A Systematic Review and Meta-Analysis of Peak Skin Dose Determination Methods during Standard and Complex...

Endovascular aneurysm repair (EVAR) is performed under real-time fluoroscopic guidance. Complex fenestrated and branched EVAR procedures may result in substantial localized radiation exposure to the patient's skin, with peak skin dose (PSD) being the most relevant metric for assessing deterministic radiation risk. Despite advances in dose monitoring technologies, no comprehensive synthesis of PSD during EVAR procedures exists.

A systematic review and meta-analysis was conducted according to PRISMA guidelines. PubMed, Scopus, and the Cochrane Library were searched without date restrictions for articles reporting PSD during EVAR. Risk-of-bias was assessed using Risk-of-Bias in Nonrandomized Studies of Interventions, and publication bias was evaluated with Egger's test. A random-effects model pooled mean PSD. Subgroup analyses compared PSD by determination method (direct versus indirect) and EVAR technique (standard versus complex).

Eleven articles comprising 19 study cohorts were included. Direct measurement methods (radiochromic films or thermoluminescent dosimeters) were used in ≈57.9% of reported PSD values, indirect methods (dose-area product (DAP) or reference air kerma (RAK) estimations) in ≈26.3%, and hybrid approaches in ≈15.8%. Reported PSD ranged from 63 mGy to 6,600 mGy. Meta-analysis showed that indirect methods yielded significantly higher pooled mean PSD than direct methods (3,115 mGy vs. 558 mGy; P < 0.001). No significant difference was observed between standard and complex EVAR (1,326 mGy vs. 2,719 mGy; P = 0.33). Heterogeneity was substantial (I² ≥ 94.9%).

A substantial discrepancy between indirect and direct PSD measurement methods during EVAR has been revealed. Indirect DAP- or RAK-based estimations yield significantly higher PSD values than direct measurements. No significant difference in PSD was observed between standard and complex EVAR procedures. Future research should prioritize prospective, multi-center studies with standardized, directly validated PSD measurement protocols.