Radial versus femoral access for coronary angiography and intervention is associated with lower patient radiation exposure in high-radial-volume centres: Insights from the RAY’ACT-1 study

Right Heart Catheterization: An Antecubital Vein Approach to Reduce Fluoroscopy Time, Radiation Dose, and Guidewires Need

Antecubital access for right heart catheterization (RHC) is a widespread technique, even though there is a need to clarify if there are differences and significant advantages compared to proximal vein access. To pursue this issue, we retrospectively identified patients who underwent RHC in our clinic over a 7 year period (between January 2015 and December 2022). We revised demographic, anthropometric, and procedural data, including the fluoroscopy time, the radiation exposure, and the use of guidewires. The presence of any complications was also assessed. In patients with antecubital access, the fluoroscopy time and the radiation exposure were lower compared to proximal vein access (6 vs. 3 min, mean difference of 2 min, CI 95% 1-4 min, p < 0.001 and 61 vs. 30 cGy/m2, mean difference 64 cGy/m2, CI 95% 50-77, p < 0.001). The number of patients requiring the use of at least one guidewire was lower in the group undergoing RHC through antecubital access compared to proximal vein access (55% vs. 43%, p = 0.01). The feasibility was optimal, as just 0.9% of procedures switched from antecubital to femoral access, with a negligible rate of complications. The choice of the antecubital site exhibits advantages, e.g., a shorter fluoroscopy time, a reduced radiation dose, and a lower average number of guidewires used compared to proximal vein access.

Update on Radiation Safety in the Cath Lab - Moving Toward a "Lead-Free" Environment

Radiation exposure in the cardiac catheterization laboratory (CCL) is an occupational hazard that predisposes health care workers to the development of adverse health effects such as cataracts, cancer, and orthopedic injury. To mitigate radiation exposure, personal protective shielding as well as permanently installed shields reduces these adverse effects. Yet, heavy protective lead aprons and poor ergonomics required for positioning movable shields remain barriers to a safer environment. Recent innovations to enhance personal protective equipment and revolutionize fixed shielding systems will permit the CCL team to work in a personal "lead-free" environment, markedly reducing occupational hazards. The purpose of this review is to update the status and future of radiation protection in the CCL.

Safety of clinical engineer-assisted percutaneous coronary intervention

Percutaneous coronary intervention (PCI) requires multiple staff members, including interventional cardiologists, with the physical burden of heavy protective measures to minimize radiation exposure. Here, we aimed to investigate the safety of task sharing with clinical engineers (CEs) working as 1st assistant during ad hoc PCI. We retrospectively included 286 patients who underwent ad hoc PCI following diagnostic catheterization for coronary artery disease between April 2019 and March 2021. Procedural complications including coronary perforation or rupture, myocardial infarction, cerebral embolism, cardiovascular death, decreased kidney function, and radiation parameters were compared between the two clinical settings [CE group, CEs as the 1st assistant from the beginning of diagnostic coronary angiography to the end of PCI vs. doctor (DR) group, others]. There was no increase in the ratio of procedural complications in the CE group (1.7%) versus the DR group (1.2%). Fluorescence time and radiation exposure dose were significantly reduced in the CE group {25 min [interquartile range (IQR), 19-35 min] vs. 28 min (IQR, 20-39 min), P = 0.036; 908 mGy (IQR, 654-1326 mGy) vs. 1062 mGy (IQR, 732-1594 mGy), P = 0.049}. The median amount of contrast medium was significantly reduced in the CE group [100 mL (IQR, 80-119 mL) vs. 110 mL (IQR 90-140 mL), P < 0.001]. After propensity matching, fluorescence time, radiation exposure dose, and contrast medium amount were similar between groups. Task sharing with CEs as the 1st assistant during ad hoc PCI could contribute to clinical safety in patients with coronary artery disease.

Impact of a medical supply bulk-buy program on treatment of patients with coronary artery disease in China: A single-center study

BACKGROUND

The Chinese government recently introduced a program to buy medical supplies in bulk to reduce the patient cost burden. For patients undergoing percutaneous coronary intervention (PCI), little is known about the effect on outcomes of this bulk-buy program.

AIMS

This study investigated whether the bulk-buy program to decrease the price of stents used in PCI affected clinical decision-making and outcomes.

METHODS

This single-center study enrolled patients undergoing PCI from January 2020-December 2021. Prices decreased for stents on January 1, 2021, and balloons on March 1, 2021. Patients were grouped by surgical year as either before (2020) or after (2021) policy implementation. All clinical data were collected. To examine whether clinical decision-making for PCI was affected by the bulk-buy program, procedure appropriateness was analyzed using the 2017 appropriate use criteria (AUC). To assess outcomes, the rates of major adverse cardiac and cerebrovascular events (MACCE) and complications were compared between groups.

RESULTS

Study participants were 601 patients in 2020 (before bulk buying) and 699 patients in 2021 (after bulk buying). Results of analysis by AUC for procedure appropriateness were 74.5% appropriate, 21.6% may be appropriate, and 3.8% rarely appropriate in 2020, with no differences for patients who underwent PCI in 2021. Between-group comparisons showed MACCE rates of 0.5% in 2020 and 0.6% in 2021, whereas complication rates were 5.5% and 5.7%, respectively. No statistically significant differences were found between groups (p > 0.05).

CONCLUSION

The bulk-buy program did not impact physician clinical decision-making or surgical outcomes for patients undergoing PCI.

Prevention and Management of AKI in ACS Patients Undergoing Invasive Treatments

PURPOSE OF REVIEW

Management of patients presenting with acute coronary syndrome (ACS) includes invasive procedures that may increase the risk of acute kidney injury (AKI). AKI adversely affects the outcomes of such procedures and complicates the management of ACS. We have summarized several strategies for the prevention and management of AKI in this critical patient group including in the pre-procedural, intraprocedural, and post-procedural settings.

RECENT FINDINGS

Definitive prevention and management strategies for AKI in patients presenting with ACS requiring invasive management can be confounded by the variation in data outcomes. Pre-procedural hydration with normal saline when accounting for time to catheterization, radial artery access, contrast stewardship, and close monitoring of renal function after catheterization should be implemented.

Occupational and Patient Radiation Dose and Quality Implications of Femoral Access Imaging During Coronary Angiography

Purpose

Cardiologists often perform angiography of the common femoral artery (CFA) access site to evaluate whether the anatomy is suitable for deployment of a vascular closure device or to assess whether iatrogenic vessel damage has occurred. The choice of acquisition mode has radiation dose implications. The objective of this study was to investigate the influence of the selected type of CFA x-ray imaging mode (fluoro save, cine acquisition and digital subtraction angiography (DSA)) and tube angle on patient and staff dose during coronary angiography.

Materials and Methods

Assessment of image quality for the different modes was performed to determine whether lower dose modes provide images of sufficient clinical quality to be routinely employed. Radiation dose levels for the patients (n=782), cardiologists (n=17), scrub nurses (n=27) and scout nurses (n=32) were measured in a prospective single-centre study between February 2017 and August 2019. Three Philips angiographic units and DoseAware dose monitoring systems were used.

Results

Among the acquisition modes, fluoro save provided acceptable diagnostic quality for visualizing femoral access points and diagnosing pathology in 99% of cases. Average patient dose area product (DAP) was 83.95, 742.50, and 3363.41mGy² and average patient air kerma (AK) was 0.87, 8.44, and 18.61mGy for fluoro save, cine, and DSA acquisitions, respectively. The use of higher dose imaging modes, imaging in the contralateral view and utilizing steeper TA was associated with a higher patient dose. Due to staff dose being highly correlated with DAP and AK, it was difficult to observe any association between staff dose and CFA imaging mode. However, this does not discount a potential increase in occupational dose due to the use of cine angiography or digital subtraction angiography during CFA imaging.

Conclusion

DSA of the CFA should be avoided during transfemoral coronary angiography unless critical to diagnostic analysis. It is recommended that fluoroscopic operators consider utilizing lower dose modes in the ipsilateral orientation ≤32° TA to reduce the risk of patient and staff radiation exposure.

Point your SmartPhone at the code above. If you have a QR code reader, the video abstract will appear. Or use:

https://youtu.be/fkaiBXXpPsE

Guipi decoction for coronary heart disease: A protocol for a systematic review and meta-analysis

BACKGROUND

Coronary heart disease (CHD) is the leading cause of morbidity and mortality worldwide. Guipi Decoction (GPD) is a classical traditional Chinese medication used to treat CHD. However, systematic review and meta-analysis regarding its efficacy and safety has not been systematically evaluated. The objective of this protocol is to determine the efficacy and safety of GPD in the treatment of CHD.

METHODS

Randomized controlled trials evaluating the effectiveness and safety of GPD in the treatment of CHD will be retrieved from 8 electronic databases, including PubMed, EMBASE, Cochrane Library, Web of science, China National Knowledge Infrastructure Database, VIP Database, Wanfang Database and China Biology Medicine Database. Study selection, data collection, risk of bias assessment, and evaluation of the quality of evidence will be performed in order. Data will be analyzed by RevMan V.5.3.5 software.

RESULTS

This study will evaluate the efficacy and safety of GPD in the treatment of CHD.

CONCLUSION

This systematic review will provide evidence for determining whether or not GPD is an effective and safe intervention for CHD.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD 42020156420.

Is trans-radial approach related to an increased risk of radiation exposure in patients who underwent diagnostic coronary angiography or percutaneous coronary intervention? (The SAKARYA study)

OBJECTIVE

It is still debatable whether diagnostic coronary angiography (CA) or percutaneous coronary interventions (PCIs) increase radiation exposure when performed via radial approach as compared to femoral approach. This question was investigated in this study by comparison of dose-area product (DAP), reference air kerma (RAK), and fluoroscopy time (FT) among radial and femoral approaches.

METHODS

All coronary procedures between November 2015 and November 2017 were assessed; and 4215 coronary procedures were enrolled in the study. Patients with bifurcation, chronic total occlusion, cardiogenic shock, or prior coronary artery bypass surgery were excluded. These 4215 procedures were evaluated for three different categories: diagnostic CA (Group I), PCI in patients with stable angina (Group II), and PCI in patients with ACS (Group III).

RESULTS

Age was significantly higher in the femoral arm of all groups. Among patients in the radial arm of Groups I and II, males were over-represented. Therefore, a multiple linear regression analysis with stepwise method was performed. After adjusting these clinical confounders, there was no significant difference with regard to DAP, RAK, and FT between femoral and radial access in Group I. In contrast, PCI via radial access was significantly associated with increased DAP, RAK, and FT in Groups II and III.

CONCLUSION

In spite of an increased experience with trans-radial approach, PCI of coronary lesions via radial route was associated with a relatively small but significant radiation exposure in our study. Compared to femoral access, diagnostic CA via radial access was not related to an increased radiation exposure.

An Update on Radial Artery Access and Best Practices for Transradial Coronary Angiography and Intervention in Acute Coronary Syndrome: A Scientific Statement From the American Heart Association

Transradial artery access for percutaneous coronary intervention is associated with lower bleeding and vascular complications than transfemoral artery access, especially in patients with acute coronary syndromes. A growing body of evidence supports adoption of transradial artery access to improve acute coronary syndrome-related outcomes, to improve healthcare quality, and to reduce cost. The purpose of this scientific statement is to propose and support a "radial-first" strategy in the United States for patients with acute coronary syndromes. This document also provides an update to previously published statements on transradial artery access technique and best practices, particularly as they relate to the management of patients with acute coronary syndromes.

Retrospective analysis of coronary interventions in a single centre and comparison of specific differences between radial and femoral access

Objectives: The aim of this study was to analyse the consequence of radial or femoral access during coronary interventions to radiation dose, fluorography time and a number of pseudoaneurysms following each type of intervention. Background: According to the results of many recent studies (RIVAL, RIFLE-STEACS, STEMI RADIAL), current guidelines favour radial over femoral access during coronary intervention for safety, especially in cases of acute coronary syndromes. However, several papers have referred to problems in the design of these studies and the management of antithrombotic therapy. The influence of access site on radiation dose and fluorography time is also still unclear. Methods: We retrospectively analysed 4522 patients who underwent coronary angiography in 2012 and 2016 in a single centre in the Czech Republic. We compared the access site with the average radiation dose and mean effective dose that each patient received in Gy/cm² or mSv, respectively. We also compared average fluorography time in minutes and the incidence of pseudoaneurysms. Results: The radiation dose was a body mass index (BMI)-dependent parameter since each five points of body mass index increased radiation dose approximately by 23%. Use of femoral access resulted in lower fluorography time in all subgroups (p < .001) and decreased radiation dose in patients with coronary artery bypass grafts (CABGs) by 26% (p = .044). On the other hand, there has been 16 times lower frequency (p < .001) of post-catheterisation pseudoaneurysms after radial access than after femoral access. Conclusions: Both the radiation dose and fluorography time were lower after femoral access compared to radial access in patients with CABGs. On the other hand, radial access led to significantly fewer periprocedural pseudoaneurysms. Radial access therefore should be considered as the preferred access site during coronary intervention in patients with a high risk of pseudoaneurysm development, and femoral access should be considered for patients with a high risk of contrast-induced nephropathy.