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Stocker TJ, Abdel-Wahab M, Möllmann H, Deseive S, Massberg S, Hausleiter J. Trends and predictors of radiation exposure in percutaneous coronary intervention: the PROTECTION VIII study. EUROINTERVENTION 2022; 18:e324-e332. [PMID: 35076020 PMCID: PMC9912963 DOI: 10.4244/eij-d-21-00856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is indispensable in cardiology; however, exposure to potentially harmful ionising radiation remains a concern. AIMS This study was designed to assess the PCI-related radiation dose over the last decade and to identify predictors of increased dose exposure. METHODS The PROcedural radiaTion dose Exposure in percutaneous Coronary intervenTION (PROTECTION VIII) study included all PCIs reported to a German quality assurance programme between 2008 and 2018. Dose area product (DAP) and radiation time were analysed. Effective dose (ED) was estimated (ED=DAP*k; conversion coefficient k=0.0022 mSv/cGy*cm2). Multivariate linear regression analysis was used to identify predictors associated with a clinically relevant increase of radiation dose (ED ≥1 mSv). RESULTS We enrolled 3,704,986 patients undergoing PCI (median age 70 years, 30% female). Indications were chronic coronary syndrome (37.5%), unstable angina pectoris and non-ST-segment elevation myocardial infarction (non-STEMI; 33.2%) and STEMI (18.5%). Median DAP was 4,203 (interquartile range [IQR] 2,313-7,300) cGy*cm, ED was 9.2 mSv and median radiation time was 9.2 (IQR 5.8-15.0) min. Within the 10-year period, radiation exposure was reduced by 36% (p<0.001) and resulted in a median DAP of 3,070 cGy*cm (ED 6.8 mSv) in 2018. A significant 5.3-fold variability of median DAP was observed between catheterisation laboratories (p<0.001). We identified patient-related (gender, coronary artery bypass graft surgery, heart failure) and procedure-related (coronary occlusion PCI, ostial lesion PCI, left main PCI, multivessel PCI) predictors of increased radiation dose (all p<0.001). CONCLUSIONS This radiation dose survey demonstrates a considerable reduction of PCI radiation exposure during the last decade. However, large variability between catheterisation laboratories underlines the need for further radiation dose reduction.
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Affiliation(s)
- Thomas J. Stocker
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität, Marchioninistraβe 15, 81377 Munich, Germany
| | | | - Helge Möllmann
- Department of Internal Medicine, Medizinische Klinik 1, St. Johannes-Hospital, Dortmund, Germany
| | - Simon Deseive
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany,European Alliance for Medical Radiation Protection Research (EURAMED): The EURAMED rocc-n-roll project (www.euramed.eu)
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Lefèvre T, Mangiameli A, Hovasse T, Louvard Y, Benamer H, Garot P, Unterseeh T, Champagne S, Tavolaro O, Amelot S, Chevalier B. On-line estimated peak skin dose during percutaneous coronary intervention for chronic total occlusion using new patient dose mapping technology. Arch Cardiovasc Dis 2022; 115:436-447. [PMID: 35840491 DOI: 10.1016/j.acvd.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND X-ray exposure during complex percutaneous coronary intervention is a very important issue. AIM To reduce patient peak skin dose during percutaneous coronary intervention procedures for chronic total occlusion using on-line estimated peak skin dose software (Dose Map). METHODS Throughout the procedure, Dose Map provided a map of local cumulative peak skin dose. This map was displayed in-room from 1Gy cumulative air kerma, and was updated every 0.5Gy. The operator's actions to minimize deterministic risks following map notification were collected. Skin reaction was evaluated 3 months after the procedure. A comparison with our historical X-ray exposure data (207 patients from January 2013 to July 2014) was performed. RESULTS From November 2015 to October 2016, 97 patients (Japanese chronic total occlusion score 2.1±1.1; 100 percutaneous coronary intervention procedures for chronic total occlusion) were prospectively enrolled. Fluoroscopy time was 40.8 (21.6-60.3) minutes, cumulative air kerma 1884 (1144-3231) mGy, estimated peak skin dose 962 (604-1474) mGy and kerma area product 115.8 (71.5-206.7) Gy.cm2. Cumulative air kerma was>3Gy in 28% of cases, and>5Gy in 11% of cases. In 68% of cases, at least one action was taken by the operator after map notification to optimize skin dose distribution. Main changes included: gantry angulation (52%); field of view (25%); and collimation (13%). No skin injuries were observed at follow-up. In comparison with our chronic total occlusion historical radiation data, median cumulative air kerma and kerma area product were reduced by 31% and 33%, respectively (P<0.005. CONCLUSION Online skin dose mapping software allows the distribution of patient skin dose during complex percutaneous coronary intervention procedures, and may minimize X-ray exposure.
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Affiliation(s)
- Thierry Lefèvre
- Institut cardiovasculaire Paris Sud, hôpital Privé Jacques-Cartier, Ramsay Santé, 6 avenue du Noyer Lamber, 91300 Massy, France.
| | - Andrea Mangiameli
- Institut cardiovasculaire Paris Sud, hôpital Privé Jacques-Cartier, Ramsay Santé, 6 avenue du Noyer Lamber, 91300 Massy, France
| | - Thomas Hovasse
- Institut cardiovasculaire Paris Sud, hôpital Privé Jacques-Cartier, Ramsay Santé, 6 avenue du Noyer Lamber, 91300 Massy, France
| | - Yves Louvard
- Institut cardiovasculaire Paris Sud, hôpital Privé Jacques-Cartier, Ramsay Santé, 6 avenue du Noyer Lamber, 91300 Massy, France
| | - Hakim Benamer
- Institut cardiovasculaire Paris Sud, hôpital Privé Jacques-Cartier, Ramsay Santé, 6 avenue du Noyer Lamber, 91300 Massy, France
| | - Philippe Garot
- Institut cardiovasculaire Paris Sud, hôpital Privé Jacques-Cartier, Ramsay Santé, 6 avenue du Noyer Lamber, 91300 Massy, France
| | - Thierry Unterseeh
- Institut cardiovasculaire Paris Sud, hôpital Privé Jacques-Cartier, Ramsay Santé, 6 avenue du Noyer Lamber, 91300 Massy, France
| | - Stéphane Champagne
- Institut cardiovasculaire Paris Sud, hôpital Privé Jacques-Cartier, Ramsay Santé, 6 avenue du Noyer Lamber, 91300 Massy, France
| | - Oscar Tavolaro
- Institut cardiovasculaire Paris Sud, hôpital Privé Jacques-Cartier, Ramsay Santé, 6 avenue du Noyer Lamber, 91300 Massy, France
| | | | - Bernard Chevalier
- Institut cardiovasculaire Paris Sud, hôpital Privé Jacques-Cartier, Ramsay Santé, 6 avenue du Noyer Lamber, 91300 Massy, France
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Wilson-Stewart KS, Fontanarosa D, Malacova E, Trapp JV. Impact of dose reducing software on patient and staff temple dose during fluoroscopically guided pacemaker insertion, closure devices implantation and coronary angiography procedures. Phys Eng Sci Med 2022; 45:589-599. [PMID: 35532868 PMCID: PMC9239962 DOI: 10.1007/s13246-022-01126-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/03/2022] [Indexed: 11/03/2022]
Abstract
AbstractThe aim of this study is to investigate the effectiveness of dose reducing software (ClarityIQ) on patient and staff dose during fluoroscopically guided cardiac procedures. Dose measurements were collected in a room without dose reducing software (n = 157) and compared with similar procedures performed in two rooms with the software (n = 1141). Procedures included diagnostic coronary angiography, percutaneous coronary intervention, deployment of cardiac closure devices (for occlusion of atrial septal defect, patent foramen ovale, and atrial appendage) and insertion of permanent pacemakers. The dose reducing software was found to be effective in reducing patient and staff dose by approximately 50%. This study has added to the limited literature reporting on the capability of dose reducing software to decrease radiation exposure during the implantation of cardiac closure devices, as well as demonstrating a reduction in dose to the cardiologist and nursing staff. Administrators should ensure timely upgrades to angiographic equipment to safeguard patients and staff against the potentially adverse effects of radiation exposure. Regardless of the use of dose reducing software, the mean occupational dose during closure devices was in descending order scout > scrub > cardiologist. Scrub nurse dose was found to be higher than the cardiologist during closure devices (0.98/0.26 μSv) and diagnostic coronary angiograms (1.51/0.82 μSv). Nursing staff should be aware that their levels of radiation dose during some cardiac procedures may come close to or even exceed that of the cardiologist.
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Werner GS, Yaginuma K, Koch M, Tischer K, Silber M, Werner J, Keuser T, Moehlis H. Reducing fluoroscopic and cineangiographic contribution to radiation exposure for chronic total coronary occlusion interventions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 36:58-64. [PMID: 33931375 DOI: 10.1016/j.carrev.2021.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The treatment of chronic total coronary occlusions (CTO) carries the highest radiation exposure among percutaneous coronary interventions (PCI). In order to minimize radiation damage, we need to understand and optimize the contribution of all components of radiation exposure. METHODS A total of 1000 CTO procedures performed between 2011 and 2020 were compared according to implemented radiation modifications. Group 1 used the original set-up of the X-ray equipment (Artis Zee, Siemens). In group 2 a modified protocol aimed at reducing the fluoroscopy exposure, in group 3 further modifications aimed at reducing cineangiographic exposure. RESULTS Despite an increased lesion complexity, Air Kerma (AK) was reduced from 2619 mGy (1653-4574) in group 1 to 2178 mGy (1332-3500; p < 0.001) in group 2 by mainly reducing fluoroscopic contribution by 54.1%, the cineangiographic contribution was lowered by only 6.6%. In group 3 AK dropped drastically to 746 mGy (480-1225; p < 0.001) mainly by reducing the cineangiographic contribution by 53.4%, still there was a further reduction of fluoroscopy contribution of 8.2%. This also led to a reduction of the skin entry dose from 1038 mGy (690-1589) in group 2 to 359 mGy (204-591; p < 0.001) in group 3. This was achieved both in normal weight and obese patients, and both in antegrade and retrograde procedures. CONCLUSIONS The present study demonstrates that by modifying both the fluoroscopic and cineangiographic contribution to radiation exposure a drastic reduction of radiation risk can be achieved, even in obese patients. Currently accepted radiation thresholds may no longer be a limit for CTO PCI.
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Affiliation(s)
- Gerald S Werner
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany.
| | - Kenji Yaginuma
- Department of Cardiology, Juntendo University Urayasu Hospital, Tokyo, Japan
| | - Matthias Koch
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | | | - Martin Silber
- Institut für Radioonkologie und Strahlentherapie, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Juliane Werner
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Thomas Keuser
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Hiller Moehlis
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany
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Werner GS, Yaginuma K, Koch M, Tischer K, Silber M, Werner J, Keuser T, Moehlis H. Modulated radiation protocol achieves marked reduction of radiation exposure for chronic total coronary occlusion intervention. Catheter Cardiovasc Interv 2020; 97:1196-1206. [DOI: 10.1002/ccd.29132] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/10/2020] [Accepted: 06/20/2020] [Indexed: 11/05/2022]
Affiliation(s)
| | - Kenji Yaginuma
- Department of Cardiology Juntendo University Urayasu Hospital Tokyo Japan
| | - Matthias Koch
- Medizinische Klinik I Klinikum Darmstadt GmbH Darmstadt Germany
| | | | - Martin Silber
- Institut für Radioonkologie und Strahlentherapie Klinikum Darmstadt GmbH Darmstadt Germany
| | - Juliane Werner
- Medizinische Klinik I Klinikum Darmstadt GmbH Darmstadt Germany
| | - Thomas Keuser
- Medizinische Klinik I Klinikum Darmstadt GmbH Darmstadt Germany
| | - Hiller Moehlis
- Medizinische Klinik I Klinikum Darmstadt GmbH Darmstadt Germany
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Ison GR, Allahwala U, Weaver JC. Radiation Management in Coronary Angiography: Percutaneous Coronary Intervention for Chronic Total Occlusion at the Frontier. Heart Lung Circ 2019; 28:1501-1509. [DOI: 10.1016/j.hlc.2019.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 04/10/2019] [Accepted: 05/01/2019] [Indexed: 10/26/2022]
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Reiber JHC, Pereira GTR, Bezerra HG, De Sutter J, Schoenhagen P, Stillman AE, Van de Veire NRL. Cardiovascular imaging 2018 in the International Journal of Cardiovascular Imaging. Int J Cardiovasc Imaging 2019; 35:1175-1188. [DOI: 10.1007/s10554-019-01579-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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