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Advanced Robotic Angiography Systems for Image Guidance During Conventional Transarterial Chemoembolization

Impact on Radiation Dose and Image Quality

Vogl, Thomas J., MD*; Alizadeh, Leona S., MED*; Maeder, Richard, MS*; Naguib, Nagy N., MD*,†; Herrmann, Eva, PhD; Bickford, Matthew W., BS§; Burck, Iris, MD*; Albrecht, Moritz H., MD*

doi: 10.1097/RLI.0000000000000519
Original Articles

Objectives The aim of this study was to compare 2 advanced robotic angiography systems for real-time image guidance in terms of radiation dose and image quality (IQ) during conventional transarterial chemoembolization (C-TACE) of hepatic malignant tumors.

Materials and Methods One hundred six patients (57 women/49 men; mean age, 60 ± 11 years) who had undergone C-TACE using 2 generations of robotic angiography platforms for image guidance were included in this retrospective study. Patients were divided into 2 groups (n = 53, respectively): group 1 (first generation) and group 2 (second generation). Radiation dose for fluoroscopy and digital subtraction angiography (DSA) was compared between first-generation and second-generation angiography equipment, respectively. Among several features of the second-generation compared with the first-generation system, improvements included a refined crystalline detector system for enhanced noise reduction and advanced CARE filter software for lowering radiation dose. Radiation dose was measured using an ionization chamber. Image quality was assessed by 3 radiologists using 5-point Likert scales.

Results Both groups were comparable in terms of number and location of lesions, as well as body weight, body mass index, and anatomical variants of feeding hepatic arteries (all P > 0.05). Dose-area product (DAP) for fluoroscopy was significantly lower in group 2 (1.4 ± 1.1 Gy·cm2) compared with group 1 (2.8 ± 3.4 Gy·cm2; P = 0.001). For DSA, DAP was significantly lower (P = 0.003) in group 2 (2.2 ± 1.2 Gy·cm2) versus group 1 (4.7 ± 2.3 Gy·cm2). Scores for DSA IQ indicated significant improvements for group 2 by 30% compared with group 1 (P = 0.004). Regarding fluoroscopy, scores for IQ were 76% higher in group 2 compared with group 1 (P = 0.001). Good to excellent interrater agreement with Fleiss kappa coefficients of κ = 0.75 for group 1 and κ = 0.74 for group 2 were achieved.

Conclusions Most recent generation robotic angiography equipment allows for considerable radiation dose reductions while improving IQ in fluoroscopy and DSA image guidance during C-TACE treatment.

From the *Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany;

Department of Interventional and Diagnostic Radiology, Alexandria University, Alexandria, Egypt;

Department of Medicine, Institute of Biostatistics and Mathematical Modeling, Goethe University Frankfurt, Frankfurt, Germany; and

§Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC.

Received for publication July 16, 2018; and accepted for publication, after revision, September 4, 2018.

Thomas J. Vogl and Leona S. Alizadeh contributed equally to the manuscript and therefore share the first authorship.

Moritz H. Albrecht received speaker fees from Siemens and Bracco.

Conflicts of interest and sources of funding: none declared.

Correspondence to: Thomas J. Vogl, MD, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany. E-mail:

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