Meta-analysis of Cumulative Radiation Duration and Dose During EVAR Using Mobile, Fixed, or Fixed/3D Fusion C-Arms

Purpose: To investigate the total fluoroscopy time and radiation exposure dose during endovascular aortic repairs using mobile, fixed, or fixed C-arms with 3-dimensional image fusion (3D-IF). Methods: A systematic search was performed to identify original articles reporting fluoroscopy time (FT) and the kerma area product (KAP) during endovascular aortic repairs. Data were grouped by noncomplex or complex (fenestrated, branched, or chimney) repairs and stratified by type of C-arm. The search identified 27 articles containing 51 study groups (35 noncomplex and 16 complex) that included 3444 patients. Random-effects meta-analysis and meta-regression models were used to calculate the pooled mean estimates of KAP and FT, as well as any effect of equipment or type of intervention. Results are presented with the 95% confidence interval and the statistical heterogeneity (I-2). Results: Within the noncomplex procedure studies, a significant (p<0.001) increase was found in the pooled mean KAP estimate in the fixed C-arm group (181 Gycm(2), 95% CI 129 to 233; I-2=99.7) compared with the mobile C-arm (78 Gycm(2), 95% CI 59.6 to 97.3; I-2=99.6). For complex cases, use of 3D-IF showed a significantly (p<0.001) lower mean KAP (139 Gycm(2), 95% CI 85 to 191; I-2=94%) compared to using fixed C-arms without 3D-IF (487 Gycm(2), 95% CI 331 to 643; I-2=94%). Conclusion: For equivalent fluoroscopy times, the use of a fixed C-arm in noncomplex procedures leads to higher patient radiation doses compared to a mobile C-arm. Complex procedures, which are predominantly performed using fixed C-arms, are associated with the highest radiation dose per intervention. Using fixed C-arms combined with 3D-IF techniques during complex cases might seem an adequate method to compensate for the higher radiation doses measured when a fixed C-arm is used.