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Computer-assisted study of the axial orientation and distances between renovisceral arteries ostia

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Purpose: Endovascular navigation in aortic, renal and visceral procedures are based on precise knowledge of arterial anatomy. Our aim was to define the anatomical localization of the ostia of renovisceral arteries and their distribution to establish anatomical landmarks for endovascular catheterization. Methods: Computer-assisted measurements performed on 55 CT scans and patients features (age, sex, aortic diameter) were analyzed. p values <0.05 were considered statistically significant. Results: The mean axial angulation of CeT and the SMA origin was 21.8° ± 10.1° and 9.9° ± 10.5°, respectively. The ostia were located on the left anterior edge of the aorta in 96 % of cases for the CeT and 73 % for the SMA. CeT and SMA angles followed Gaussian distribution. Left renal artery (LRA) rose at 96° ± 15° and in 67 % of cases on the left posterior edge. The right renal artery (RRA) rose at -62° ± 16.5° and in 98 % of cases on the right anterior edge of the aorta. RRA angle measurements and cranio-caudal RRA-LRA distance measurements did not follow Gaussian distribution. The mean distances between the CeT and the SMA, LRA, and RRA were 16.7 ± 5.0, 30.7 ± 7.9 and 30.5 ± 7.7 mm, respectively. CeT-SMA distance showed correlation with age and aortic diameter (p = 0.03). CeT-LRA distance showed correlation with age (p = 0.04). The mean distance between the renal ostia was 3.75 ± 0.21 mm. The RRA ostium was higher than the LRA ostium in 52 % of cases. RRA and LRA origins were located at the same level in 7 % of cases. Conclusion: Our results illustrate aortic elongation with ageing and high anatomical variability of renal arteries. Our findings are complementary to anatomical features previously published and might contribute to enhance endovascular procedures safety and efficacy for vascular surgeons and interventional radiologists.
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ANATOMIC BASES OF MEDICAL, RADIOLOGICAL AND SURGICAL TECHNIQUES
Computer-assisted study of the axial orientation and distances
between renovisceral arteries ostia
James Lawton
1
Joseph Touma
1
Jean Se
´ne
´maud
1
Paul de Boissieu
2
Julien Brossier
1
Hicham Kobeiter
3
Pascal Desgranges
1
Received: 9 March 2016 / Accepted: 15 June 2016 / Published online: 25 June 2016
ÓSpringer-Verlag France 2016
Abstract
Purpose Endovascular navigation in aortic, renal and vis-
ceral procedures are based on precise knowledge of arterial
anatomy. Our aim was to define the anatomical localization
of the ostia of renovisceral arteries and their distribution to
establish anatomical landmarks for endovascular
catheterization.
Methods Computer-assisted measurements performed on
55 CT scans and patients features (age, sex, aortic diame-
ter) were analyzed. pvalues \0.05 were considered sta-
tistically significant.
Results The mean axial angulation of CeT and the SMA
origin was 21.8°±10.1°and 9.9°±10.5°, respectively.
The ostia were located on the left anterior edge of the aorta
in 96 % of cases for the CeT and 73 % for the SMA. CeT
and SMA angles followed Gaussian distribution. Left renal
artery (LRA) rose at 96°±15°and in 67 % of cases on
the left posterior edge. The right renal artery (RRA) rose at
-62°±16.5°and in 98 % of cases on the right anterior
edge of the aorta. RRA angle measurements and cranio-
caudal RRA-LRA distance measurements did not follow
Gaussian distribution. The mean distances between the
CeT and the SMA, LRA, and RRA were 16.7 ±5.0,
30.7 ±7.9 and 30.5 ±7.7 mm, respectively. CeT-SMA
distance showed correlation with age and aortic diameter
(p=0.03). CeT-LRA distance showed correlation with
age (p=0.04). The mean distance between the renal ostia
was 3.75 ±0.21 mm. The RRA ostium was higher than
the LRA ostium in 52 % of cases. RRA and LRA origins
were located at the same level in 7 % of cases.
Conclusion Our results illustrate aortic elongation with
ageing and high anatomical variability of renal arteries.
Our findings are complementary to anatomical features
previously published and might contribute to enhance
endovascular procedures safety and efficacy for vascular
surgeons and interventional radiologists.
Keywords Visceral branches orientations Celiac trunk
Superior mesenteric artery Renal arteries Radiological
anatomy Endovascular navigation
Introduction
Endovascular treatment is the procedure of choice for
aortic aneurysms (AAA) and aorto-iliac or aortic branches
occlusive disease in cases with favorable anatomy [22].
Endovascular approach can also be used as an alternative
procedure in patients deemed unfit for open surgery [7].
Endovascular techniques are based on fluoroscopy-guided
intra-arterial navigation. Catheterization of renal and
digestive arteries is mandatory in numerous procedures
such as the treatment of renovisceral arteries stenosis or
aneurysms [22], para-renal and thoraco-abdominal aneur-
ysms repair [11] and selective embolization.
Target vessels ostia localization is often possible with
repeated contrast agent injections and prolonged radiation
time with, however, an increased morbidity of the
&James Lawton
jameslawton.ihp@gmail.com
1
Department of Vascular Surgery, Henri Mondor University
Hospital, 51 Avenue du Mare
´chal de Lattre de Tassigny,
94010 Cre
´teil, France
2
Department of Research and Innovation, Robert Debre
´
Hospital, Reims University Hospitals, rue du Ge
´ne
´ral Koenig,
51100 Reims, France
3
Department of Radiology, Henri Mondor University
Hospital, 51 Avenue du Mare
´chal de Lattre de Tassigny,
94010 Cre
´teil, France
123
Surg Radiol Anat (2017) 39:149–160
DOI 10.1007/s00276-016-1718-6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... In particular, the LRA originates from the anterolateral wall in 52%, from the lateral wall in 45%, and from the posterior wall of the aorta in 3% of cases [5]. Cadaveric studies have shown great variability in the distance between the ostia of origin of the CT, SMA, and RA, generally not exceeding the value of 10 mm [5][6][7][8], varying around an average of 6 mm between the SMA and the LRA [9][10][11] in studies based on in vivo computed tomography scans ( Figure 1). wall in most cases, whereas RAs originate from the lateral or anterolateral wall of the aorta. ...
... In particular, the LRA originates from the anterolateral wall in 52%, from the lateral wall in 45%, and from the posterior wall of the aorta in 3% of cases [5]. Cadaveric studies have shown great variability in the distance between the ostia of origin of the CT, SMA, and RA, generally not exceeding the value of 10 mm [5][6][7][8], varying around an average of 6 mm between the SMA and the LRA [9][10][11] in studies based on in vivo computed tomography scans (Figure 1). ...
... The risk factors most commonly reported for the occurrence of an iatrogenic injury of the SMA and/or CT during left nephrectomy/adrenalectomy are the close spatial relationship between renal and visceral arteries [5][6][7][8][9][10][11]; surgery indicated for large neoplasms of the left upper renal pole or left adrenal gland (Figure 2), extra-renal spread, or bulky hilar lymph node involvement [15,21]; surgery indicated for inflammatory renal diseases or completion nephrectomy after partial resection with perivisceral inflammatory adhesion to the aorta and its visceral branches [15]; morbid obesity [35]; and the surgeon's lack of experience [28,36]. ...
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Due to their proximity to the left renal hilum, injuries to the superior mesenteric artery and celiac trunk are still reported during left radical nephrectomy, whether performed via open, laparoscopic, or robotic methods. The aim of this 50-year narrative review is to emphasize the anatomical and pathophysiological bases, risk factors, and strategies for the prevention, diagnosis, and treatment of such injuries.
... In particular, the LRA originates from the anterolateral wall in 52%, from the lateral wall in 45% and from the posterior wall of the aorta in 3% of cases [5]. Cadaveric studies have shown great variability of the distance between the ostia of origin of CT, SMA, and RA, generally not exceeding the value of 10 mm [5][6][7][8], varying around an average of 6 mm between the SMA and the LRA [9][10][11] in studies based on in-vivo computed tomography scans (Figure 1). Moreover, the left renal vein (LRV) generally crosses the abdominal aorta anteriorly and courses posterior to the SMA in the crotch of the angle between the SMA and the aorta. ...
... Risk factors most commonly reported for the occurrence of a iatrogenic injury of the SMA and/or CT during left nephrectomy/adrenalectomy are: the close spatial relations between renal and visceral arteries [5][6][7][8][9][10][11]; surgery indicated for large neoplasms of the left upper renal pole or left adrenal gland (Figure 2), or with extra-renal spread or bulky hilar lymph node involvement [15,21]; surgery indicated for inflammatory renal diseases or completion nephrectomy after partial resection with perivisceral inflammatory adhesion to the aorta and its visceral branches [15]; morbid obesity [35]; lack of surgeon's experience [28,36]. ...
... Unfortunately, in the vast majority of cases the procedure continues after clipping and division of the misperceived LRA, and further intraoperative suspect of extra-renal arterial injury may arise because of: 1) venous engorgement of the renal stump of the divided left renal vein; 2) identification of a LRA anterior to the LRV; 3) atypical course of the artery (i.e., transversal); 4) arterial origin from the anterior aortic wall; 5) finding another artery after division of the first LRA (with preoperative imaging negative for multiple LRA); 6) impossibility of clear identification of the left aortic wall due to the disease (neoplastic and/or inflammatory). Considering the above-reported variability of origin of the RA close to the visceral vessels, therefore, the first measure for the prevention of iatrogenic arterial injuries is preoperative evaluation of the vascular anatomy of the kidneys before nephrectomy [22,39], using a computed tomography scan with intravenous contrast (Figure 5), which allows the number and course of renal arteries to be identified in 99% of cases [11,40]. In a non-negligible number of cases, however, the diagnosis is suspected later, once the nephrectomy is completed, due to the change in color of the small intestine induced by arterial hypoperfusion, or, even later in the postoperative course, due to the appearance of abdominal pain, metabolic acidosis and/or increased serum lactates due to intestinal necrosis. ...
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Due to their close anatomical and spatial relationships with left renal hilum, both superior mesenteric artery and celiac trunk injuries continue to be reported during left radical nephrectomy, either through an open, laparoscopic or robotic approach. The aim of this review, 50 years after the first reported cases, is to highlight anatomical and pathophysiological basis, risk factors, as well as diagnostic and therapeutic strategies for dealing with these injuries.
... The current study is the initial and unique imaging study to evaluate the vascular distances in children according to their age and gender. The mean distances between the origins of the CTR-SMA, CTR-RRA, CTR-LRA, and CTR-IMA were between 20% and 30% lower than those reported in adults [7][8][9]13 . Moreover, these distances increased significantly with age possibly related to aortic elongation with the age and body height of the children. ...
... Although not statistically significant, these distances were slightly longer among females probably due to the fact that girls in the pubertal and prepubertal periods tend to be taller than the boys. These findings were consistent with previously published results 8,14 . ...
... Our distance measurements were more than 20% lower than those reported in adults 9,14 . In the current study, the origin of the RRA was higher than LRA, which is in agreement with previous reports on adults 8 14 . In the present study, the distances between the aorta at the diaphragmatic region and the origins of the major branches in children were between 40% and 65% lower than those reported by Anamaria et al. 14 Moreover, these distances were significantly longer among females, which is in disagreement with the previous study 14 . ...
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Aim:The aim of the present study was to determine the normal distances between the origins of the major branches of the abdominal aorta, and their distances to the aorta at the diaphragmatic region and iliac bifurcation on multidetector computed tomography (MDCT) angiography in pediatric patients.Materials and Methods:The MDCT angiography scans obtained from 245 children aged between 0 and 18 years (mean age±standard deviation, 8.48±5.14 years) were retrospectively re-evaluated. The distances between the origins of the celiac trunk (CTR), superior mesenteric artery (SMA), right renal artery (RRA), left renal artery (LRA), and inferior mesenteric artery (IMA) were measured. The distance measurements between the aorta at the diaphragmatic region, iliac bifurcation, and the origins of the major branches (CTR, SMA, RRA, LRA, IMA) were performed as well.Results:The distances between the abdominal aorta and its branches were reported to vary in the age groups. All the distance measurements increased significantly with increasing age (p
... Tuổi trung bình nghiên cứu của chúng tôi thấp hơn so với nghiên cứu của các tác giả Panagouli [9] nhưng cao hơn của các tác giả Nguyễn Thị Thanh Thiên [6], Lawton [7] và Binit Sureca [8]. Về độ phân bố tuổi nghiên cứu của chúng tôi hẹp hơn tác giả Nguyễn Thị Thanh Thiên [6] nhưng rộng hơn tác giả Panagouli [9]. ...
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Đặt vấn đề: Hệ thống động mạch gan là một hệ động mạch có nhiều biến đổi giải phẫu khác nhau. Với sự phát triển và hữu ích của hình ảnh học, việc khảo sát giải phẫu mang đặc trưng dịch tễ giúp ích cho phẫu thuật nói chung và can thiệp nội mạch nói riêng. Mục tiêu nghiên cứu: (1) Khảo sát dạng phân nhánh động mạch gan trên chụp cắt lớp vi tính, (2) Tương quan giữa kích thước động mạch gan với tuổi, giới và dạng phân nhánh. Đối tượng và phương pháp nghiên cứu: Nghiên cứu mô tả cắt ngang, hồi cứu, người ≥ 18 tuổi, không mắc các bệnh ảnh hưởng đến giải phẫu động mạch gan được chụp cắt lớp vi tính vùng bụng có tiêm thuốc tương phản thì động mạch. Khảo sát mối tương quan giữa kích thước động mạch gan với tuổi, giới và dạng phân nhánh. Kết quả: Tuổi trung bình của đối tượng là 59,2 tuổi, nữ giới chiếm 42%, nam giới chiếm 58%. Dạng phân nhánh phổ biến nhất theo Michels là động mạch gan chung (ĐMGC) xuất phát từ động mạch thân tạng (dạng 1) chiếm tỉ lệ 94,9%. Đường kính trung bình của ĐMGC là 5,3 ± 1,0 mm. Chiều dài trung bình của ĐMGC là 34,9 ± 8,4 mm. Đường kính trung bình của động mạch gan riêng (ĐMGR) là 4,4 ±1,0 mm. ĐMGR có 96,6% nguyên uỷ từ ĐMGC, 3,4% trường hợp còn lại không có ĐMGR. Chiều dài ĐMGC tăng theo nhóm tuổi (p<0,05). Đường kính ĐMGC và đường kính ĐMGR ở nam lớn hơn nữ. Sự khác biệt có ý nghĩa thống kê (p<0,05). Kết luận: Do tần suất biến thể giải phẫu động mạch gan ngày càng cao. Nên hiểu rõ kiến thức giải phẫu của động mạch gan là cần thiết đối với bác sĩ lâm sàng, cũng như bác sĩ chẩn đoán hình ảnh.
... Trong khi nhiều nơi trên thế giới đã công bố các công trình nghiên cứu giải phẫu mạch máu gan bằng XQCLVT [6], [7], [8], [9], các nghiên cứu ở Việt Nam về vấn đề này vẫn còn hạn chế. Trên cơ sở đó, chúng tôi tiến hành nghiên cứu nhằm xác định các số đo chiều dài, đường kính mạch máu gan bao gồm hệ ĐMG, TMC và TMG. ...
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TÓM TẮTMục tiêu nghiên cứu: Xác định mối tương quan giữa các chỉ số kích thước của hệ động mạch gan (ĐMG), hệ tĩnh mạch cửa (TMC) và hệ tĩnh mạch gan (TMG) với các yếu tố tuổi, giới tính và dạng giải phẫu bằng hình x quang cắt lớp vi tính (XQCLVT).Phương pháp: Nghiên cứu hồi cứu, cắt ngang mô tả. Dân số chọn mẫu bao gồm 611 các bệnh nhân trưởng thành (344 nam, 277 nữ, tuổi trung bình 55,0 ± 13,1 tuổi), đến khám bệnh tại bệnh viện Đại học Y Dược (BV ĐHYD) tpHCM vì nhiều triệu chứng khác nhau từ tháng 08/2017 đến tháng 08/2018, được chụp XQCLVT vùng bụng có tiêm thuốc tương phản thỏa tiêu chuẩn chọn mẫu. Từ hình chụp XQCLVT lưu trên hệ thống PACS của bệnh viện, sử dụng các phần mềm xử lý hình ảnh để dựng hình hệ ĐMG, TMC và TMG nhằm xác định kích thước các mạch máu gan, mối tương quan giữa các chỉ số này với các yếu tố tuổi, giới tính và dạng giải phẫu.Kết quả: Ở hệ ĐMG, có mối tương quan giữa đường kính ĐMG chung và dạng phân chia giải phẫu cụ thể đường kính động mạch này ở nhóm biến thể nhỏ hơn so với nhóm có dạng giải phẫu thường gặp (p<0,05), chiều dài của ĐMGC tăng theo tuổi (p<0,05). Chúng tôi cũng tìm thấy mối tương quan thuận với mức độ mạnh (r = 0,77) giữa đường kính ĐMG chung và ĐMG riêng. Ở hệ TMC, chúng tôi không tìm thấy mối tương quan giữa dạng phân chia giải phẫu với kích thước TMC, chúng tôi xác định được các đường kính của hệ TMC (bao gồm TMC chính, TMC trái và TMC phải) giảm theo tuổi (p<0,05). Ở hệ TMG, không có mối tương quan giữa yếu tố tuổi, giới tính và dạng phân chia giải phẫu với các chỉ số kích thước của hệ TMG. Nghiên cứu cũng chỉ ra đa số các chỉ số đường kính của hệ ĐMG và TMC ở nam giới lớn hơn nữ giới (p<0,05).Kết luận: XQCLVT là phương tiện hữu hiệu trong việc đánh giá mối tương quan giữa kích thước mạch máu gan với các yếu tố tuổi, giới và dạng giải phẫu.
... Multiple renal arteries (MRA) were founded in 4.146 kidneys (19,95%) of the total. The number of MRA arriving to the kidney varied from two to six (Thomson et al., 1889;Satyapal et al., 2001;Sampaio et al., 1992;Saldarriaga et al., 2008;Ali-El-Dein et al., 2003;Katariya et al., 2015;Bordei et al., 2004;Raman et al., 2007;Çiçekcibaşi et al., 2005;Hung et al., 2012;Harrison et al., 1978;Ugurel et al., 2010;Kaneko et al., 2008;Virendra et al., 2010;Budhiraja, et al., 2013;Özkan et al., 2006;Natsis et al., 2014;Bouali et al., 2012;Stanca et al., 2009;Jacek et al., 2007;Kornafel et al., 2010;Aristotle et al., 2013;Tarzamni et al., 2008;Méndez López et al., 2014;Sofía et al., 2008;Olave et al., 2009;Shaikh et al., 2014;Vasi et al., 2015;Palmieri et al., 2011;Ayuso et al., 2006;Patil et al., 2001;Jee et al., 2008;Platt et al., 1997;Johnson et al., 2013;Soares et al., 2013;Talović et al., 2007;Munnusamy et al., 2016;Zağyapan et al., 2009;Saritha et al., 2013;Vatsala et al., 2014;Zăhoi et al., 2015;Tayyba et al., 2016;Refaat et al., 2013;Aragão et al., 2012;Calle Toro et al., 2016;Khamanarong et al., 2004;Aubert et al., 1975;Holden et al., 2005;Janschek et al., 2004;Costa et al., 2011;Tyson et al., 2011;Kapoor et al., 2011;Tao et al., 2013;Kok et al., 2008;Han et al., 1998;Chabchoub et al., 2011;Sezer et al., 2012;Lloyd et al., 1935;Vilhova et al., 2001;Gümüş et al., 2012;Mustafa et al., 2016;Lawton et al., 2017;Cases et al., 2017). ...
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... Aortic remodeling with ageing and important heterogeneity of visceral vessels distribution should be carefully studied in preoperative course and the patients must be evaluated by himself' measurements which may be variated by various factors such as age, hypertension, atherosclerosis and genetic (Lawton et al., 2016). Kornreich et al. remarked that the positions of the aortic branching (as well as common iliac bifurcation) and venous confluence showed a highly significant downward shift with increasing age and the shift was more pronounced in Gynecologic Oncology Reports xxx (2017) xxx-xxx GORE-00216; No. of pages: 2; 4C: ...
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Background We performed this study in order to investigate the shape of the origin of the celiac artery in maximum intensity projection (MIP) using routine 64 multidetector-row computed tomography (MDCT) data in order to plan for the implantation of an intra-arterial hepatic port system. Methods A total of 1,104 patients with hepatocellular carcinoma were assessed with MDCT. In the definition of the branching angle, the anterior side of the abdominal aorta was considered the baseline, and the cranial and caudal sides were designated as 0 and 180 degrees, respectively. The angles between 0 and 90 degrees and between 90 and 180 degrees from the cranial side were considered upward and downward, respectively, and the branching angle of the celiac artery was classified every 30 degrees. The subclavian arterial route was used for the implantation of an intra-arterial hepatic port system in patients with branching angles of 150 degrees or more (sharp downward). Results The median branching angle was (median ± standard deviation) 135 ± 23 (range, 51–174) degrees. The branching was upward in 77 patients (7%) and downward in 1,027 patients (93%). The branching was downward with an angle of 120 to150 degrees in most patients (n = 613). The branching was sharply downward with an angle of 150 degrees or more in 177 patients (16%). A total of 10 patients were referred for interventional placement of an intra-arterial hepatic port system. The subclavian arterial route was used for implantation of an intra-arterial hepatic port system in 2 patients with sharp downward branching. Conclusions The branching angle of the celiac artery can be easily determined by the preparation of MIP images from routine MDCT data. MIP may provide useful information for the selection of the catheter insertion route in order to avoid a sharp branching angle of the celiac artery.
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Background Surgeon radiation dose during complex fluoroscopically guided interventions (FGIs) has not been well studied. We sought to characterize radiation exposure to surgeons during FGIs based on procedure type, operator position, level of operator training, upper vs lower body exposure, and addition of protective shielding. Methods Optically stimulable, luminescent nanoDot (Landauer, Inc, Glenwood, Ill) detectors were used to measure radiation dose prospectively to surgeons during FGIs. The nanoDot dosimeters were placed outside the lead apron of the primary and assistant operators at the left upper chest and left lower pelvis positions. For each case, the procedure type, the reference air kerma, the kerma-area product, the relative position of the operator, the level of training of the fellow, and the presence or absence of external additional shielding devices were recorded. Three positions were assigned on the right-hand side of the patient in decreasing relative proximity to the flat panel detector (A, B, and C, respectively). Position A (main operator) was closest to the flat panel detector. Position D was on the left side of the patient at the brachial access site. The nanoDots were read using a microSTARii medical dosimetry system (Landauer, Inc) after every procedure. The nanoDot dosimetry system was calibrated for scattered radiation in an endovascular suite with a National Institute of Standards and Technology traceable solid-state radiation detector (Piranha T20; RTI Electronics, Fairfield, NJ). Comparative statistical analysis of nanoDot dose levels between categories was performed by analysis of variance with Tukey pairwise comparisons. Bonferroni correction was used for multiple comparisons. Results There were 415 nanoDot measurements with the following case distribution: 16 thoracic endovascular aortic repairs/endovascular aneurysm repairs, 18 fenestrated endovascular aneurysm repairs (FEVARs), 13 embolizations, 41 lower extremity interventions, 10 fistulograms, 13 visceral interventions, and 3 cerebrovascular procedures. The mean operator effective dose for FEVARs was higher than for other case types (P <.03), 20 μSv at position A and 9 μSv at position B. For all case types, position A (9.0 μSv) and position D (20 μSv) received statistically higher effective doses than position B (4 μSv) or position C (0.4 μSv) (P <.001). However, the mean operator effective dose for position D was not statistically different from that for position A. The addition of the lead skirt significantly decreased the lower body dose (33 ± 3.4 μSv to 6.3 ± 3.3 μSv) but not the upper body dose (6.5 ± 3.3 μSv to 5.7 ± 2.2 μSv). Neither ceiling-mounted shielding nor level of fellow training affected operator dose. Conclusions Surgeon radiation dose during FGIs depends on case type, operator position, and table skirt use but not on the level of fellow training. On the basis of these data, the primary operator could perform approximately 12 FEVARs/wk and have an annual dose <10 mSv, which would not exceed lifetime occupational dose limits during a 35-year career. With practical case loads, operator doses are relatively low and unlikely to exceed occupational limits.
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Detailed knowledge of the dimensions and shape of the main arteries of the body and how they change with age and disease is important for understanding arterial pathophysiology and improving minimally invasive devices to treat arterial diseases. Our goal was to describe and compare geometric remodeling of the aorta and peripheral arteries in the context of patient demographics and cardiovascular risk factors. Three-dimensional reconstructions of computed tomography angiography scans were performed in 122 subjects 5-93 years of age (mean 47 ± 24 years, 64 M/58 F). Best-fit arterial diameters, lengths, and tortuosity for the principle named arteries in the chest, abdomen, pelvis, and upper thigh were measured, and multiple linear regression analysis was performed to examine how these morphologic parameters associate with patient demographics and risk factors. Large elastic arteries increased their diameter, length, and tortuosity with age, whereas muscular arteries primarily became more tortuous. Demographics and risk factors explained >70% of the variation in diameters of the abdominal aorta, paravisceral aorta, and the aortic arch; and >75% of variation in tortuosity from the profunda femoris to the brachiocephalic artery. Male sex, larger body mass index, and hypertension contributed to larger diameters, whereas the presence of diabetes was associated with somewhat-straighter arteries. Overall, the effects of cardiovascular risk factors on geometric remodeling were small compared with those of demographics. The geometry of the vascular tree is greatly affected by aging, demographics, and some risk factors. Elastic and muscular arteries remodel differently, possibly as the result of differences in their microstructure. Copyright © 2015 Elsevier Inc. All rights reserved.
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Surgeon radiation dose during complex fluoroscopically guided interventions (FGIs) has not been well studied. We sought to characterize radiation exposure to surgeons during FGIs based on procedure type, operator position, level of operator training, upper vs lower body exposure, and addition of protective shielding. Optically stimulable, luminescent nanoDot (Landauer, Inc, Glenwood, Ill) detectors were used to measure radiation dose prospectively to surgeons during FGIs. The nanoDot dosimeters were placed outside the lead apron of the primary and assistant operators at the left upper chest and left lower pelvis positions. For each case, the procedure type, the reference air kerma, the kerma-area product, the relative position of the operator, the level of training of the fellow, and the presence or absence of external additional shielding devices were recorded. Three positions were assigned on the right-hand side of the patient in decreasing relative proximity to the flat panel detector (A, B, and C, respectively). Position A (main operator) was closest to the flat panel detector. Position D was on the left side of the patient at the brachial access site. The nanoDots were read using a microSTARii medical dosimetry system (Landauer, Inc) after every procedure. The nanoDot dosimetry system was calibrated for scattered radiation in an endovascular suite with a National Institute of Standards and Technology traceable solid-state radiation detector (Piranha T20; RTI Electronics, Fairfield, NJ). Comparative statistical analysis of nanoDot dose levels between categories was performed by analysis of variance with Tukey pairwise comparisons. Bonferroni correction was used for multiple comparisons. There were 415 nanoDot measurements with the following case distribution: 16 thoracic endovascular aortic repairs/endovascular aneurysm repairs, 18 fenestrated endovascular aneurysm repairs (FEVARs), 13 embolizations, 41 lower extremity interventions, 10 fistulograms, 13 visceral interventions, and 3 cerebrovascular procedures. The mean operator effective dose for FEVARs was higher than for other case types (P < .03), 20 μSv at position A and 9 μSv at position B. For all case types, position A (9.0 μSv) and position D (20 μSv) received statistically higher effective doses than position B (4 μSv) or position C (0.4 μSv) (P < .001). However, the mean operator effective dose for position D was not statistically different from that for position A. The addition of the lead skirt significantly decreased the lower body dose (33 ± 3.4 μSv to 6.3 ± 3.3 μSv) but not the upper body dose (6.5 ± 3.3 μSv to 5.7 ± 2.2 μSv). Neither ceiling-mounted shielding nor level of fellow training affected operator dose. Surgeon radiation dose during FGIs depends on case type, operator position, and table skirt use but not on the level of fellow training. On the basis of these data, the primary operator could perform approximately 12 FEVARs/wk and have an annual dose <10 mSv, which would not exceed lifetime occupational dose limits during a 35-year career. With practical case loads, operator doses are relatively low and unlikely to exceed occupational limits. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
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To analyze the variability of origin of the celiac trunk (CT), the superior mesenteric artery (SMA), the right renal artery (RRA), and the left renal artery (LRA) in terms of mutual distances, angle from the sagittal aortic axis (clock position), and ostial diameters on computed tomography angiographies (CTAs) in three groups of patients. One hundred and fifty CTAs of 50 patients with a non-dilated thoracoabdominal aorta (group A), 50 with thoracoabdominal aneurysm (B), and 50 with infrarenal aneurysm (C) were reviewed. The measurements performed on CTAs, as well as the patients' age, sex, and body surface area, were analyzed. p values <.05 were considered statistically significant. The clock position of the CT and the SMA, the diameters of all vessels, and the distance of the CT-SMA followed a Gaussian distribution. In contrast, the clock position of the renal vessels did not follow a normal distribution, and nor did the distances of the SMA-RRA, SMA-LRA, RRA-LRA or the distances between the renal arteries and the aortic bifurcation. The same values did not differ significantly among the three groups, with the exception of the distances between the renal arteries and the aortic bifurcation, significantly greater in group C. The clock position of the LRA and the distances of the SMA-LRA, SMA-RRA, RRA-LRA and between both renal arteries and the aortic bifurcation showed a significant correlation with the increase of aortic diameter. The anatomic variability of the origin of both the CT and the SMA in terms of clock position and mutual distances followed a Gaussian distribution, regardless of group. The same applies to the ostial diameters of renal and visceral vessels. In contrast, the origin of the renal vessels had a statistically significant heterogeneity that seemed to be correlated with the increase of aortic diameter in the mesenteric and renal aortic region. Copyright © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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To evaluate the feasibility of image fusion (IF) of preprocedural arterial-phase computed tomography with intraprocedural fluoroscopy for roadmapping in endovascular repair of complex aortic aneurysms, and to compare this approach versus current roadmapping methods (ie, two-dimensional [2D] and three-dimensional [3D] angiography). Thirty-seven consecutive patients with complex aortic aneurysms treated with endovascular techniques were retrospectively reviewed; these included aneurysms of digestive and/or renal arteries and pararenal and juxtarenal aortic aneurysms. All interventions were performed with the same angiographic system. According to the availability of different roadmapping software, patients were successively placed into three intraprocedural image guidance groups: (i) 2D angiography (n = 9), (ii) 3D rotational angiography (n = 14), and (iii) IF (n = 14). X-ray exposure (dose-area product [DAP]), injected contrast medium volume, and procedure time were recorded. Patient characteristics were similar among groups, with no statistically significant differences (P ≥ .05). There was no statistical difference in endograft deployment success between groups (2D angiography, eight of nine patients [89%]; 3D angiography and IF, 14 of 14 patients each [100%]). The IF group showed significant reduction (P < .0001) in injected contrast medium volume versus other groups (2D, 235 mL ± 145; 3D, 225 mL ± 119; IF, 65 mL ± 28). Mean DAP values showed no significant difference between groups (2D, 1,188 Gy·cm(2) ± 1,067; 3D, 984 Gy·cm(2) ± 581; IF, 655 Gy·cm(2) ± 457; P = .18); nor did procedure times (2D, 233 min ± 123; 3D, 181 min ± 53; IF, 189 min ± 60; P = .59). The use of IF-based roadmapping is a feasible technique for endovascular complex aneurysm repair associated with significant reduction of injected contrast agent volume and similar x-ray exposure and procedure time.
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Acute kidney injury (AKI) after any type of intervention negatively impacts mortality, length of hospitalization, and perhaps long-term survival. In the case of endovascular aneurysm repair (EVAR), the incidence of AKI ranges from 1% to 23% for elective and emergency procedures and is lower compared to open repair. The pathophysiology of AKI in EVAR is complex: contrast-induced nephropathy, renal microembolization, and acute tubular necrosis are all implicated. Prevention strategies include hydration, ischemic preconditioning, regional anesthesia, and pharmacological agents. There is no level I evidence regarding the prevention of AKI in EVAR, so this review sought to examine the mechanisms and prevention strategies for this potentially fatal complication.