intraoperative imaging guidance during complex endovascular aortic procedures. We aim to evaluate radiation exposure, operative safety metrics, and postoperative renal outcomes following implementation of Cydar imaging guidance using a manually matched cohort of aortic procedures.

We retrospectively reviewed our prospectively maintained database of endovascular aortic cases. Patients repaired using Cydar imaging were matched to patients who underwent a similar procedure without using Cydar. Matching was performed manually on a 1:1 basis using anatomy, device configuration, number of branches/fenestrations, and adjunctive procedures including in-situ laser fenestration. Radiation, contrast use, and other operative metrics were compared. Preoperative and postoperative maximum creatinine was compared to assess for acute kidney injury (AKI) based on risk, injury, failure, loss of kidney function, and end-stage kidney disease (RIFLE) criteria.

Hundred patients from 2012 to 2023 were identified: 50 cases (38 fenestrated endovascular aortic repairs, 2 thoracic endovascular aortic repairs, 3 octopus-type thoracoabdominal aortic aneurysm repair, 7 endovascular aneurysm repairs) where Cydar imaging was used, with suitable matches to 50 non-Cydar cases. Baseline characteristics including body mass index did not differ significantly between the 2 groups (27.8 ± 5.6 vs. 26.7 ± 6.1; P = 0.31). Radiation dose was significantly lower in the Cydar group (2529 ± 2256 vs. 3676 ± 2976 mGy; P < 0.03), despite there being no difference in fluoroscopy time (51 ± 29.4 vs. 58 ± 37.2 min; P = 0.37). Contrast volume (94 ± 37.4 vs. 93 ± 43.9 mL; P = 0.73), estimated blood loss (169 ± 223 vs. 193 ± 222 mL; P = 0.97), and procedure time (154 ± 78 vs. 165 ± 89.1 min) did not differ significantly. Additionally, Cydar versus non-Cydar patients did not show a significant difference between precreatinine and postcreatinine changes (0.13 ± 0.08 vs. 0.05 ± 0.07; P = 0.34). Only one patient in the non-Cydar group met RIFLE criteria for AKI postoperatively.

The use of cloud-based augmented intelligence imaging was associated with a significant reduction in radiation dose in a cohort of matched aortic procedures but did not appear to affect other parameters or renal function. Even with advanced imaging, surgeons should remain conscientious about radiation safety and administration of nephrotoxic contrast agents.