National Diagnostic Reference Levels for Endovascular Aneurysm Repair and Optimisation Strategies

Eur J Vasc Endovasc Surg . 2020 Dec;60(6):837-842. doi: 10.1016/j.ejvs.2020.08.006. Epub 2020 Sep 8.

Fecha de la publicación: 08/09/2020

Autor: Rodrigo Rial (1), Eliseo Vañó (2), Maria L Del Río-Solá (3), José M Fernández (4), Roberto M Sánchez (2), Lino A Camblor Santervás (5), Sergi Bellmunt (6), Estrella Blanco (7), Mehdi El Amrani Joutey (8), Elena González Cañas (9), Francisco J Gomez Palones (10), Jose A González Fajardo (11), Enrique González Tabares (12), Secundino Llagostera Pujol (13), Francisco Rielo Arias (14), Luis M Salmerón Febres (15), Claudia Aramendi Arieta-Araunabeña (16), Elena Iborra Ortega (17), Mercedes Guerra Requena (7)

Palabras clave: DRLs, European directive, EVAR, Optimisation, Patient dose



1Vascular Surgery Department, University Hospital Clinico San Carlos, Madrid, Spain. Electronic address:

2Medical Physics Service, Hospital Clínico San Carlos and IdISSC, Madrid, Spain; Radiology Department, Complutense University, Madrid, Spain.

3Vascular Surgery Department, University Hospital Clinico Valladolid, Valladolid, Spain.

4Medical Physics Service, Hospital Clínico San Carlos and IdISSC, Madrid, Spain.

5Vascular Surgery Department, Asturias Central Universitery Hospital, Oviedo, Spain.

6Vascular Surgery Department, University Hospital Vall D’hebron, Barcelona, Spain.

7Vascular Surgery Department, Guadalajara University Hospital, Guadalajara, Spain.

8Vascular Surgery Department, University Hospital Ramon y Cajal, Madrid, Spain.

9Vascular Surgery Department, University Hospital Parc Tauli, Sabadell, Spain.

10Head of Vascular Surgery, Vascular Surgery Department, University Hospital Dr. Peset, Valencia, Spain.

11Vascular Surgery Department, University Hospital 12 Octubre, Madrid, Spain.

12University Hospital of Canarias, Tenerife, Spain.

13Vascular Surgery Department, University Hospital German Trias y Pujol, Badalona, Spain.

14Vascular Surgery Department, University Hospital Lucus Augusti, Lugo, Spain.

15Vascular Surgery Department, University Hospital, San Cecilio, Granada, Spain.

16Vascular Surgery Department, Basurto Hospital, Bilbao, Spain.

17Vascular Surgery Department, University Hospital Bellvitge, L’Hospitalet de Llobregat, Spain.


Objective: The International Commission on Radiological Protection (ICRP) has highlighted the large number of medical specialties using fluoroscopy outside imaging departments without programmes of radiation protection (RP) for patients and staff. Vascular surgery is one of these specialties and endovascular aneurysm repair (EVAR) is one of the most challenging procedures requiring RP guidance and optimisation actions. The recent European Directive on Basic Safety Standards requires the use and regular update of diagnostic reference levels (DRL) for interventional procedures. The objective of the study was to know the doses of patients undergoing EVAR with mobile Xray systems and with hybrid rooms (fixed Xray systems), to obtain national DRLs and suggest optimisation actions.

Methods: The Spanish Chapter of Endovascular Surgery launched a national survey that involved hospitals for 10 autonomous communities representing the 77% of the Spanish population (46.7 million inhabitants). Patient dose values from mobile Xray systems were available from nine hospitals (sample of 165 EVAR procedures) and data from hybrid rooms, from seven hospitals, with dosimetric data from 123 procedures. The initial national DRLs have been obtained, as the third quartile of the median values from the different centres involved in the survey.

Results: The proposed national DRLs are 278 Gy cm2 for hybrid rooms and 87 Gy cm2 for mobile Xray systems, and for cumulative air kerma (cumulative AK) at the patient entrance reference point, 1403 mGy for hybrid rooms, and 292 mGy for mobile systems.

Conclusion: An audit of patient doses for EVAR procedures to identify optimised imaging protocol strategies is needed. It is also appropriate to evaluate the diagnostic information required for EVAR procedures. The increase by a factor of 3.2 (for kerma area product) and 4.8 (for cumulative AK) in the DRLs needs to be justified when the procedures are performed in the hybrid rooms rather than with mobile Xray systems.