does transradial intervention impact radiation exposure dr jim nolan university hospital of north...
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DOES TRANSRADIAL INTERVENTION IMPACT RADIATION EXPOSURE
Dr Jim Nolan
University Hospital of North Staffordshire
18/04/23 2
Mihran Kassabian (1870-1910)
RADIATION EXPOSURE IS IMPORTANTSkin injury due to cardiac intervention
RADIATION EXPOSURE IS IMPORTANTAccessory pathway ablation
3 weeks
5 months
6.5 months
OPERATORS ALSO GET RADIATION INDUCED SKIN INJURY
RADIATION EXPOSURE AND CANCER RISK
RADIATION IS IMPORTANT
If radial access is associated with a significant increase in radiation
exposure this will offset some of its other proven benefits and could limit
its applicability
Review of recent literature comparing radiation exposure in transfemoral and transradial cardiac catheterisation
Reference FA RA
No DAP (Gycm2)
FT (min) Rad Exp (uSv)
No DAP (Gycm2)
FT (min) Rad Exp (uSv)
Mann et al 1996 -PCI
126 8.8 138 13.5
Sandborg et al 2003 -CA
40 38±22 4.6±4 36 51±25 7.5±4
Sandborg et al 2003 –CA+PCI
42 47±34 12.5±9 24 75±47 18.4±9
Sandborg et al 2003 -All
82 43±29 8.6±8 60 61±37 11.9±9
Larrazet et al 2003 –ad hoc PCI
184 138 12 218 175 17
Geijer et al 2004 - PCI
114 69.8 16.4 55 70.5 18.1
Lange et al 2006 –CA
103 13.1±8.5 1.7±1.4 32±39 92 15.1±8.4 2.8±2.1 64±55
Lange et al 2006 -PCI
48 51±29.4 10.4±6.8 110±115 54 46.3±28.7 11.4±8.4 166±188
RADIAL ACCESS INCREASES RADIATION EXPOSURE FOR PATIENTS AND OPERATORS
Review of recent literature comparing radiation exposure in transfemoral and transradial cardiac catheterisation
Reference FA RA
No DAP (Gycm2)
FT (min) Rad Exp (uSv)
No DAP (Gycm2)
FT (min) Rad Exp (uSv)
Mann et al 1996 -PCI
126 8.8 138 13.5
Sandborg et al 2003 -CA
40 38±22 4.6±4 36 51±25 7.5±4
Sandborg et al 2003 –CA+PCI
42 47±34 12.5±9 24 75±47 18.4±9
Sandborg et al 2003 -All
82 43±29 8.6±8 60 61±37 11.9±9
Larrazet et al 2003 –ad hoc PCI
184 138 12 218 175 17
Geijer et al 2004 - PCI
114 69.8 16.4 55 70.5 18.1
Lange et al 2006 –CA
103 13.1±8.5 1.7±1.4 32±39 92 15.1±8.4 2.8±2.1 64±55
Lange et al 2006 -PCI
48 51±29.4 10.4±6.8 110±115 54 46.3±28.7 11.4±8.4 166±188
TRANSRADIAL APPROACHTHE LEARNING CURVE
• Puncture failure, spasm, different guide manipulation
Is it valid to compare experienced femoral operators with less experienced radial operators
4700
4200
3400
0
500
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FIRST 4/ 12 MIDDLE 4/ 12 LAST 4/ 12
DA
P
28% reduction in radiation exposure related to learning curve
Influence of learning curve on radiation exposure
0
10
20
30
40
50
Fem
Rad
DA
P G
ycm
2
PATIENT CHARACTERISTICS ARE IMPORTANT
FLUOROSCOPY MODE AND PATIENT MORPHOLOGY ARE IMPORTANT
PERIPHERAL VASCULAR DISEEASE ALSO IMPACTS ON RADIAL OPERATORS
MISMATCH OF PATIENT AND OPERATOR VARIABLES
INVALIDATE THE EXISTING OBSERVATIONAL STUDIES
RANDOMISED COMPARISON OF OPERATOR RADIATION EXPOSURE AND ACCESS SITE(Lange et al, CCI 2006, n = 297)
RADIAL FEMORAL PDIAGNOSTIC STUDIES
FT (mins) 2.8 1.7 <0.001
DAP (Gy.cm2) 15.1 13.1 <0.05
ORE (µSv.cm2) 64 32 <0.001
PERCUTANEOUS
FT (mins) 11.4 10.4 NS
DAP (Gy.cm2) 46.3 51.0 NS
ORE (µSv.cm2) 166 110 <0.05
USE OF ADDITIONAL RADIATION SCREENING(Tift Mann et al, JIC 1996, n = 264)
FEMORAL RAD-1 RAD-2
FLUORO TIME 16 19 18
(mins)
OPERATOR DOSE 8.8 13.5 3.3
PER CASE
(mrem/min)
The inadeqate radiation protection protocol imposed
on the radial operators invalidates the randomised
trial
WHAT CAN AN EXPERIENCED RADIAL OPERATOR ACHIEVE?
TRANSRADIAL PROCEDURES AT UHNS – RADIATION PROTECTION PROTOCOL
• Minimise screening and acquisition times, and use of oblique views
• Aduct arm after puncture
• Under and over table shields
• Extension tubing from catheter to manifold to optimise benefits of inverse square law
• Increased operator shielding (shin pads, glasses, hat)
FLUOROSCOPY TIMES OF PATIENTS UNDERGOING CA & PCI BY THE RADIAL AND FEMORAL ROUTES (UHNS PILOT DATA, N=300)
n=50 n=50
n=50 n=50
n=50 n=50
0
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4
6
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18
Tim
e (
se
c)
CA Single Vessel PCI Multi Vessel PCI
Fluoroscopy Time
Radial
Femoral
RADIATION DOSES OF PATIENTS UNDERGOING RADIAL AND FEMORAL PCI (UHNS PILOT DATA, N=200)
n=50 n=50
n=50 n=50
0
20
40
60
80
100
120
DA
P (
Gy
cm
2 )
Single Vessel PCI Multi Vessel PCI
Dose Area Product (DAP)
Radial
Femoral
Operator radiation exposure and access site – UHNS controlled study
0
5
10
Rad
Fem
0
5
10
Rad
Fem
μS
v
μS
v
EXPERT OPERATOR TRAINEE OPERATOR
P=NS P=NS
PCI OPERATIVE RADIATION EXPOSURE 2003 – 2004TLD BADGE READINGS - UHNS
0
5
10
15
A B C D E
CONCLUSION
• The existing literature is unreliable and invalid
• For an experienced operator employing good radiation protection practice……
• There is no radiation hazard to operators or patients