Radiation Induced DNA Damage in Operators Performing Endovascular Aortic Repair

Abstract

BACKGROUND:Radiation exposure during fluoroscopically guided interventions such as endovascular aortic repair (EVAR) is a growing concern for operators. This study aimed to measure DNA damage/repair markers in operators perfoming EVAR. METHODS:Expression of the DNA damage/repair marker, γ-H2AX and DNA damage response marker, phosphorylated ataxia telangiectasia mutated (pATM), were quantified in circulating lymphocytes in operators during the peri-operative period of endovascular (infrarenal, branched, and fenestrated) and open aortic repair using flow cytometry. These markers were separately measured in the same operators but this time wearing leg lead shielding in addition to upper body protection and compared with those operating with unprotected legs. Susceptibility to radiation damage was determined by irradiating operators' blood in vitro.RESULTS: γ-H2AX and pATM levels increased significantly in operators immediately after branched endovascular aortic repair/fenestrated endovascular aortic repair (P<0.0003 for both). Only pATM levels increased after infrarenal endovascular aortic repair (P<0.04). Expression of both markers fell to baseline in operators after 24 hours (P<0.003 for both). There was no change in γ-H2AX or pATM expression after open repair. Leg protection abrogated γ-H2AX and pATM response after branched endovascular aortic repair/fenestrated endovascular aortic repair. The expression of γ-H2AX varied significantly when operators' blood was exposed to the same radiation dose in vitro (P<0.0001).CONCLUSIONS: This is the first study to detect an acute DNA damage response in operators performing fluoroscopically guided aortic procedures and highlights the protective effect of leg shielding. Defining the relationship between this response and cancer risk may better inform safe levels of chronic low-dose radiation exposure. 1,2 The growing number and complexity of procedures means that interventionists are exposed to higher amounts of radiation, a subject that is becoming increasingly topical. Radiation-Induced3-7 A recently published 15-year follow-up study of the EVAR trial, comparing endovascular and open aortic repair, reported an increased incidence of malignancy in patients treated by EVAR. 8 There is, rightly so, a significant focus currently on reducing the patients' exposure to radiation, but mounting evidence suggests that recurrent lowdose exposure to the practitioner is equally as important. Robust data collection to assess the risks posed to the interventionist is in its infancy, but a number of studies suggest a link to adverse health effects, including a higher risk of posterior subcapsular lens changes and malignancy.9-11 One recent study found a higher incidence of malignancy, including brain cancer, breast cancer, and melanoma, in interventionists who performed fluoroscopically guided procedures compared with those who had never performed these.12 A better understanding of the hazards of occupational radiation exposure requires sensitive tools to measure exposure at an individu...

Evaluation of patient and staff exposure with state of the art X‐ray technology in cardiac catheterization: A randomized controlled trial

“…Table shows that the OD measured by the leg dosimeter was much higher than for the chest dosimeter, which has been observed before by El‐Sayed et al for aortic repair procedures. Their study also showed that operators without additional leg shielding suffered acute DNA damage, as opposed to the operators equipped with additional leg shielding who did not show any acute DNA damage.…”

“…Their study also showed that operators without additional leg shielding suffered acute DNA damage, as opposed to the operators equipped with additional leg shielding who did not show any acute DNA damage. The leg doses measured by El‐Sayed et al (145 μSv) were in between the leg doses in room B of the current study (91.4 μSv) and the ones in room A (213 μSv). This highlights that also for less complex procedures like diagnostic coronary angiographies, the performing physicians may benefit significantly from additional leg shielding.…”

Fusion Imaging Significantly Reduces Contrast and Radiation Exposure During Standard EVAR

“…In contrast, 2D-3D registration with an initial DSA makes up for only 0.6% of dose area product. This is of note as major concerns of EVAR comprise occupational contrast and radiation exposure besides durability and rates of re-intervention [6,20,21]. Although radiation exposure is higher with complex EVAR cases (f/bEVAR), radiation protection during standard EVAR is essential since this procedure is more frequent and DNA damage of operators performing complex and standard EVAR cases has been observed [5,6].…”

“…Radiation exposure on the other hand may put patients and interventionalists at risk [4,5]. Acute radiation-induced DNA damage has been confirmed in operators performing EVAR cases [6]. Hence it seems important to reduce both radiation and contrast exposure during EVAR.…”

Peripheral vascular interventional advances in 2017

“…One team investigated DNA damage/ repair markers in operators without leg shielding and found elevated levels of DNA damage markers such as gamma-H2AX and phosphorylated ataxia telangiectasia in circulating lymphocytes. 43 Randomized trials have shown initial mortality benefit in also showed in patients with baseline renal dysfunction or coronary artery disease there was no benefit of EVAR even at first 6 months.…”