SCAI multi‐society position statement on occupational health hazards of the catheterization laboratory: Shifting the paradigm for Healthcare Workers' Protection

Comprehensive radiation shield minimizes operator radiation exposure in coronary and structural heart procedures

OBJECTIVES

This study evaluated the efficacy of a novel comprehensive shield designed to minimize radiation exposure (RE) to Physicians performing coronary and structural heart procedures.

BACKGROUND

The Protego™ radiation shielding system (Image Diagnostics Inc., Fitchburg, Ma) is designed to provide comprehensive protection from RE and has been State certified sufficient to allow operators to perform procedures without orthopedically burdensome lead aprons.

METHODS

This single center two-group cohort study assessed the efficacy of this shield in a large number of cardiac procedures (coronary and structural), comparing operator RE compared to standard protection methods (personal lead apparel and "drop down" shield).

RESULTS

The Protego™ system reduced operator RE by 99 % compared to Standard Protection. RE was significantly lower at both "Head" level by thyroid median dose 0.0 (0.0, 0,0) vs 5.7 (2.9, 8.2) μSv (p < 0.001), as well as waist dose 0.0 (0.0, 0.0) vs 10.0 (5.0, 16.6) μSv (p < 0.001). "Zero" Total RE was documented by Raysafe™ in 64 % (n = 32) of TAVR cases and 73.2 % (n = 183) of the coronary cases utilizing Protego™. In contrast, standard protection did not achieve "Zero" exposure in a single case. These dramatic differences in RE were achieved despite higher fluoroscopy times in the Protego™ arm (11.9 ± 8.6 vs 14.3 ± 12.5 min, p = 0.015). Per case procedural exposure measured by Dose Area Product was higher in the Protego™ group compared to standard protection (115.4 ± 139.2 vs 74.9 ± 69.3, p < 0.001).

CONCLUSION

The Protego™ shield provides total body RE protection for operators performing both coronary and structural heart procedures. This shield allows procedural performance without the need for personal lead aprons and has potential to reduce catheterization laboratory occupational health hazards.

Updated Estimates of Radiation Risk for Cancer and Cardiovascular Disease: Implications for Cardiology Practice

This review aims to furnish an updated assessment of the societal healthcare load, including cancer and cardiovascular disease resulting from diagnostic radiologic operations. The previously projected additional cancer risk of 0.9% in a United States 2004 study referred to radiological conditions in 1996 with an X-ray exposure of 0.50 millisievert (mSv) per capita annually. Radiological exposure (radiology + nuclear medicine) has escalated to 2.29 mSv (2016) per capita per year. Low-dose exposures were previously assumed to have a lower biological impact, since they allow the DNA repair system to mitigate molecular damage. However, epidemiological data matured and disproved this assumption, as shown by updated cancer risk assessments derived from the World Health Organization 2013 and the German Institute of Radioprotection 2014 data. The risk of cardiovascular disease aligns within the same order of magnitude as cancer risk and compounds it, as shown by a comprehensive meta-analysis of 93 studies. The collective societal burden arising from the augmented risks of cancer and cardiovascular disease attributable to diagnostic radiology and nuclear medicine is higher than previously thought.

Radiation Exposure Using Rampart vs Standard Lead Aprons and Shields During Invasive Cardiovascular Procedures

Background

Radiation exposure during invasive cardiovascular procedures remains an important health care issue. Lead aprons and shields (LAS) are used to decrease radiation exposure but leave large portions of the body unshielded. The Rampart IC M1128 is a portable radiation shielding system that may significantly attenuate radiation exposure.

Methods

Catheterization laboratory teams were randomized in a 1:1 fashion to perform elective invasive cardiovascular procedures utilizing either traditional LAS or the Rampart IC M1128. Radiation exposure was measured using real-time dosimetry monitoring in prespecified anatomic locations on 3 operators (position 1: first operator/fellow; position 2: second operator/attending; and position 3: catheterization laboratory nurse/technologist). Radiation exposure was measured on a per-case basis.

Results

In total, 100 consecutive cases were randomized in this study (47 Rampart; 53 LAS). There was no difference in fluoroscopy time (12.3 minutes for Rampart vs 15.4 minutes for LAS; P = .52), dose area product (288 Gy⋅cm2 for Rampart vs 376.5 Gy⋅cm2 for LAS; P = .52), or scatter radiation (38.8 mRem for Rampart vs 46.8 mRem for LAS; P = .61) between the groups. There was significantly lower total body radiation (in milliroentgen equivalent man) exposure using the Rampart than that using LAS for each team member: position 1-0.1 mRem for Rampart vs 2.2 mRem for LAS; P < .001; position 2-0.1 mRem Rampart vs 3.2 mRem LAS; P < .001; and position 3-0.0 mRem for Rampart vs 0.8 mRem for LAS; P < .001.

Conclusions

During routine clinical procedures, the Rampart system significantly decreases total body radiation exposure compared with traditional LAS.

Comprehensive Shielding System Enhances Radiation Protection for Structural Heart Procedures

Background

This study of radiation exposure (RE) to physicians performing structural heart procedures evaluated the efficacy of a novel comprehensive radiation shield compared to those of traditional shielding methods. A novel comprehensive shielding system (Protego, Image Diagnostics Inc) has been documented to provide superior RE protection during coronary procedures compared to that provided by a standard "drop down" shield. The purpose of this study was to assess the efficacy of this shield in transcatheter aortic valve replacement (TAVR) procedures, which are associated with disproportionate RE to operators.

Methods

This single-center, 2-group cohort, observational analysis compared RE to the primary physician operator performing TAVR using the Protego shield (n = 25) with that using a standard drop-down shield with personal leaded apparel (n = 25). RE was measured at both thyroid and waist levels with a real-time dosimetry system (RaySafe i3, RaySafe) and was calculated on a mean per case basis. Data were collected on additional procedural parameters, including access site(s) for device implantation, per case fluoroscopy time, air kerma, and patient factors, including body mass index. Between-group comparisons were conducted to evaluate RE by group and measurement sites.

Results

The Protego system reduced operator RE by 99% compared to that using standard protection. RE was significantly lower at both the thyroid level (0.08 ± 0.27 vs 79.2 ± 62.4 μSv; P < .001) and the waist level (0.70 ± 1.50 vs 162.0 ± 91.0 μSv, P < .001). "Zero" total RE was documented by RaySafe in 60% (n = 15) of TAVR cases using Protego. In contrast, standard protection did not achieve zero exposure in a single case.

Conclusions

The Protego shield system provides superior operator RE protection during TAVR procedures. This shield allows operators to work without the need for personal lead aprons and has potential to reduce catheterization laboratory occupational health hazards.

Comprehensive Radiation Shield Minimizes Operator Radiation Exposure and Obviates Need for Lead Aprons

Background

The catheterization laboratory predisposes to occupational health hazards. Chronic radiation exposure (RE) direct injuries include a predilection to cataracts and concerns for cancers. Indirectly adverse effects underly the prevalence of orthopedic maladies in interventionists, linked to the burden of mandatory protective lead aprons. A novel comprehensive shielding system (Protego, Image Diagnostics Inc) has been validated in early studies to provide excellent radiation protection. The system is designed to reduce operator RE sufficient to eliminate the need for personal lead aprons. Recent system refinements offer potentially even greater degrees of protection. This clinical study evaluated the efficacy of this system.

Methods

This single-center 2-group cohort study compared physician operator RE utilizing the latest iteration of the Protego shield (n = 25 cases) or standard protection (personal leaded apparel and drop-down shield, n = 25 cases) during routine cardiac catheterization procedures. RE at both thyroid and waist levels were measured with a real-time dosimetry system (Raysafe) and calculated on a mean per case basis at both thyroid and waist levels. Additional parameters collected included procedure type, access site, per case fluoroscopy time, and patient factors including body mass index. Between-group comparisons were conducted to evaluate RE by group and measurement sites.

Results

Protection with Protego was superior to standard methods. Protego showed markedly lower RE at both the thyroid level (0.36 ± 0.86 vs 58.5 ± 50.2 μSv; P < .001) and the waist level (0.84 ± 2.99 vs 121.4 ± 171.2 μSv; P < .001. "Zero" total RE was documented in 68% (n = 17) of Protego cases; in contrast, standard protection did not achieve "zero" exposure in a single case.

Conclusions

The Protego shield system provides excellent RE protection to the physician operator, achieving "zero" RE in two-thirds of cases. RE was superior to standard protection methods. The magnitude of protection achieves state regulatory standards sufficient to allow operators to perform procedures without orthopedically burdensome lead aprons. This shield system has the potential to reduce occupational health hazards.

A novel comprehensive radiation shielding system eliminates need for personal lead aprons in the catheterization laboratory

OBJECTIVES

This clinical study evaluated the efficacy of a novel radiation shielding system for the cardiac catheterization laboratory designed to provide comprehensive protection that obviates the need for personal lead aprons.

BACKGROUND

Invasive Cardiologists are exposed to occupational health hazards related directly to radiation exposure (RE) and indirectly to the orthopedic burden of wearing only partially protective lead aprons. Innovations to reduce these risks are warranted. A novel comprehensive shielding system (Protego^TM , Image Diagnostics Inc, Fitchburg, Ma) has been validated in pre-clinical studies to provide excellent radiation protection, sufficient for the State of Michigan to certify it for use without need for personal lead aprons.

METHODS

This clinical analysis measured RE to a single Physician operator utilizing the Protego^TM shield (and not wearing personal lead apron) during routine cardiac catheterization procedures (diagnostic and interventional). RE was measured at both thyroid and waist level with a real-time dosimetry system (Raysafe^TM , Billdal, Sweden), calculated on a median per case basis (mrems). Additional parameters collected included procedure type, access site, per case fluoroscopy time, and patient factors including body mass index.

RESULTS

In n=98 cases (25% diagnostic, 75% interventional including 22% chronic total occlusions), median/case RE was 0.4 mrems (thyroid) and 0.2 mrems (waist). RE=0 in 12 cases. In no case did radiation exposure exceed 3.2 mrems.

CONCLUSION

The Protego^TM shield system provides excellent RE protection to the Physician operator, without the need for personal lead aprons and has the potential to reduce catheterization laboratory occupational health hazards.

Safety and Efficacy of Robotic-Assisted PCI

PURPOSE OF REVIEW

Robotics has been used in multiple areas of procedural medical intervention. Robotic percutaneous coronary intervention (PCI) has been available since 2004. Its adoption has been slow with initial application in simple cases.

RECENT FINDINGS

With increasing adoption, robotic PCI has been applied to a broader variety of coronary substrates with demonstration of safety and efficacy. Improvements in the robotic console with future generation devices should add to the utility of this platform. Robotic PCI advances the innovations in endovascular space into a different dimension, removing the dependence of the procedure on patient-operator ergonomics and likely operator skill.

A novel catheterization laboratory radiation shielding system: Results of pre-clinical testing

BACKGROUND

This pre-clinical study evaluated the efficacy of a novel shielding system to reduce scatter radiation in the cardiac catheterization laboratory.

METHODS

Using a scatter radiation phantom in a standard cardiac catheterization laboratory, a radiation physicist recorded radiation measurements at 20 reference points on the operator side of the table. Measurements were made with fluoroscopy and cine with the C-arm in the posterior-anterior (PA) and 40 degrees left anterior oblique (LAO) orientations. Scatter radiation doses were compared with and without use of the shielding system.

RESULTS

Use of the shielding system was associated with >94.2% reduction in scatter radiation across all reference points in the PA and LAO projections with fluoroscopy and cine. With the shielding system, dose reductions at the location of the primary operator ranged from 97.8% to 99.8%. At locations of maximum scatter radiation, use of the shielding system resulted in dose reductions ranging from 97.8% to 99.8% with fluoroscopy and from 97.9% to 99.8% with cine.

CONCLUSIONS

In this pre-clinical study, a novel radiation shielding system was observed to dramatically reduce scatter radiation doses. Based on these results, clinical testing is warranted to determine whether the shielding system will enable operators and staff to perform interventional procedures with less radiation exposure that may obviate the need to wear standard lead apparel.

INDEXING WORDS

Radiation safety; occupational health; occupational hazard.

SCAI expert consensus update on best practices in the cardiac catheterization laboratory: This statement was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) in April 2021

The current document commissioned by the Society for Cardiovascular Angiography and Interventions (SCAI) and endorsed by the American College of Cardiology, the American Heart Association, and Heart Rhythm Society represents a comprehensive update to the 2012 and 2016 consensus documents on patient-centered best practices in the cardiac catheterization laboratory. Comprising updates to staffing and credentialing, as well as evidence-based updates to the pre-, intra-, and post-procedural logistics, clinical standards and patient flow, the document also includes an expanded section on CCL governance, administration, and approach to quality metrics. This update also acknowledges the collaboration with various specialties, including discussion of the heart team approach to management, and working with electrophysiology colleagues in particular. It is hoped that this document will be utilized by hospitals, health systems, as well as regulatory bodies involved in assuring and maintaining quality, safety, efficiency, and cost-effectiveness of patient throughput in this high volume area.