Determinants of operator radiation exposure during percutaneous coronary procedures

doi:10.1016/j.ahj.2017.02.012

American Heart Journal

Volume 187, May 2017, Pages 10-18

https://doi.org/10.1016/j.ahj.2017.02.012 Get rights and content

Background

Radiation exposure is an important issue for interventional cardiologists that is often underevaluated. Our aim was to evaluate determinants of operator radiation exposure during percutaneous coronary procedures.

Methods

The RADIANT (NCT01974453) is a prospective, single-center observational study involving 4 expert operators and 2 fellows performing percutaneous coronary procedures. The operator radiation dose was evaluated using dedicated electronic dosimeters in 2,028 procedures: 1,897 transradial access (TRA; 1,120 right and 777 left TRA) and 131 transfemoral access (TFA).

Results

In the whole population, operator radiation dose at the thorax did not differ between TFA (9 μSv [interquartile range 5-18 μSv]) and TRA (9 μSv [4-21 μSv]), but after propensity score matching analysis, TFA showed lower dose (9 μSv [5-18 μSv]) compared with TRA (17 μSv [9-28 μSv], P < .001). In the whole transradial group, left TRA (5 μSv [2-12 μSv]) was associated with significant lower operator dose compared with right TRA (13 μSv [6-26 μSv], P < .001).The use of adjunctive protective pelvic drapes was significantly associated with lower radiation doses compared with procedures performed without drapes (P < .001). Among the operators, an inverse relation between height and dose was observed. Finally, left projections and the use of angiographic systems not dedicated for coronary and high frame rates were all associated with a significant higher operator radiation exposure.

Conclusions

In a high-volume center for transradial procedures, TFA is associated with lower operator radiation dose compared with TRA. The use of adjunctive anti-rx drapes seems a valuable tool to reduce the higher operator radiation exposure associated with TRA.

Graphical Abstract

Section snippets

Study design and population

The RAdiation Dose In percutANeuos Coronary Procedures Through Transradial Approach (RADIANT) study (NCT01974453) is a single-center prospective, observational study designed to evaluate radiation dose absorbed by operators during percutaneous coronary procedures using different vascular accesses.

All patients who underwent diagnostic or interventional percutaneous coronary procedures older than 18 years were eligible for the study. Only patients with hemodynamic instability were excluded.

All

Results

From October 2012 to January 2016, a total of 2,028 procedures performed in 1,508 patients were included in the study. Most procedures were performed through transradial access (94%) and only a minority through transfemoral approach (6%). Compared with radial approach, transfemoral access was preferred in patients with previous coronary artery bypass surgery and in patients with acute myocardial infarction (Table I). After propensity-matched analysis, the 2 groups did not show significant

Discussion

In our study, we investigated the determinants of operator radiation dose during percutaneous coronary procedures and the results of our work underline 3 important messages:

1.
The femoral access is associated with a significant lower operator radiation dose compared with the transradial approach even in operator with high experience in radial access.
2.
The left radial access is associated with a significant lower radiation dose compared with the right access, but this effect seems to be limited to

Conclusions

In our study, the use of the radial access for percutaneous coronary procedures, even if performed by expert transradial operators, is associated with a significantly higher operator radiation exposure compared with the femoral access. Consequently, transradial operators should use adjunctive measures, as the use of protective drapes, to reduce their radiation exposure.

The following are the supplementary data related to this article.

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Cited by (22)

Factors affecting radiation exposure during transradial cardiac catheterisation and percutaneous coronary intervention
2022, Clinical Radiology
Citation Excerpt :
Although there are concerns about possible increased radiation exposure,6 radial access (RA) has being adopted increasingly as the preferred vascular access in interventional cardiology over the last decade, mainly due to less severe bleeding, fewer access site complications, lower morbidity and mortality (especially in acute coronary syndromes), immediate mobilisation, and short hospital stay.7–11 Several studies have been conducted in the past (most of which include patients with transfemoral procedures) investigating possible factors that increase radiation exposure, demonstrating that patient age and body weight, C-arm model, access site and angioplasty, especially multivessel or complex lesions, are some of the factors increasing radiation.12–15 Another major concern in transradial procedures is RA side, as data are ambiguous and it is not clear which side (right or left) is preferable regarding radiation exposure.16–18
To evaluate the factors affecting radiation exposure using radial access (RA) including technical aspects and clinical characteristics.
Patients (n=6,967) who underwent coronary angiography (CA) with or without percutaneous coronary intervention (PCI), performed via a right or left RA were evaluated retrospectively. Data were evaluated in two different categories: diagnostic CA group and PCI group. The primary end-points of the study were fluoroscopy time (FT), dose–area product (DAP), and air kerma (AK).
Male sex and left RA were characterised by increased DAP and AK, in both the CA and PCI groups. In the CA group, body weight, height, body surface area (BSA), left RA, and male sex were independent prognostic factors of increased radiation. In the PCI group, body weight, height, BSA, left RA, male sex, and older age were independent prognostic factors of increased radiation while older age and left RA were independent prognostic factors for increased FT.
Radial side, gender, and the physical characteristics of the patients were factors that increased radiation exposure in patients undergoing transradial coronary procedures. Therefore, these factors should be taken into account to help minimise radiation exposure for both patients and operators.
Does reducing radiation levels for procedures affect image quality and radiation to proceduralists? A double-blinded randomised study of two protocols
2021, Clinical Radiology
Citation Excerpt :
The RaySafe monitor display, which provided real-time scattered radiation exposure, was placed outside the procedure room away from the study participants to avoid biases. A similar method of measuring scattered radiation exposure to proceduralists has been used in previous studies.7,8 Direct radiation exposures to patients, i.e., dose–area product (DAP) and cumulative dose (cumulative air kerma, CAK) per procedure, were recorded from the protocol report generated by the Artis One system.
To evaluate the ultra-lose dose imaging protocol (ULDP), compared to the standard low-dose imaging protocol (LDP), which are used for haemodialysis access, in terms of radiation exposure and image quality.
This was a single-centre, institutional review board-approved, prospective, double-blinded randomised controlled study to compare radiation exposure and image quality of the ULDP and LDP. Ten proceduralists, two radiographers, and 11 nurses were enrolled. Radiation exposure during 80 procedures (40 angioplasties and 40 thrombolysis) was recorded (direct radiation to patients from protocol report and scattered radiation to participants from the RaySafe i2 real-time dosimetry system). Baseline characteristics of procedure were recorded. Image quality was assessed subjectively using questionnaires based on the five-point Likert scale after each procedure.
Compared with LDP, the use of ULDP was associated with a significantly lower rate of radiation exposure to proceduralists, patients, and scrub nurses (0.506±0.430 versus 0.847±0.965 μSv/s, p=0.044; 0.571±1.284 versus 1.284±1.007 mGy/s, p<0.001; and 0.052±0.071 versus 0.141±0.185 μSv/s, p=0.005, respectively). No significant difference in image quality or duration of procedure was observed (all p values >0.05).
Compared with LDP, the use of ULDP was associated with a significantly lower rate of radiation exposure to proceduralists, patients, and scrub nurses without compromising the image quality or duration of procedure.
Staff radiation dose during percutaneous coronary procedures: Role of adjunctive protective drapes
2018, Cardiovascular Revascularization Medicine
Citation Excerpt :
The aim of our study was to evaluate staff radiation exposure during percutaneous coronary procedures and, in this setting, to evaluate if the use of adjunctive protective drapes placed on the patient could reduce staff radiation exposure. The RADIANT (RAdiation Dose In percutANeuos Coronary Procedures Through Transradial Approach) study (NCT01974453) is a single-centre prospective, observational study designed to evaluate radiation dose absorbed by operators during percutaneous coronary procedures using different vascular accesses [13]. Operator radiation exposure was measured using wearable personal electronic dosimeters (PM1610, Polimaster, Austria) and expressed in μSv.
The use of adjunctive protective drapes placed on the patient protects the operating physician from scatter radiation during percutaneous coronary procedures (PCP). No data are available on the effect of these drapes for staff members' radio-protection.
To evaluate staff radiation exposure during PCP and the effect of adjunctive protective drapes on dose reduction.
The RADIANT study (NCT01974453) is a prospective, observational study evaluating operator radiation exposure during PCP using electronic dosimeter. In a sub-group of procedures all the staff members (II operator, nurse circulator and technologist) were also equipped with a dedicated electronic dosimeter.
From a total of 2028 procedures included in the RADIANT study, staff members' doses were available for 122 procedures (67 coronarography and 55 percutaneous coronary interventions). Median fluoroscopy time was 306 s (Interquartile range 155–526 s) and the dose area product (DAP) was 18.0 Gy*cm² (10–35.5 Gy*cm²). The radiation exposure was highest for the operating physician (6.7 μSv) and progressively lower for the nurse circulator (1.8 μSv), the II operator (1 μSv) and the technologist (0.7 μSv, p < 0.001). Protective pelvic drapes were used in 43 procedures and associated with a lower radiation exposure for all staff members (14 μSv vs 2.2 μSv for operating physician, p < 0.001, 1.7 μSv vs 0.49 μSv for II operator, p < 0.001, 2.16 μSv vs 0.93 μSv for nurse circulator, p = 0.02 and 0.85 μSv vs 0.39 μSv for technologist, p = 0.01).
The use of adjunctive protective drapes is effective in reducing radiation protection for all staff members during PCP.
Staff knowledge of radiation protection in endovascular surgery
2018, Design Studies
Le personnel de chirurgie endovasculaire manipulant les amplificateurs de brillance est exposé aux rayonnements ionisants et doit s’en protéger. Les objectifs de ce travail étaient d’identifier les connaissances du personnel médical et paramédical vis-à-vis des effets des rayonnements ionisants et de vérifier la disponibilité des moyens de protection individuelle et collective.
Il s’agissait d’une étude transversale et descriptive réalisée auprès du personnel de chirurgie endovasculaire durant le mois de septembre 2017. Notre étude a porté sur deux volets : le premier basé sur une étude de poste pour relever les moyens de protection disponibles dans la salle opératoire et un deuxième volet basé sur un questionnaire distribué à tout le personnel et portant sur les connaissances concernant la radioprotection. Nous avons établi un score global des connaissances sur la radioprotection et nous avons recherché des corrélations entre le score et des paramètres socioprofessionnels.
Notre échantillon d’étude était de 85 travailleurs. Soixante-quatre ont répondu à notre questionnaire soit un taux de réponse de 75 %. Soixante-cinq pour cent étaient de sexe masculin. L’âge médian était de 34 ans (25–61). Trente-cinq pour cent étaient des chirurgiens, 34 % des infirmiers, 18 % des techniciens supérieurs et 13 % des ouvriers. Le score global des connaissances moyen était de 8,15/20 avec des extrêmes de 2 et de 18. Ce score augmentait significativement en fonction du grade et de l’ancienneté. Les moyens de protection étaient en nombre insuffisant.
Les connaissances du personnel de chirurgie endovasculaire concernant la radioprotection sont insuffisantes. Les moyens de radioprotection sont peu disponibles ce qui justifie la planification de séances de formation et de sensibilisation du personnel du bloc vis-à-vis du risque radiologique.
Image intensification exposes the endovascular surgery staff to ionizing radiation. The aim of this study was to determine awareness of ionizing radiation risks among personnel working in the endovascular surgery environment and the availability of radiation protection clothes and to propose appropriate corrective measures.
This descriptive study was performed in the endovascular operating theatre equipped with a mobile image intensifier unit in La Rabta vascular department in September 2017. We visited the endovascular theatre to identify the availability of radiation protection clothes. We used a questionnaire to identify personnel knowledge about ionizing radiation. We established a global score of knowledge to classify our population.
We identified 85 professionals exposed to ionizing radiation. Sixty-four of them (75%) responded to our questionnaire; 65% were male; median age was 34 years (range: 25–61). Endovascular theatre personnel were surgeons (35%), nurses (34%), qualified technicians (18%) and other department employees (13%). The mean global score of knowledge was 8.15/20 (2–18). This score increased significantly with grade and seniority (Kruskal–Wallis test).
In the present study, the results indicate insufficiency knowledge about radiation exposure among the endovascular staff and in radioprotection tools availability. In order to minimize all unnecessary radiation, attempts should be made to increase vascular theatre staff knowledge about radiation protection. Safety culture is a referral method to reduce radiation exposure as low as possible.
Determinants of radiation dose during right transradial access: Insights from the RAD-MATRIX study
2018, American Heart Journal
The RAD-MATRIX trial reported a large operator radiation exposure variability in right radial percutaneous coronary procedures. The reasons of these differences are not well understood. Our aim was to appraise the determinants of operator radiation exposure during coronary right transradial procedures.
Patient arrangement during transradial intervention was investigated across operators involved in the RAD-MATRIX trial. Operator radiation exposure was analyzed according to the position of the patient right arm (close or far from the body) and in relation to the size of the upper leaded glass.
Among the 14 operators who agreed to participate, there was a greater than 10-fold difference in radiation dose at thorax level (from 21.5 to 267 μSv) that persisted after normalization by dose-area product (from 0.35 to 3.5 μSv/Gy*cm²). Among the operators who positioned the instrumented right arm far from the body (110.4 μSv, interquartile range 71.5-146.5 μSv), thorax dose was greater than that in those who placed the instrumented arm close to the right leg (46.1 μSv, 31.3-56.8 μSv, P = .02). This difference persisted after normalization by dose-area product (P = .028). The use of a smaller full glass shield was also associated with a higher radiation exposure compared with a larger composite shield (147.5 and 60 μSv, respectively, P = .016).
In the context of the biggest radiation study conducted in patients undergoing transradial catheterization, the instrumented right arm arrangement close to the leg and greater upper leaded shield dimensions were associated with a lower operator radiation exposure. Our findings emphasize the importance of implementing simple preventive measures to mitigate the extra risks of radiation exposure with right radial as compared with femoral access.
Radiation dose to nurses, cardiologists, and patients during coronary angiography: a comparison of femoral and radial access
2022, European Journal of Cardiovascular Nursing

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: RCT No. NCT01974453.

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Clinical InvestigationDeterminants of operator radiation exposure during percutaneous coronary procedures

Background

Methods

Results

Conclusions

Graphical Abstract

Section snippets

Study design and population

Results

Discussion

Conclusions

Am J Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

Lancet

Int J Cardiol

Lancet

JACC Cardiovasc Interv

JACC Cardiovasc Interv

Am J Cardiol

JACC Cardiovasc Interv

Cardiovasc Revasc Med

Clinical Investigation
Determinants of operator radiation exposure during percutaneous coronary procedures