Impact of an extension tube on operator radiation exposure during coronary procedures performed through the radial approach

Intraoperative Staff Radiation Exposure During Aortic Endovascular Procedures

BACKGROUND

The risk of radiation exposure in the surgical operating room (OR) and/or catheterization laboratory is now well established. Complex endovascular procedures often require multiple approaches and different positioning of the staff members around the patient, potentially increasing the levels of radiations exposure. Our goal was to evaluate the levels of radiation exposure of the members of the staff during endovascular aortic procedures in order to propose radioprotection optimization.

METHODS

We included 41 aortic endovascular procedures out of 114 procedures performed between January 12, 2014, and August 31, 2015, including 24 standard endovascular aortic aneurysm repair (EVAR), 7 EVAR with iliac branch (EVARib), 8 complex fenestrated/branched EVAR (F/B EVAR), and 2 thoracic EVAR (TEVAR). Procedures were performed in an OR equipped with a carbon fiber table and a mobile fluoroscopy C-arm. We collected the usual dosimetry data given by the C-arm as well as the patient's peak skin dose (PSD). In all staff members, radiation exposure was measured with thermoluminescent chip dosimeters placed on both temples, on posterior sides of both hands, and on both lower legs.

RESULTS

PSD levels were low for EVAR because 24 patients had values below the reading threshold. PSD significantly increased with more complex procedures. Main operator (MO) received the higher level of irradiation on whole body, hands, and ankles. Eye lenses irradiation was higher on both assistant operators (AOs). Other members received low levels of irradiation. We found a high ranges of radiation exposure with a high risk of exposure for the AO, mainly for F/B EVAR and EVARib.

CONCLUSIONS

Even if all personal protections are used, staff positioning is a major point that must be considered. If MO is supposed to be the most exposed to X-rays, specific conditions of positioning of the AO may be at risk of exposure.

Safety and effectiveness of strategies to reduce radiation exposure to proceduralists performing cardiac catheterization procedures: a systematic review

OBJECTIVE

The objective of this systematic review was to synthesize the best available evidence on the effect of various radiation protection strategies on radiation dose received by proceduralists performing cardiac catheterization procedures involving fluoroscopy.

INTRODUCTION

Cardiac catheterization procedures under fluoroscopy are the gold standard diagnostic and treatment method for patients with coronary artery disease. The growing demand of procedures means that proceduralists are being exposed to increasing amounts of radiation, resulting in an increased risk of deterministic and stochastic effects. Standard protective strategies and equipment such as lead garments reduce radiation exposure; however, the evidence surrounding additional equipment is contradictory.

INCLUSION CRITERIA

Randomized controlled trials that compared the use of an additional radiation protection strategy with conventional radiation protection methods were considered for inclusion. The primary outcome of interest was the radiation dose received by the proceduralist during cardiac catheterization procedures.

METHODS

A three-step search was conducted in MEDLINE, CINAHL, Embase, and the Cochrane Library (CENTRAL). Trials published in the English language with adult participants were included. Trials published from database inception until July 2019 were eligible for inclusion. The methodological quality of the included studies was assessed using the JBI critical appraisal checklist for randomized controlled trials. Quantitative data were extracted from the included papers using the JBI data extraction tool. Results that could not be pooled in meta-analysis were reported in a narrative form.

RESULTS

Fifteen randomized controlled trials were included in the review. Six radiation protection strategies were assessed: leaded and unleaded pelvic or arm drapes, transradial protection board, remotely controlled mechanical contrast injector, extension tubing for contrast injection, real-time radiation monitor, and a reduction in frame rate to 7.5 frames per second. Pooled data from two trials demonstrated a statistically significant decrease in the mean radiation dose (P < 0.00001) received by proceduralists performing transfemoral cardiac catheterization on patients who received a leaded pelvic drape compared to standard protection. One trial that compared the use of unleaded pelvic drapes placed on patients compared to standard protection reported a statistically significant decrease (P = 0.004) in the mean radiation dose received by proceduralists.Compared to standard protection, two trials that used unleaded arm drapes for patients, one trial that used a remotely controlled mechanical contrast injector, and one trial that used a transradial protection board demonstrated a statistically significant reduction in the radiation dose received by proceduralists.Similarly, using a frame rate of 7.5 versus 15 frames per second and monitoring radiation dose in real-time radiation significantly lowered the radiation dose received by the proceduralist. One trial demonstrated no statistically significant difference in proceduralist radiation dose among those who used the extension tubing compared to standard protection (P = 1).

CONCLUSIONS

This review provides evidence to support the use of leaded pelvic drapes for patients as an additional radiation protection strategy for proceduralists performing transradial or transfemoral cardiac catheterization. Further studies on the effectiveness of using a lower fluoroscopy frame rate, real-time radiation monitor, and transradial protection board are needed.

Occupational radiation exposure in femoral artery approach is higher than radial artery approach during coronary angiography or percutaneous coronary intervention

Medical radiation exposure is a significant concern for interventional cardiologists (IC). This study was aimed at estimating the radiation exposure of IC operators and assistants in real clinical practice. The radiation exposure of the operator and assistant was evaluated by conducting two types of procedures via coronary angiography (CAG) and percutaneous coronary intervention (PCI) on 1090 patients in 11-cardiovascular centers in Korea. Radiation exposure was measured using an electronic personal dosimeter (EPD). EPD were attached at 3 points on each participant: on the apron on the left anterior chest (A1), under the apron on the sternum (A2), and on the thyroid shield (T). Average radiation exposure (ARE) of operators at A1, A2, and T was 19.219 uSv, 4.398 uSv, and 16.949 uSv during CAG and 68.618 uSv, 15.213 uSv, and 51.197 uSv during PCI, respectively. ARE of assistants at A1, A2, and T was 4.941 uSv, 0.860 uSv, and 5.232 uSv during CAG and 20.517 uSv, 4.455 uSv, and 16.109 uSv during PCI, respectively. AED of operator was 3.4 times greater during PCI than during CAG.

Strategies to Reduce Radiation Exposure in Electrophysiology and Interventional Cardiology

Clinical diagnosis sometimes involves the use of medical instruments that employ ionizing radiation. However, ionizing radiation exposure is a workplace hazard that goes undetected and is detrimental to patients and staff in the catheterization laboratory. Every possible effort should be made to reduce the amount of radiation, including scattered radiation. Implementing radiation dose feedback may have a role in reducing exposure. In medicine, it is important to estimate the potential biologic effects on, and the risk to, an individual. In general, implantation of cardiac resynchronization devices is associated with one of the highest operator exposure doses due to the proximity of the operator to the radiation source. All physicians should work on the principle of as low as reasonably achievable. Methods for reducing radiation exposure must be implemented in the catheterization laboratory. In this article, we review the available tools to lower the radiation exposure dose to the operator during diagnostic, interventional, and electrophysiological cardiac procedures.

Radiation exposure, the forgotten enemy: Toward implementation of national safety program

Radiation safety is an important counterpart in all facilities utilizing ionizing radiations. The concept of radiation safety has always been a hot topic, especially with the late reports pointing to increased hazards with chronic radiation exposure. Adopting a nationwide radiation safety program is considered one of the most urging topics, and is a conjoint responsibility of multiple disciplines within the health facility.

Randomized comparison of long and short vascular sheaths in reduction of the operator radiation exposure during uterine artery embolization

OBJECTIVE

To introduce a method in which a long sheath is used instead of the traditional short sheath, to reduce the radiation exposure of operators in uterine artery embolization (UAE).

METHODS

52 patients undergoing UAE were randomly divided into two groups before the procedure: an 11-cm short sheath was used in Group A (n = 25), and a 45-cm-long sheath was used in Group B (n = 27); the 45-cm-long sheath was only partly inserted such that the hub of the sheath was approximately 34 cm caudal to the groin puncture site. All the procedures were standard bilateral UAE operations through unilateral approach. The other parameters of the two groups were kept the same, including the fluoroscopy conditions and the pelvic radiation field size. The thermoluminescent personal dosemeters were attached to the left wrist and left outer side of the thyroid collar of the operator during each operation. The radiation exposure of the operator, procedure duration and fluoroscopy time of each procedure were recorded. Statistical analysis was performed using independent samples t-test.

RESULTS

The radiation exposure of both the left hand and thyroid of the operator was significantly reduced with the long sheath compared with the short sheath (89.5 ± 7.2 μGy vs 186.7 ± 12.6 μGy, p < 0.001, and 54.1 ± 5.5 μGy vs 63.9 ± 7.4 μGy, p < 0.001, respectively). No significant differences were found in the procedure duration and fluoroscopy time between the two groups (p > 0.1).

CONCLUSION

Using a long sheath in UAE could significantly reduce the radiation exposure to the interventionists without extending the procedure duration or fluoroscopy time.

ADVANCES IN KNOWLEDGE

For the first time, we introduce a simple and convenient method to reduce the radiation exposure of the operator in the UAE procedure.

Radiation protection methods for the interventionalist's hands: use of an extension tube

PURPOSE

Cumulative radiation exposure to the hands during certain interventional procedures may be high. It is important to decrease the amount of radiation to the operator due to the possibility of deterministic effects. We performed a pilot study to demonstrate a significant decrease in operator dose when using extension tubing (ET) in combination with shielding and collimation during a simulated percutaneous transhepatic cholangiogram (PTC) procedure.

METHODS

A whole body, anthropomorphic phantom was used to simulate the patient. A Unfors-Xi Survey detector (to measure scatter) supported by a retort stand and trolley was placed in various positions to simulate the position of hands and eyes/thyroid of an interventionalist. Radiation dose was measured simulating left and right-sided PTC punctures with and without a lead shield, and with and without ET.

RESULTS

Regarding the radiation dose to the hands; the use of an ET reduces dose by 54 % in right-sided PTC punctures without a shield and by 91 % if used in combination with a shield. For left-sided PTC punctures, ET reduces hand dose by 75 %. The use of collimation decreases hand dose by approximately 60 %. The use of shielding reduces dose to the eyes/thyroid by 98 %.

CONCLUSIONS

The dose to the hands can be significantly reduced with the appropriate use of a shield, ET, and tight collimation. The use of a shield is paramount to reduce dose to the eyes/thyroid. It is important for interventionalists to adhere to radiation protective practice considering the potential deterministic effects during a lifelong career.

Comparison of radiation dose to operator between transradial and transfemoral coronary angiography with optimised radiation protection: a phantom study

A growing concern in applying radial access in cardiac catheterisation is the increased operator radiation exposure. This study used an anthropomorphic phantom to simulate transradial and transfemoral coronary angiography with optimised radiation protection conditions. Operator radiation exposure was measured with thermoluminescent dosemeters at predefined locations. Compared with the femoral route, the radial route was associated with a dose decrease of 15 % at the operator's chest level with optimised radiation shielding. However, radiation exposure to the operator's hand remained significantly higher when applying radial access even with collective protective equipment used (by a factor of 2). Furthermore, the efficiency of operator radiation protection was found to be dependent on the tube incidence. Awareness should be raised about the significant increase of radiation exposure to operators' hands in transradial coronary angiography. Protection to reduce the dose level to the hands is necessary and should be further improved.

Reduction of operator radiation dose by a pelvic lead shield during cardiac catheterization by radial access: comparison with femoral access

OBJECTIVES

This study sought to determine the efficacy of patient pelvic lead shielding for the reduction of operator radiation exposure during cardiac catheterization via the radial access in comparison with the femoral access.

BACKGROUND

Cardiac catheterization via the radial access is associated with significantly increased radiation dose to the patient and the operator. Improvements in radiation protection are needed to minimize this drawback. Pelvic lead shielding has the potential to reduce operator radiation dose.

METHODS

We randomly assigned 210 patients undergoing elective coronary angiography by the same operator to a radial and femoral access with and without pelvic lead shielding of the patient. Operator radiation dose was measured by a radiation dosimeter attached to the outside breast pocket of the lead apron.

RESULTS

For radial access, operator dose decreased from 20.9 ± 13.8 μSv to 9.0 ± 5.4 μSv, p < 0.0001 with pelvic lead shielding. For femoral access, it decreased from 15.3 ± 10.4 μSv to 2.9 ± 2.7 μSv, p < 0.0001. Pelvic lead shielding significantly decreased the dose-area product-normalized operator dose (operator dose divided by the dose-area product) by the same amount for radial and femoral access (0.94 ± 0.28 to 0.39 ± 0.19 μSv × Gy(-1) × cm(-2) and 0.70 ± 0.26 to 0.16 ± 0.13 μSv × Gy(-1) × cm(-2), respectively).

CONCLUSIONS

Pelvic lead shielding is highly effective in reducing operator radiation exposure for radial as well as femoral procedures. However, despite its use, radial access remains associated with a higher operator radiation dose.

Operator Radiation Exposure During Percutaneous Coronary Procedures Through the Left or Right Radial Approach

Background—

Transradial percutaneous coronary procedures may be effectively performed through the right radial approach (RRA) or the left radial approach (LRA), but data on radiation dose absorbed by operators comparing the two approaches are lacking. The aim of the present study was to evaluate radiation dose absorbed by operators during coronary procedures through the RRA and LRA.

Methods and Results—

Three operators were equipped with 5 different dosimeters (left wrist, shoulder, thorax outside the lead apron, thorax under the lead apron, and thyroid) during RRA or LRA for coronary procedures. Each month, the dosimeters were analyzed to determine the radiation dose absorbed. From February to December 2009, 390 patients were randomly assigned to the RRA (185 patients; age, 66±11 years) or the LRA (185 patients; age, 66±11 years). There were no significant differences in fluoroscopy time (for RRA, 369 seconds; interquartile range, 134 to 857 seconds; for LRA, 362 seconds; interquartile range, 142 to 885 seconds; P =0.58) between the 2 groups. There were no significant differences in monthly radiation dose at the thorax (0.85±0.46 mSv for RRA and 1.12±0.78 mSv for LRA, P =0.33), at the thyroid (0.36±0.2 mSv for RRA and 0.34±0.3 mSv for LRA, P =0.87), and at the shoulder (0.73±0.44 mSv for RRA and 0.94±0.42 mSv for LRA, P =0.27). The dose at the wrist was significantly higher for the RRA (2.44±1.12 mSv) compared with the LRA (1±0.8 mSv, P =0.002). In both radial approaches, the thoracic radiation dose under the lead apron was undetectable.

Conclusions—

Compared with RRA, LRA for coronary procedures is associated with similar radiation dose for operators at the body, shoulder, or thyroid level, with a possible significant advantage at the wrist. The cumulative radiation dose for both approaches is well under to the annual dose-equivalent limit.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00282646.

Radiation exposure during cardiac catheterization: Implications for the transradial approach

Coronary angiography and intervention became an integral part of the modern cardiology. These invasive procedures beside their firmly established benefits also expose the patient to a hazard for access site complication, contrast material and radiation exposure. Transradial access significantly reduces the risk associated with the arterial puncture; however its effect regarding the radiation exposure is debated. Our aim was to review the aspects of transradial coronary intervention in the context of the radiation exposure. This review focuses on key aspects of feasibility and safety related to the access site choice and the learning curve.