At this year’s Critical Issues America annual meeting (Coral Gables, USA), Bijan Modarai (Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK) gave a progress update on forthcoming European Society for Vascular Surgery (ESVS) radiation safety guidelines for endovascular aneurysm repair (EVAR) procedures. He concluded by underlining his hope that the guidelines will “propel” research into some unanswered questions and “insist” on a benchmark for safety.
“While there is a plethora of guidance already published about best practice when it comes to radiation safety, very little of this is relevant specifically to vascular interventions,” Modarai began. As a result, the ESVS commissioned a committee to come up with some radiation safety guidelines, Modarai explained, adding that he co-chairs the committee with Stéphan Haulon (Aortic Centre, Groupe Hospitalier Paris Saint Joseph, hôpital Marie Lannelongue, Paris, France), with representation from the USA through Mark Farber (University of North Carolina Heath Care, Chapel Hill, USA).
Modarai explained that the committee had their first “kick-off” meeting in May 2019, during which the group decided on the key areas they felt should be included in the guidelines. These areas included the basics about radiation dosimetry, how to set up the operating environment, considerations for patients, staff exposure, and best radiation safety practice. He noted that the committee also had some discussion about what the future areas of research might be.
The first topic Modarai discussed at Critical Issues was reported exposures of radiation, which can vary “quite a lot”. He explained that the concept of diagnostic reference level (DRL)—an expected dose or amount of exposure for a specific procedure—does not apply to vascular procedures, while it does apply to other specialities. Therefore, one of the recommendations that is likely to come out in these guidelines, Modarai emphasises, is the need to standardise doses. “We need to start working groups at national level that looks at endovascular procedures and come up with what an expected exposure should be,” he explained.
Another recommendation is likely to suggest that a significant amount of the work pertaining to reducing exposure needs to come outside the operating theatre. “We now have access to 3D workstations, meaning we can perform detailed preoperative planning to get the angles correct to minimise radiation even before we get into the operating theatre,” Modarai detailed.
In terms of patient exposure, Modarai noted that ESVS guidelines have become increasingly patient-centred as a result of consultation with patient groups. In terms of these guidelines, he noted that the committee is going to put the recommendations to patients and make a point of finding out how the group can recommend more transparency about risk and joint decision-making when it comes to the possible consequences of radiation exposure during EVAR.
Modarai mentioned that an area which has been discussed in detail is exposure during pregnancy. “When you actually look at the exposure, the amount that the foetus receives is very, very small and the calculated increased risk of cancer or malformation to the foetus with these exposures is tiny,” he clarified, adding that “part of the duty we have is to inform and reduce anxiety about that”. Modarai elaborated that it is important to have a supportive environment to reduce that anxiety. Furthermore, there needs to be clarity on best practice and on the actual risks, but an acceptance that the dose rates can vary.
Tara Mastracci (Royal Free London NHS Foundation Trust, London, UK) commented that there should also be consideration of women who are not pregnant, as they “all carry ovaries for [their] entire lives”. “I would ask all of you to consider your young, junior, female colleagues, because very frequently the nurses in the operating room will have bespoke lead, but those of us who are juniors will not have this and, frequently, PPE [personal protective equipment] does not fit women as well as it does men,” she commented, urging the committee to “expand the guidelines a bit to talk about that”.
“I totally agree,” replied Modarai, adding that consideration of personalised protection will be an element of the recommendations. “We have got to get away from trainees having to use ‘make-do’ protection and introduce a minimum set that hospitals are required to have available. This is something that we will discuss in the guidelines I am sure.”
Considering how to reduce exposure to the operator in general, Modarai mentioned that the amount by which particular garments reduce exposure varies, and that this is also something the guidelines will address.
Following discussion of some of the key areas the recommendations will cover, Modarai also touched upon some of the areas of future research the committee believe need to be addressed, including the requirement for more data on the biological consequences of radiation exposure and individual sensitivity to radiation exposure. “We hope to propel some of this research by recommending more work in these areas,” Modarai explained.
“Maybe one day these guidelines will be redundant,” Modarai posited, noting current efforts to instigate radiation-free interventions, including FORS technology and the IOPS system, adding that these will be included in the guidelines.
At the end of the presentation, Farber added that the document the committee is putting together “will be the sort of document for you to take to your hospital and say ‘I need this protection’, because most of us across the world will not have that ability. It is not one document that will teach you every little thing about radiation safety, but it will give you the tools to go to your hospital and get what you need.”
“We need a minimum requirement that these guidelines will hopefully insist on,” Modarai concluded, adding that “hopefully we can update with some firm recommendations at the ESVS meeting later this year.”