An Optimized Ultra-Low-Dose Imaging Protocol for Endovascular Aortic Repair Significantly Reduces Radiation and
Bharti Singh1,2, Umar Sadat1,2, Angelos Karelis1,2
1Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Inga Marie Nilssons Gata 47, 214 28 Malmö, Sweden.
Abstract:
Objective: To evaluate the impact of a systematic, multi-component ultra-low-dose imaging protocol on radiation and contrast exposure during endovascular aortic repair (EVAR) across diverse anatomical complexities. Methods: In this retrospective cohort study, 331 consecutive EVAR procedures at a tertiary vascular center were analyzed. Patients treated with an integrated ultra-low-dose protocol (Group A, n = 228) incorporating 2D/3D fusion navigation, low-frame-rate fluoroscopy (3.75 frames/s), restricted digital subtraction angiography (DSA), structured collimation, and routine CO2 angiography were compared with historical controls treated with a standard low-dose protocol (Group B, n = 103) where the frame rate was the same and CO2 was only used for fusion registration. Primary endpoint was total dose-area product (DAP). Secondary endpoints included component DAP values, fluoroscopy time, contrast volume, and technical success. Results: Group A demonstrated a 71% reduction in median total DAP (57.9 vs. 199.3 Gy·cm2, p < 0.001), driven primarily by an 79% reduction in DSA-associated and 45% fluoroscopy-associated radiation. Contrast volume decreased by 20% (101 vs. 126 mL, p < 0.001) without increased fluoroscopy time (57 vs. 64 s, p = 0.278). Technical success remained comparable (86% vs. 87%, p = 0.809). Reductions were consistent across all repair types, most pronounced in infrarenal repairs with iliac-branch-devices (70% DAP reduction). Within Group A, a dose-response relationship was evident: procedures with ≥70% ultra-low-dose DSA utilization achieved 61% lower radiation than those with <70% adherence. Conclusions: A protocolized, system-level ultra-low-dose imaging workflow achieves substantial, durable reductions in radiation and contrast exposure during EVAR of varying complexity without compromising technical success. This integrated approach represents a scalable strategy for enhancing safety for patients and procedural staff alike.
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