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

1000

1500

2000

2500

3000

3500

4000

4500

5000

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

2

4

6

8

10

12

14

16

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