CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 4, September/October 2023 AFRICA 215 Discussion In this study, we investigated how the anatomical region of the arterial lesion, the complexity of the lesion, the patient’s BMI, age, type of endovascular intervention and preferred puncture point to reach the lesion affected the patient’s radiation dose. The most important factors affecting the radiation dose were the anatomical region, the patient’s BMI and the type of endovascular intervention. Pelvic interventions for aorta-iliac lesions had higher DAP values than interventions below the iliac ligament that included femoropopliteal lesions. Regarding high radiation doses in pelvic interventions, similar results were reported in studies by Boc et al.5 and Sigterman et al.6 The main reason for this is explained as follows: the mass and properties of the tissues exposed to radiation in the pelvic region direct the automatic exposure control of the X-ray system, which aims to keep the image brightness and contrast constant, to higher tube current and voltage and consequently to higher dose rates.7 The positive correlation between BMI values of our patients and DAP is consistent with this explanation (Figs 1, 2). Behrendt et al. reported that female and elderly patients had lower DAP values than males and younger patients.8 Considering that we also found a negative correlation between the ages of our patients and DAP values, it seemed to be consistent with our results. High radiation rates in the pelvic region, mainly due to tissue properties, require the avoidance of pelvic region radiation when choosing the approach preferences, especially in the revascularisation of femoropopliteal lesions. Using the contralateral approach only when there are valid reasons against the ipsilateral approach should be encouraged in view of the ‘as low as reasonably achievable (ALARA)’ principles.2 In our patients, we preferred the ipsilateral popliteal retrograde approach rather than the contralateral femoral retrograde approach in combined iliofemoral and long-segment total occlusions. Disadvantages of this method such as long stay in the prone position, development of popliteal pseudoaneurysm and arteriovenous fistula were mentioned.10 However, arteriovenous fistulae developed in only two of 78 patients in our series, and surgical operation was not required in these patients. There has been an increasing number of studies advocating that this method can be performed safely and effectively in the hands of operators with good Doppler ultrasonography experience.9,11 When the radiation doses were examined, the DAP value of the patients in whom we preferred the ipsilateral popliteal retrograde approach was found to be statistically higher than those in whom we preferred only the ipsilateral femoral antegrade approach. Considering that we mostly prefer the ipsilateral popliteal retrograde approach in patients with lesions of the common femoral artery, iliac artery or even bilateral lesions where ipsilateral femoral puncture is not possible, it can be concluded that our preference is safe in terms of radiation doses. Limitations The main limitation of our study was that it was a retrospective, single-centre study. Our number of contralateral femoral retrograde approaches could have been higher, but we believe that our ipsilateral femoral retrograde approach preference standards and the high success and low complication rates in the procedure affected this. The relatively low percentage of complex lesions could be attributed to the low DAP values in our study. Our angiographic equipment did not provide information about air kerma to the interventional reference point and we did not use this skin dose in our analysis. Conclusions The incidence of endovascular interventions for lower-extremity arteries are growing daily, and patient and operator radiation doses are increasing as more complex lesions are intervened. Therefore, attention should be paid to pre-operative planning, especially in patients undergoing multiple diagnostic and 34.0 32.0 30.0 28.0 26.0 24.0 22.0 20.0 DAP (Gy cm2) BMI 0 25.0 50.0 75.0 100.0 125.0 y = 25.22 + 0.08 x R2 linear = 0.302 Fig. 3. Correlation between BMI and DAP in the femoropopliteal region. 35.0 32.5 30.0 27.0 25.0 22.5 DAP (Gy cm2) BMI 0 20.0 10.0 60.0 y = 25.94 + 0.13 x R2 linear = 0.442 Fig. 4. Correlation between BMI and DAP in the pelvic region.
RkJQdWJsaXNoZXIy NDIzNzc=