Comparison of operator radiation exposure during coronary sinus catheter placement via the femoral or jugular vein approach

Metal interference alert guided septal approach with 3 catheter positions on intracardiac echocardiography for a near-zero fluoroscopy catheter ablation of atrial fibrillation

BACKGROUND

Attempting to minimize radiation exposure during catheter ablation of atrial fibrillation (AF) for patients, operators and medical staffs should be performed. This study aimed to investigate the feasibility and safety of a metal interference alert guided septal approach using 3 intracardiac echocardiography viewing positions for near-zero fluoroscopy AF ablation procedures.

METHODS/RESULTS

A total of 668 procedures among 608 consecutive patients with AF (67.2 ± 7.3 years, 408 males) who underwent catheter ablation were retrospectively evaluated and divided into 2 groups, near-zero group (n = 42) and conventional group (n = 595). In the near-zero group, a metal interference alert guided septal approach with 3 different catheter intracardiac echocardiography positions to minimize the fluoroscopy time was applied, and a left atrial access with 2 long sheaths from a single septal puncture without fluoroscopy was successfully achieved in 41 out of 42 cases. The total fluoroscopy time was significantly shorter in the near-zero group than that in the conventional group (0.5 ± 2.0 vs. 21.4 ± 12.9 min p < 0.0001). The total procedure time and time to the septal puncture were both significantly longer in the near-zero group than those in the conventional group (131.4 ± 40.2 vs. 116.6 ± 46.4p = 0.0453, 31.6 ± 9.2 vs. 19.9 ± 10.2 min, p < 0.0001), The ablation time did not differ between the 2 groups (Near-zero: 99.8 ± 41.0 vs. Conventional: 96.8 ± 44.3 min, p = 0.6663). There were no significant differences in the complication rate between the 2 groups (Near-zero: 0 vs. Conventional 14 case, p = 0.6151).

CONCLUSION

A metal interference alert guided septal approach using 3 intracardiac echocardiography viewing positions was feasible and safe for a near-zero fluoroscopy catheter ablation of AF.

Femoral versus jugular access for Denali Vena Cava Filter placement: Analysis of fluoroscopic time, filter tilt and retrieval outcomes

PURPOSE

To analyze relevant metrics involved in Denali Vena Cava Filter placement via different venous access sites.

MATERIALS AND METHODS

Patients with Denali filters inserted between March 2017 and February 2018 were retrospectively analyzed. Pre-procedural and pre-retrieval computed tomography (CT) were reviewed. We compared inferior vena cava (IVC) diameter, filter tilt angle, filter tip IVC wall abutment, fluoroscopy time, and retrieval outcomes by venous access site. Filter tip abutment/limb penetration and procedure-related complications were investigated.

RESULTS

Seventy-eight patients had successfully-placed Denali filters. Seventy-one of 78 (91%) patients had both pre-procedural and pre-retrieval CT. The majority (35 [49%]) were placed via the right femoral vein (left femoral vein: 22 [31%]; right internal jugular vein: 14 [20%]). The jugular approach involved a longer fluoroscopy time (mean 117 ± 37 s [s]) than the right and left femoral approaches (mean 64 ± 21 s, mean 67 ± 15 s, respectively [p < 0.05]). Filter tilt and filter tip abutment were not significantly different between the 3 access routes. Filter tip abutment and limb penetration were observed in 8/71 (11%) and 2/71 (3%) patients, respectively. Filter retrieval was attempted in 68 of 78 (87%) cases, and all filters were successfully retrieved. One filter arm fractured during advanced retrieval; no other procedure related complications were recorded.

CONCLUSIONS

Both femoral venous approaches can be safely used for placement of the Denali filter. Femoral venous access involved a shorter fluoroscopy time without any differences in filter tilt and filter tip abutment compared to transjugular access.

InterCardioRisk: a novel online tool for estimating doses of ionising radiation to occupationally-exposed medical staff and their associated health risks

Those working in interventional cardiology and related medical procedures are potentially subject to considerable exposure to x-rays. Two types of tissue of particular concern that may receive considerable doses during such procedures are the lens of the eye and the brain. Ocular radiation exposure results in lens changes that, with time, may progress to partial or total lens opacification (cataracts). In the early stages, such opacities do not result in visual disability; the severity of such changes tends to increase progressively with dose and time until vision is impaired and cataract surgery is required. Scattered radiation doses to the eye lens of an interventional cardiologist in typical working conditions can exceed 34 μGy min^-1 in high-dose fluoroscopy modes and 3 μGy per image during image acquisition (instantaneous rate values) when radiation protection tools are not used. A causal relation between exposure to ionising radiation and increased risk of brain and central nervous system tumours has been shown in a number of studies. Although absorbed doses to the brain in interventional cardiology procedures are lower than those to the eye lens by a factor between 3.40 and 8.08 according to our simulations, doses to both tissues are among the highest occupational radiation doses documented for medical staff whose work involves exposures to x-rays. We present InterCardioRisk, a tool featuring an easy-to-use web interface that provides a general estimation of both cumulated absorbed doses experienced by medical staff exposed in the interventional cardiology setting and their estimated associated health risks. The tool is available at http://intercardiorisk.creal.cat.

Factors associated with the internal jugular venous approach for Melody™ Transcatheter Pulmonary Valve implantation

BACKGROUND

Transcatheter pulmonary valve implantation is usually performed from a femoral venous - transfemoral - approach, but this may not be the optimal vascular access option in some patients. This study aimed to determine which group of patients might benefit from an internal jugular - transjugular - approach for transcatheter pulmonary valve implantation.

METHODS

This multicentre retrospective study included all patients who underwent attempted transcatheter pulmonary valve placement in the right ventricular outflow tract between April 2010 and June 2012 at two large congenital heart centres. Patients were divided into two groups based on venous access site - transfemoral or transjugular. Patient characteristics, procedural outcomes, and complications were compared between groups.

RESULTS

Of 81 patients meeting the inclusion criteria (median age 16.4 years), the transjugular approach was used in 14 patients (17%). The transjugular group was younger (median age 11.9 versus 17.3 years), had lower body surface area (mean 1.33 versus 1.61 m2), more often had moderate or greater tricuspid regurgitation (29% versus 7%), and had a higher ratio of right ventricle-to-systemic systolic pressure (mean 82.4 versus 64.7). Patients requiring a transjugular approach after an unsuccessful transfemoral approach had longer fluoroscopic times and procedure duration.

CONCLUSIONS

The transjugular approach for transcatheter pulmonary valve implantation is used infrequently but is more often used in younger and smaller patients. Technical limitations from a transfemoral approach may be anticipated if there is moderate or greater tricuspid regurgitation or higher right ventricular pressures. In these patients, a transjugular approach should be considered early.

The Growing Culture Of A Minimally Fluoroscopic Approach In Electrophysiology Lab

Most of interventional procedures in cardiology are carried out under fluoroscopic imaging guidance. Besides other peri-interventional risks, radiation exposure should be considered for its stochastic (inducing malignancy) and deterministic effects on health (tissue reactions like erythema, hair loss and cataracts). In this article we analized the radiation risk from cardiovascular imaging to both patients and medical staff and discusses how customize the X-ray system and how to implement shielding measures in the cath lab. Finally, we reviewed the most recent developments and the latest findings in catheter navigation and 3D electronatomical mapping systems that may help to reduce patient and operator exposure.

Radiation exposure to operating room personnel and patients during endovascular procedures

OBJECTIVE

To characterize radiation exposure to patients and operating room personnel during fluoroscopic procedures.

METHODS

Patient dose information was collected from the imaging equipment. Real-time dosimetry was used to measure doses to the operators, scrub nurse, radiologic technologist (RT), and anesthesiologist in 39 cases of endovascular thoracoabdominal aortic aneurysm repair using fenestrated endografts. Overall equivalent doses and dose rates at time points of interest were noted and compared with the corresponding patient doses.

RESULTS

The dosimeter on the anesthesia equipment received 143 μSv (38-247) more radiation per case than the average operator, and the scrub nurse and RT received 106 μSv (66-146) and 100 μSv (55-145) less, respectively. Adjusting for protective lead aprons by the Webster methodology, the average operator received an effective dose of 38 μSv. Except for the RT, personnel doses were well correlated with patient dose as measured by kerma area product (KAP) (r = .82 for average operator, r = .85 for scrub nurse, and r = .86 for anesthesia; all P < .001) but less well correlated with fluoroscopy time or cumulative air kerma (CAK). When preoperative cone beam computed tomography was performed, the equivalent dose to the RT was 1.1 μSv (0.6-1.5) when using shielding and 37 μSv (22-53) when unshielded. Digital subtraction acquisitions accounted for a large fraction of all individuals' doses. Decreasing field size (and thus, increasing magnification) was associated with decreased KAP (r = .47; P < .001) and increased CAK (r = -.56; P < .001). The square of the field size correlated strongly with the KAP/CAK ratio (r = .99; P < .001). Increased lateral angulation of the C-arm increased both CAK and KAP (at field size, 22 cm; r = .54 and r = .44; both P < .001) and the average dose rate to an operator was 1.78 (1.37-2.31) times as high in a lateral projection as in a posterior-anterior projection.

CONCLUSIONS

Personnel doses were best correlated with KAP and less well correlated with fluoroscopy time or CAK. The dosimeter on the anesthesia equipment recorded the highest doses attributable to ineffective shielding. Operators can reduce the effective dose to themselves, the patient, and other personnel by minimizing the use of digital subtraction acquisitions, avoiding lateral angulation, using higher magnification levels when possible, and being diligent about the use of shielding during fluoroscopy cases.

Feasibility and procedure-related patient discomfort of peripheral venous access for coronary sinus cannulation during electrophysiology procedures

BACKGROUND

Placement of an electrode catheter in the coronary sinus (CS) through the jugular or subclavian vein, as part of electrophysiology (EP) procedures, increases patient discomfort and the possibility of adverse events. We studied the hypothesis that peripheral venous access for CS cannulation, as part of EP procedures, is feasible and can reduce patient discomfort, eliminating central venous access-associated risks.

METHODS

Consecutive patients submitted to EP procedures were randomly assigned to peripheral or central venous access for CS cannulation. If after 30 min from initial needle insertion the CS was still not catheterized, the attempt was considered unsuccessful. Patient level of discomfort was assessed with a visual analog scale (VAS).

RESULTS

Success rate was 90% in the peripheral versus 95% in the central venous access group (p = 1.00). No complications related to venous access were observed in the peripheral venous access group, whereas one case of pneumothorax and one case of extensive hematoma in the anterior cervical area were recorded in the central venous access group. Patients submitted to central vein catheterization reported higher VAS scores, 46.8 ± 16.3 versus 36.8 ± 12.9 (p = 0.04). No significant difference was observed in fluoroscopy time needed for CS cannulation (51.1 ± 9.2 s versus 51.4 ± 7.9 s; p = 0.71) between the two groups.

CONCLUSION

This small, randomized study indicates that peripheral venous access for CS catheter placement during EP procedures is feasible, with equivalent success rate to the central venous access approach, and associated with lower levels of self-reported patient discomfort.