Orthopedic Afflictions in the Interventional Laboratory

StemRad MD, An Exoskeleton-Based Radiation Protection System, Reduces Ergonomic Posture Risk Based on a Prospective Observational Study

OBJECTIVE

Poor ergonomic posture during interventional procedures might lead to increased physical discomfort and work-related musculoskeletal disorders. Adjunctive equipment such as lead aprons (LAs) has been shown to increase ergonomic posture risk (EPR). The objective of this study was to evaluate the effectiveness of StemRad MD (StemRad Ltd., Tel Aviv, Israel), a weightless exoskeleton-based radiation protective ensemble, in reducing EPR on the operator using wearable inertial measurement unit (IMU) sensors.

METHODS

A prospective, observational study was conducted at an academic hospital. Inertial measurement unit sensors were affixed to the upper back of 9 interventionalists to assess ergonomic risk posture during endovascular procedures while wearing a traditional LA or the StemRad MD radiation protection system. Total fluoroscopy time, procedure type, and ergonomic risk postures were recorded and analyzed.

RESULTS

Twenty-one cases were performed with StemRad MD and 30 with LAs. Mean procedure time for the StemRad MD procedures was 48.4±23.3 minutes (range: 24-106 min), and for LA procedures, it was 34.66±25.83 minutes (range: 6-100 min) (p=.060). The operators assumed low-risk ergonomic positions in 96.1% of StemRad MD cases and in 62.9% of LA cases (p=.001), and high-risk ergonomic positions in 0% and 6.2%, respectively (p=.80). Mean EPR score for StemRad MD was 1.16, and for the LA, it was 1.49 (p=.001).

CONCLUSIONS

StemRad MD significantly reduces the EPR to the torso compared with a LA-based radiation protection system.

CLINICAL IMPACT

Poor ergonomic posture during interventional procedures might leas to work-related musculoskeletal disorders for healthcare workers. StemRad MD, a weightless, exoskeleton-based radiation protection system was shown to significantly reduce ergonomic posture risk to the torso compared to conventional lead aprons. This might lead to reduced physical discomfort for procedure-based specialists.

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.

Local impedance and contact force guidance to predict successful cavotricuspid isthmus ablation with a zero-fluoroscopy approach

Introduction

A new technology capable of monitoring local impedance (LI) and contact force (CF) has recently been developed. At the same time, there is growing concern regarding catheter ablation performed under fluoroscopy guidance, due to its harmful effects for both patients and practitioners. The aim of this study was to assess the safety and effectiveness of zero-fluoroscopy cavotricuspid isthmus (CTI) ablation monitoring LI drop and CF as well as to elucidate if these parameters can predict successful radiofrequency (RF) applications in CTI ablation.

Methods

We conducted a prospective observational study recruiting 50 consecutive patients who underwent CTI ablation. A zero-fluoroscopy approach guided by the combination of LI drop and CF was performed. In each RF application, CF and LI drop were monitored. A 6-month follow-up visit was scheduled to assess recurrences.

Results

A total of 767 first-pass RF applications were evaluated in 50 patients. First-pass effective RF applications were associated with greater LI drops: absolute LI drops (30.05 ± 6.23 Ω vs. 25.01 ± 5.95 Ω), p = 0.004) and relative LI drops (-23.3 ± 4.9% vs. -18.3 ± 5.6%, p = 0.0005). RF applications with a CF between 5 and 15 grams achieved a higher LI drop compared to those with a CF below 5 grams (29.4 ± 8.76 Ω vs. 24.8 ± 8.18 Ω, p < 0.0003). However, there were no significant differences in LI drop between RF applications with a CF between 5 and 15 grams and those with a CF beyond 15 grams (29.4 ± 8.76 Ω vs. 31.2 ± 9.81 Ω, p = 0.19). CF by itself, without considering LI drop, did not predict effective RF applications (12.3 ± 7.54 g vs. 11.18 ± 5.18 g, p = 0.545). Successful CTI ablation guided by a zero-fluoroscopy approach was achieved in all patients. Only one patient experienced a recurrence during the 6-month follow-up.

Conclusions

LI drop (absolute and relative values) appears to be a good predictor of successful RF applications to achieve CTI conduction block. The optimal CF to achieve a good LI drop is between 5 and 15 g. A zero-fluoroscopy approach guided by LI and CF was feasible, effective, and safe.

X-Ray Protective Aprons Re-Evaluated

BACKGROUND

The evaluation of the protective effect of X-ray protective clothing requires new criteria. The current concept assumes more or less uniform covering of the torso with protective material. The frequently worn heavy wrap-around aprons can weigh 7 to 8 kg. As relevant studies show, orthopedic damage can result from long-term activity. It should therefore be investigated whether the apron weight can be reduced by optimizing the material distribution. For a radiobiological evaluation of the protective effect, the "effective dose" should be used.

METHODS

Numerous laboratory measurements were performed with an Alderson Rando phantom as well as dose measurements on clinical personnel. The measurements were supplemented by Monte Carlo simulation of an interventional workplace in which a female ICRP reference phantom was used for the operator. The measured back doses on the Alderson phantom as well as the measured back doses at interventional workplaces were based on the personal equivalent dose Hp(10). Monte Carlo simulations were used to introduce protection factors for the protective clothing based on the "effective dose" introduced in radiation protection.

RESULTS

Back doses in clinical radiology personnel are largely negligible. Therefore, back protection can be much lower than currently used or can even be eliminated. The Monte Carlo simulations show that the protective effect of protective aprons worn on the body is higher than when the flat protective material is radiated through (3 D effect). About 80 % of the effective dose is attributed to the body region from the gonads to the chest. By additional shielding of this area, the effective dose can be lowered or, optionally, aprons with less weight can be produced. Attention must also be paid to the "radiation leaks" (upper arms, neck, skull), which can reduce the whole-body protective effect.

CONCLUSION

In the future, the evaluation of the protective effect of X-ray protective clothing should be based on the effective dose. For this purpose, effective dose-based protection factors could be introduced, while the lead equivalent should be used for measurement purposes only. If the results are implemented, protective aprons with approx. 40 % less weight can be produced with a comparable protective effect.

KEY POINTS

· The protective effect of X-ray protective clothing should be described by protection factors based on effective dose.. · The lead equivalent should only be used for measurement purposes.. · More than 80 % of the effective dose is attributed to the body region from the gonads to the chest.. · A reinforcing layer in this area increases the protective effect considerably.. · With optimized material distribution, protective aprons could be up to 40 % lighter..

CITATION FORMAT

· Eder H. X-Ray Protective Aprons Re-Evaluated. Fortschr Röntgenstr 2023; 195: 234 - 243.

Integrity of personal radiation protective equipment (PRPE): a 4-year longitudinal follow-up study

BACKGROUND

Personal radiation protective equipment (PRPE) such as lead aprons minimises radiation exposure of operators using X-ray systems. However, PRPE might be prone to cracks in the attenuating layer resulting in inadequate radiation protection. This study aims to investigate the prevalence, qualification and quantification of PRPE integrity during a longitudinal follow-up study.

METHODS

All PRPE of a large, general hospital was evaluated yearly in the period 2018-2021. The equipment was inspected on a tele-operated X-ray table, and tears were qualified and quantified using an X-ray opaque ruler. Rejection criteria of Lambert & McKeon, with an extra rejection criterion of 15 mm² for individual tears, were applied to accept or reject further use of the PRPE.

RESULTS

Over the 4-year follow-up period, a total of 1011 pieces of PRPE were evaluated. In total, 47.3% of the PRPE showed tears of which 31% exceeded the mentioned rejection criteria. Remarkably, of the 287 newly registered pieces of PRPE, 6.0% showed tears in the first year of use of which 88.2% needed to be rejected. Also, 48% of the repaired PRPE was rejected again in the consecutive year.

CONCLUSIONS

PRPE is prone to cracks. Up to 50% of PRPE showed tears and cracks resulting in 31% rejections. Newly purchased PRPE is not guaranteed to remain free of cracks and tears in the first year of use. Repair does not guarantee a long-term solution for prolonging the lifespan. Regular X-ray-based integrity analysis of PRPE is needed to ensure adequate radioprotection for operators using X-ray systems.

Results of catheter ablation with zero or near zero fluoroscopy in pediatric patients with supraventricular tachyarrhythmias

INTRODUCTION AND OBJECTIVES

Ionizing radiation exposure in catheter ablation procedures carries health risks, especially in pediatric patients. Our aim was to compare the safety and efficacy of catheter ablation guided by a nonfluoroscopic intracardiac navigation system (NFINS) with those of an exclusively fluoroscopy-guided approach in pediatric patients.

METHODS

We analyzed catheter ablation results in pediatric patients with high-risk accessory pathways or supraventricular tachycardia referred to our center during a 6-year period. We compared fluoroscopy-guided procedures (group A) with NFINS guided procedures (group B).

RESULTS

We analyzed 120 catheter ablation procedures in 110 pediatric patients (11±3.2 years, 70% male); there were 62 procedures in group A and 58 in group B. We found no significant differences between the 2 groups in procedure success (95% group A vs 93.5% group B; P=.53), complications (1.7% vs 1.6%; P=.23), or recurrences (7.3% vs 6.9%; P = .61). However, fluoroscopy time (median 1.1minutes vs 12minutes; P <.0005) and ablation time (median 96.5seconds vs 133.5seconds; P=.03) were lower in group B. The presence of structural heart disease was independently associated with recurrence (P=.03).

CONCLUSIONS

The use of NFINS to guide catheter ablation procedures in pediatric patients reduces radiation exposure time. Its widespread use in pediatric ablations could decrease the risk of ionizing radiation.

Use of effective dose to assess x-ray protective clothing

This review article provides an overview on the results of studies conducted by the authors to improve the current personal protection concept in the clinical application of x-rays. With the aid of personal dose equivalent measurements during radiologically guided clinical interventions, laboratory tests using the Alderson-Rando phantom as well as Monte Carlo simulations various x-ray application scenarios were investigated. The organ doses and the effective doses of staff persons standing near the patient were determined. The 3D-attenuation properties of protective clothing under the scattered radiation emitted by the patient play a special role here. With regard to the minimisation of the quantity 'effective dose' the protection of the lower body from the gonads to the chest is of particular importance, since 80% of the effective dose is contributed by this region of the body. In contrast, protection of the back plays a subordinate role. Protective aprons optimised in terms of effective dose can be significantly lighter than conventional aprons, providing equal protection. The assessment of the attenuation properties of protective clothing should be based on the risk-related dose quantity, effective dose, rather than lead equivalent. In the future, the evaluation of radiation protective clothing could be based on the calculation of the effective dose assuming standardised irradiation conditions.

Improving IR Ergonomics Using a Flexible C-Arm System

PURPOSE

To evaluate the impact of a versatile flexible ceiling-mounted C-arm on active table and gantry repositioning during interventions and its effect on operator discomfort, system usability, and patient safety compared with a traditional ceiling-mounted system.

MATERIALS AND METHODS

There were 100 IR procedures studied: 50 in a traditional IR system (standard group) and 50 with a novel multiaxis ceiling-mounted system (test group). FlexArm was capable of multiple gantry rotation points allowing increased access to the patient in addition to 236 cm of lateral x-ray detector travel. For each procedure, both the table and the gantry repositioning were measured. Patient safety, patient/equipment repositioning effort, and physical discomfort were evaluated through an operator survey.

RESULTS

Table repositioning was reduced from 42 to 16 instances per procedure (P < .001) in the test group compared with the standard group. The operators perceived less table and gantry repositioning effort (P < .0001) and decreased risks of equipment collisions, displacement of vascular access, and dislodgment of tubes/lines with the test group (P < .0001). Operator discomfort was reduced for all body areas in the test group over the standard group (P < .0001).

CONCLUSIONS

The FlexArm system geometry enhances operator ergonomics, as there was a decrease need to move the table, leading to a perceived decrease in patient risk and decrease operator physical discomfort when compared to a traditional imaging system.

Knowledge deficiency of work-related radiation hazards associated with psychological distress among orthopedic surgeons: A cross-sectional study

Knowledge and concern degree about work-related radiation hazards remained unknown among orthopedic surgeons. The aim of the cross-sectional study is to investigate whether the knowledge degree of work-related radiation is associated with psychological distress among orthopedic surgeons. This cross-sectional study sent electronic questionnaire via WeChat to orthopedic surgeons nationwide. Concern and knowing degree over radiation exposure was evaluated by a single self-reported question. Professional evaluation of concern degree was reflected by general psychological distress, which was assessed with the Kessler 10 scale (K10) and depressive symptoms with the Center for Epidemiologic Studies Depression Scale (CES-D). Only 43.23% (115/266) respondents knew well about radiation and a total of 78.20% (208/266) respondents considered radiation exposure as a great concern. Among those who reported concerns about radiation exposure, a total of 57.69% (120/208) respondents reported knowing little about radiation. Respondents who reported concerns over radiation exposure were significantly associated with higher scores on CES-D and K10 (P < .05). Among respondents who reported concerns over radiation exposure, those who have fewer knowledge about radiation, had higher CES-D and K10 scores than those who knew well about radiation (P < .05). Among respondents who reported no concerns over radiation exposure, those who knew little about radiation still had higher CES-D and K10 scores (P < .05). Fewer radiation knowledge tends to induce more radiation concerns associated with higher psychological distress in orthopedic surgeons. Radiation knowledge should be enhanced for surgeons who daily work with radiation-related fluoroscopy.

Occupational Health Risks in Cardiac Catheterization Laboratory Workers

BACKGROUND

Orthopedic strain and radiation exposure are recognized risk factors in personnel staff performing fluoroscopically guided cardiovascular procedures. However, the potential occupational health effects are still unclear. The purpose of this study was to examine the prevalence of health problems among personnel staff working in interventional cardiology/cardiac electrophysiology and correlate them with the length of occupational radiation exposure.

METHODS AND RESULTS

We used a self-administered questionnaire to collect demographic information, work-related information, lifestyle-confounding factors, all current medications, and health status. A total number of 746 questionnaires were properly filled comprising 466 exposed staff (281 males; 44±9 years) and 280 unexposed subjects (179 males; 43±7years). Exposed personnel included 218 interventional cardiologists and electrophysiologists (168 males; 46±9 years); 191 nurses (76 males; 42±7 years), and 57 technicians (37 males; 40±12 years) working for a median of 10 years (quartiles: 5-24 years). Skin lesions (P=0.002), orthopedic illness (P<0.001), cataract (P=0.003), hypertension (P=0.02), and hypercholesterolemia (P<0.001) were all significantly higher in exposed versus nonexposed group, with a clear gradient unfavorable for physicians over technicians and nurses and for longer history of work (>16 years). In highly exposed physicians, adjusted odds ratio ranged from 1.7 for hypertension (95% confidence interval: 1-3; P=0.05), 2.9 for hypercholesterolemia (95% confidence interval: 1-5; P=0.004), 4.5 for cancer (95% confidence interval: 0.9-25; P=0.06), to 9 for cataract (95% confidence interval: 2-41; P=0.004).

CONCLUSIONS

Health problems are more frequently observed in workers performing fluoroscopically guided cardiovascular procedures than in unexposed controls, raising the need to spread the culture of safety in the cath laboratory.

The fluoro-less and contrast-less peripheral endovascular intervention: Halfway there

INTRODUCTION

Percutaneous endovascular revascularization requires the use of fluoroscopic guidance and radiopaque contrast. We present a successful intervention without the use of iodinated contrast.

CASE

A 92-year-old man with dry gangrene involving the second and fourth left toes had acute on chronic kidney injury. Arterial duplex showed severe stenosis in bilateral superficial femoral arteries (SFAs). Fluoroscopic and ultrasound guidance and intravascular imaging were used to avoid iodinated contrast. After right to left femoral crossover, the entire left SFA was imaged with ultrasound. The lesion was delineated with radiopaque measuring tapes then wired. Near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS) imaging were performed. Points of interest were correlated with corresponding radiopaque markings on the ruler. Stenting and post-dilation resulted in complete stent expansion and no evidence of dissection by IVUS. The total procedure time was 113min and the total radiation dose 813mGy. The day after the procedure, there was a palpable dorsalis pedis pulse. He was discharged to inpatient rehabilitation on dual antiplatelet therapy.

DISCUSSION

Contrast and radiation continue to limit the feasibility of endovascular angiography and intervention. Carbon dioxide (CO2) digital subtraction angiography is an alternative for these patients but has several disadvantages. Previously proposed projects demonstrated the real potential of performing endovascular peripheral intervention without fluoroscopy or contrast.

CONCLUSION

This case is a clear demonstration of a successful use of a combination of fluoroscopy, ultrasonography and intravascular imaging to achieve a successful endovascular intervention to treat critical limb ischemia, without the use of iodinated contrast.