Digital variance angiography enables up to 80% reduction in stationary acquisition radiation dose during prostatic artery embolization: a prospective randomized trial

OBJECTIVES: Digital variance angiography (DVA) has demonstrated superior image quality compared to digital subtraction angiography (DSA), but its potential remains underexplored for complex procedures. MATERIALS AND METHODS: This prospective randomized controlled trial enrolled 70 patients (mean ± SD age: 69.23 ± 8.7, range 53-96) undergoing PAE between January and October 2023. Patients were randomized to normal dose (ND) DSA (n = 35) or ultra-low dose (ULD) DSA (n = 35), with the latter reducing target detector dose by 72% for stationary acquisitions only. Radiation dose analysis was limited to stationary acquisitions, as only these series were acquired using the modified low-dose protocol. Dose-area product (DAP), contrast-to-noise ratios (CNR), and visual image quality of DSA and DVA images were compared. Three experienced interventional radiologists conducted a randomized, blinded 5-point Likert evaluation of large and small vessels, tissue blush, and background noise. Statistical analysis included Mann-Whitney tests, Spearman correlation, Kendall Tau B, and Bangdiwala's B for interrater agreement. RESULTS: ratios of 3.85 in ND and 4.60 in ULD. DVA images achieved significantly higher scores for small vessels and tissue blush visualization (p < 0.001; CNR: 4.10 vs 2.88; Likert rating: 2.79 vs 1.58). CONCLUSION: DVA enables substantial radiation dose reduction in PAE while maintaining superior image quality versus DSA, potentially improving angiographic safety and efficacy. KEY POINTS: Question DVA is useful in reducing dose and enhancing image quality, yet it was not validated for complex angiographic procedures. Findings DVA provides better qualitative and quantitative image quality than DSA with reduced dose for prostatic artery embolizations. Clinical relevance DVA significantly improves image quality in Prostatic Artery Embolization compared to DSA, which allows up to 80% reduction in radiation burden to patients and interventionalists alike, while it also maintains diagnostic image quality.