Retrospective evaluation of occurrence of skin injuries in interventional cardiac procedures

Interventional non-operative management of low back and neck pain

Background

Chronic neck and back pain are among the most commonly encountered health problems in neurosurgical practice. Many cases fail prolonged pharmacological and physical therapy and are not proper candidates for surgical interventions, or had refused proposed surgical treatment.

Objective

To provide an informative critical summary of the literature about the topic of interventional management of axial neck and low back pain and highlighting the new trends and pieces of evidence.

Methods

The English literature published over the last two decades was reviewed by the author for recent and relevant data about the principles of interventional management of chronic neck and low back pain. A PubMed search was performed through phrase searching and combined searching using Boolean operators. The articles thought to be most relevant to the study aim and the neurosurgeons’ practice were extracted.

Results

Neck and low back pain continue to be among the most common musculoskeletal health problems and the most common cause of disability worldwide. A detailed understanding of relevant spine anatomy is crucial for interventionists who should deal with the concept of “functional spine unit” with multiple potential pain generators. Chronic spinal pain is best managed through a dedicated multidisciplinary team in well-equipped healthcare facilities. An algorithmic approach for the diagnosis and management of spinal pain is the mainstay of providing the best patient care and should be based on the commonality and treatability of pain generators, values of patients and available resources.

Conclusion

Management of chronic neck and back pain can represent a clinical dilemma due to the multiplicity of pain generators that may coexist in the same individual resulting in a complex type and pattern of pain. Approach to these patients requires contributions from the members of a multidisciplinary team, implementing a standardized approach in a well-equipped healthcare facility.

Patient follow-up for possible radiation injury from fluoroscopically-guided interventions: Need to consider high cumulative exposure from multiple procedures

PURPOSE

Patient skin dose from interventional fluoroscopy procedures may exceed the threshold of tissue injuries and established guidelines recommend patient follow-up for air kerma at reference point (K_a,r) ≥ 5 Gy for individual procedures. Patients may undergo multiple procedures and skin injuries may be possible by cumulative exposure, even when individually insufficient to cause injury. This study sought to quantify the frequency of patients whose individual procedure doses are below 5 Gy but whose cumulative K_a,r is ≥ 5 Gy.

METHODS

This retrospective study analyzed 37,917 consecutive procedures in interventional radiology and vascular surgery at a tertiary-care hospital between January 2016 and June 2021. Radiation dosage was retrieved from the fluoroscopy acquisition systems. For a patient receiving multiple procedures, but each with K_a,r < 5 Gy, cumulative K_a,r within 2, 7, 14, 30, 183, and 365 days was assessed.

RESULTS

Nearly 1/3rd (37.4 %) patients underwent multiple procedures. With individual procedures of K_a,r < 5 Gy exclusively, 1.9, 4.4, and 5.6 in 1000 patients received cumulative K_a,r of 5-14.1 Gy from the procedures within 30, 183, and 365 days, respectively. From the procedures within 14 days, 1.3 in 1000 patients received cumulative K_a,r of 5-11.4 Gy; and from those within 7 days, 0.87 in 1000 patients received 5-9.1 Gy. In comparison, 4.3 in 1000 patients received K_a,r of 5-12 Gy from a single procedure.

CONCLUSIONS

In the absence of guidelines on patient follow-up for multiple procedures, our study may provide good material for setting up such guidelines.

Radiation Protection in Interventional Radiology

There has been a rapid development in the field of interventional radiology over recent years, and this has led to a rapid increase in the number of interventional radiology procedures being performed. There is, however, a growing concern regarding radiation exposure to the patients and the operators during these procedures. In this article, we review the basics of radiation exposure, radiation protection techniques, radiation protection tools available to interventional radiologists, and radiation protection during pregnancy.

MEASUREMENT OF SKIN DOSE AND RADIATION-INDUCED CHANGES IN SKIN MICROCIRCULATION IN CHRONIC TOTAL OCCLUSION PERCUTANEOUS CARDIAC INTERVENTIONS (CTO-PCI)

Skin injuries may occur when radiation doses to the skin exceed 2 Gy. This study aimed to measure changes in skin microcirculation in patients undergoing chronic total occlusion percutaneous coronary interventions (CTO-PCI). In 14 patients, peak skin dose (PSD) was estimated with radiographic films and skin microcirculation was assessed with laser speckle contrast imaging (LSCI), before, 1 day after the intervention, and 4-6 weeks later. The mean PSD was 1.8 ± 0.9 Gy. Peak skin microcirculation increased by 12% from 45 ± 6 PU before to 50 ± 9 PU 1 day after the intervention (p = 0.01), and returned to 46 ± 8 PU after 4-6 weeks (p = 0.15). There was no significant correlation between PSD and the change in perfusion, neither 1 day (r = -0.13, p = 0.69) nor 4-6 weeks after the intervention (r = 0.33, p = 0.35). These results suggest that there are no radiation-induced microvascular changes in the skin after CTO-PCI at skin doses below 2 Gy.

Evaluation of peak skin dose during percutaneous coronary intervention procedures: relationship with fluoroscopic pulse rate and target vessel

This study aimed to evaluate the relationship between the peak skin dose (PSD) associated with radiation skin injury and the fluoroscopic pulse rate or target vessel during percutaneous coronary intervention (PCI) procedures. We consecutively included 213 patients who underwent PCI procedures. The fluoroscopic time (FT), total number of cine frames, reference air kerma (RAK), and PSD were compared between the two types of fluoroscopic pulse rates (10 and 7.5 pulses/s) and among target vessels. The total number of X-ray tube angulations for each target vessel was also investigated. The median FT was 21.5 min in the 10 pulses/s group and 19.4 min in the 7.5 pulses/s group (p = 0.068, Wilcoxon rank sum test). The median PSD in the 10 pulses/s group was 749 mGy, which was significantly higher than that in the 7.5 pulses/s group (549 mGy) (p < 0.001). The median RAK in the right coronary artery (RCA) was equivalent to that in the left anterior descending artery. However, among the target vessels, the median PSD tended to be the highest in the RCA. There was a difference in the X-ray tube angulation used depending on the target vessel. PCI in the RCA used the left anterior oblique angle more frequently than PCI in the other vessels and tended to use only one angulation. The calculated PSD was related to the target vessel of the PCI procedure, and it was also closely related to the X-ray tube angulation.

[Evaluation of the incidence of radiodermatitis lesions in interventional cardiology]

PURPOSE

The percutaneous coronary interventions use large doses of ionizing radiation, particularly when treating complex lesions. The incidence of radio-induced skin lesions is poorly known. Our goal was to evaluate the frequency of occurrence of such lesions, as well as the factors that may contribute to a high radiation dose. The recommended DAP (dose-area product) cutoff for skin monitoring after percutaneous coronary interventions is 500Gy cm².

PATIENTS AND METHOD

We prospectively studied the incidence of acute (after 5-7 days) and subacute (after 7 days to 6 months) skin lesions following angioplasty with a dose-area product (DAP) ≥200Gy cm² in patients who underwent coronary angioplasty in our center in 2013.

RESULTS

Nine hundred and thirty three consecutive procedures were analyzed, of which 102 with a DAP ≥200Gy cm². Three patients presented an acute lesion. Two of these three patients also had subacute lesions. Another patient presented only a subacute lesion. 4.82% (95% CI: [0-10]) of the patients with a DAP ≥200Gy cm² developed radiodermitis lesions, or 0.47% (95% CI: [0-0.9]) of all the patients who underwent angioplasty. The Body Mass Index and the elective (as opposed to energy) procedures were independently associated with a procedure with a DAP ≥200Gy cm².

CONCLUSION

Radiodermatitis lesions occur for 4.82% of patients benefiting from procedures with a DAP ≥200Gy cm². We suggest the establishment of a DAP threshold for dermal monitoring of patients of 200Gy cm² per procedure instead of 500Gy cm².

Direct Dose Measurement On Patient During Percutaneous Coronary Intervention Procedures Using Radiophotoluminescence Glass Dosimeters

The purpose of this research was to measure accurate patient entrance skin dose and maximum skin absorbed dose (MSD) to prevent radiation skin injuries in percutaneous coronary interventions (PCIs). We directly measured the MSD on 50 PCIs by using multiple radiophotoluminescence glass dosimeters and a modified dosimetry gown. Also, we analysed the correlation between the MSD and indirect measurement parameters, such as fluoroscopic time (FT), dose-area product (DAP) and cumulative air kerma (C-AK). There were very strong correlations between MSD and FT, DAP and C-AK, with the correlation between MSD and C-AK being the strongest (r = 0.938). In conclusion, the regression lines using MSD as an outcome value (y) and C-AK as predictor variables (x) were y = 1.12x (R2 = 0.880). From the linear regression equation, MSD is estimated to be ~1.12 times that of C-AK in real time.

The contribution of interventional cardiology procedures to the population radiation dose in a 'health-care level I' representative region

This study evaluates per-procedure, collective and per capita effective dose to the population by interventional cardiology (IC) procedures performed during 2002-11 at the main hospital of Aosta Valley Region that can be considered as representative of the health-care level I countries, as defined by the UNSCEAR, based on its socio-demographic characteristics. IC procedures investigated were often multiple procedures in patients older than 60 y. The median extreme dose-area product values of 300 and 22 908 cGycm(2) were found for standard pacemaker implantation and coronary angioplasty, respectively, while the relative mean per-procedure effective dose ranged from 0.7 to 47 mSv. A 3-fold increase in frequency has been observed together with a correlated increase in the delivered per capita dose (0.05-0.27 mSv y(-1)) and the collective dose (5.8-35 man Sv y(-1)). Doses increased particularly from 2008 onwards mainly because of the introduction of coronary angioplasty procedures in the authors' institution. IC practice contributed remarkably in terms of effective dose to the population, delivering ∼10% of the total dose by medical ionising radiation examination categories.

Fundamental study on the characteristics of a radiophotoluminescence glass dosemeter with no energy compensation filter for measuring patient entrance doses in cardiac interventional procedures

Cardiac interventional procedures have been increasing year by year. However, radiation skin injuries have been still reported. There is a necessity to measure the patient entrance skin dose (ESD), but an accurate dose measurement method has not been established. To measure the ESD, a lot of radiophotoluminescence dosemeters (RPLDs) provide an accurate measurement of the direct actual ESD at the points they are arrayed. The purpose of this study was to examine the characteristics of RPLD to measure the ESD. As a result, X-ray permeable RPLD (with no tin filter) did not interfere with the percutaneous coronary intervention procedure. The RPLD also had good fundamental performance characteristics. Although the RPLD had a little energy dependence, it showed excellent dose and dose-rate linearity, and good angular dependence. In conclusion, by calibrating the energy dependence, RPLDs are useful dosemeter to measure the ESD in cardiac intervention.

Short-term results of transcatheter arterial embolization for abnormal neovessels in patients with adhesive capsulitis: a pilot study

BACKGROUND

Neovessels and accompanying nerves are possible sources of pain. We postulated that transcatheter arterial embolization of abnormal neovessels would relieve pain and symptoms in patients with adhesive capsulitis.

METHODS

Adhesive capsulitis was treated by transcatheter arterial embolization in 7 patients. Adverse events, changes in visual analog scale scores for night pain and overall shoulder pain, and changes in range of motion and American Shoulder and Elbow Surgeons scores were assessed at 1 week and at 1, 3, and 6 months after the procedure.

RESULTS

Abnormal neovessels were identified at the rotator interval in all patients. No major or minor adverse events were associated with the procedures. Transcatheter arterial embolization rapidly decreased nighttime pain scores from 67 ± 14 mm to 27 ± 14 mm at 1 week after the procedure, with further improvement at 1 and 6 months (6 ± 8 mm and 2 ± 5 mm, respectively). The American Shoulder and Elbow Surgeons score significantly improved from 17.8 ± 4.5 to 39.8 ± 12.0, 64.3 ± 13.9, and 76.2 ± 4.4 at 1, 3, and 6 months, respectively.

CONCLUSION

All patients with adhesive capsulitis had abnormal neovessels at the rotator interval. Transcatheter arterial embolization was feasible, relieved unrelenting pain, and restored shoulder function.

Effectiveness of fluorography versus cineangiography at reducing radiation exposure during diagnostic coronary angiography

Coronary angiography is the gold standard for defining obstructive coronary disease. However, radiation exposure remains an unwanted hazard. Patients referred for coronary angiography with abdominal circumference<45 inches and glomerular filtration rate>60 ml/min were randomized to the fluorography (n=25) or cineangiography (n=25) group. Patients in the fluorography group underwent coronary angiography using retrospectively stored fluorography with repeat injection under cineangiography only when needed for better resolution per operator's discretion. Patients in the cineangiography group underwent coronary angiography using routine cineangiography. The primary end point was patient radiation exposure measured by radiochromic film. Secondary end points included the radiation output measurement of kerma-area product and air kerma at the interventional reference point (Ka,r) and operator radiation exposure measured by a dosimeter. Patient radiation exposure (158.2 mGy [76.5 to 210.2] vs 272.5 mGy [163.3 to 314.0], p=0.001), kerma-area product (1,323 μGy·m2 [826 to 1,765] vs 3,451 μGy·m2 [2,464 to 4,818], p<0.001), and Ka,r (175 mGy [112 to 252] vs 558 mGy [313 to 621], p<0.001) were significantly lower in the fluorography compared with cineangiography group (42%, 62%, and 69% relative reduction, respectively). Operator radiation exposure trended in the same direction, although statistically nonsignificant (fluorography 2.35 μGy [1.24 to 6.30] vs cineangiography 5.03 μGy [2.48 to 7.80], p=0.059). In conclusion, the use of fluorography in a select group of patients during coronary angiography, with repeat injection under cineangiography only when needed, was efficacious at reducing patient radiation exposure.

Radiation-induced noncancer risks in interventional cardiology: optimisation of procedures and staff and patient dose reduction

Concerns about ionizing radiation during interventional cardiology have been increased in recent years as a result of rapid growth in interventional procedure volumes and the high radiation doses associated with some procedures. Noncancer radiation risks to cardiologists and medical staff in terms of radiation-induced cataracts and skin injuries for patients appear clear potential consequences of interventional cardiology procedures, while radiation-induced potential risk of developing cardiovascular effects remains less clear. This paper provides an overview of the evidence-based reviews of concerns about noncancer risks of radiation exposure in interventional cardiology. Strategies commonly undertaken to reduce radiation doses to both medical staff and patients during interventional cardiology procedures are discussed; optimisation of interventional cardiology procedures is highlighted.

ICRP PUBLICATION 120: Radiological protection in cardiology

Cardiac nuclear medicine, cardiac computed tomography (CT), interventional cardiology procedures, and electrophysiology procedures are increasing in number and account for an important share of patient radiation exposure in medicine. Complex percutaneous coronary interventions and cardiac electrophysiology procedures are associated with high radiation doses. These procedures can result in patient skin doses that are high enough to cause radiation injury and an increased risk of cancer. Treatment of congenital heart disease in children is of particular concern. Additionally, staff(1) in cardiac catheterisation laboratories may receive high doses of radiation if radiological protection tools are not used properly. The Commission provided recommendations for radiological protection during fluoroscopically guided interventions in Publication 85, for radiological protection in CT in Publications 87 and 102, and for training in radiological protection in Publication 113 (ICRP, 2000b,c, 2007a, 2009). This report is focused specifically on cardiology, and brings together information relevant to cardiology from the Commission's published documents. There is emphasis on those imaging procedures and interventions specific to cardiology. The material and recommendations in the current document have been updated to reflect the most recent recommendations of the Commission. This report provides guidance to assist the cardiologist with justification procedures and optimisation of protection in cardiac CT studies, cardiac nuclear medicine studies, and fluoroscopically guided cardiac interventions. It includes discussions of the biological effects of radiation, principles of radiological protection, protection of staff during fluoroscopically guided interventions, radiological protection training, and establishment of a quality assurance programme for cardiac imaging and intervention. As tissue injury, principally skin injury, is a risk for fluoroscopically guided interventions, particular attention is devoted to clinical examples of radiation-related skin injuries from cardiac interventions, methods to reduce patient radiation dose, training recommendations, and quality assurance programmes for interventional fluoroscopy.

The necessity of follow-up for radiation skin injuries in patients after percutaneous coronary interventions: radiation skin injuries will often be overlooked clinically

BACKGROUND

Percutaneous coronary intervention (PCI) offers great benefit that could improve a patient's quality of life. However, numerous case reports of patient radiation injury resulting from PCI are being published, these reports likely represent a small fraction of the actual cases.

PURPOSE

To demonstrate the appropriate duration of patient follow-up after PCI to identify radiation effects.

MATERIAL AND METHODS

We evaluated 400 consecutive PCIs. The radiation dose (dose-area product, cumulative dose, maximum skin dose), number of cine runs, and fluoroscopic time were recorded for all patients. The skin on the patients' backs was reviewed periodically after PCI.

RESULTS

Radiation skin effects occurred in six patients from PCI of the right coronary artery in chronic total occlusion (CTO) patients (mild erythema; occurrence rate 1.5%). Skin injury in two patients appeared in cycles. In most cases, erythema was vividly seen at 4 weeks after PCI.

CONCLUSION

Careful observation for skin injury is needed. At a few days following PCI, early erythema can be detected through careful observation by well-trained staff. At 7-10 days after PCI, most erythematous pigmentation can be detected. At 4 weeks after PCI, most skin erythema appears clearly, however, some cases of skin erythema occur without back pain. After that, follow-up every 6 months is needed to detect the reappearance of erythema.

Radiation doses in a newly founded Interventional Cardiology department

Coronary angiography (CA) and percutaneous transluminal coronary angioplasty (PTCA) radiation doses were investigated in a recently founded Interventional Cardiology (IC) department. The study includes 336 procedures (177 CAs and 159 PTCAs) carried out with a Philips digital flat detector monoplane system. Patient dose was measured in terms of kerma-area product (KAP) and cumulative dose. Using appropriate conversion factors, peak skin dose (PSD) and effective dose (E) were estimated. Median values of KAP (Gy cm(2)), PSD (mGy) and E (mSv) were: 34 478 and 6.1, respectively for CA and 80 885 and 14.4 for PTCA, within European and international reference levels. Only 1.5 % of patients received radiation dose over the 2 Gy threshold (PTCA procedures) for deterministic effects and none reported any skin effect. Radiation doses were within international standards and comparable with other radiological examinations. The percentage of the high-risk patients for radiation skin effects is extremely low.

Comprehensive review of TIPS technical complications and how to avoid them

OBJECTIVE

The goal of this article is to describe potential technical complications related to transjugular intrahepatic portosystemic shunts (TIPS) placement and to discuss strategies to avoid and manage complications if they arise.

CONCLUSION

TIPS is an established interventional therapy for complications of portal hypertension. Although TIPS remains a relatively safe procedure, direct procedure-related morbidity rates are as high as 20%. The technical complexity of this intervention increases the risk for methodologic mishaps during all phases of TIPS placement, including venous access and imaging, transhepatic needle puncture, shunt insertion, and variceal embolization. Thus, interventional radiologists require a thorough stepwise understanding of TIPS insertion, possible adverse sequela, and technical tips and tricks to maximize the safety of this procedure.

Evaluating the maximum patient radiation dose in cardiac interventional procedures

Many of the X-ray systems that are used for cardiac interventional radiology provide no way to evaluate the patient maximum skin dose (MSD). The authors report a new method for evaluating the MSD by using the cumulative patient entrance skin dose (ESD), which includes a back-scatter factor and the number of cineangiography frames during percutaneous coronary intervention (PCI). Four hundred consecutive PCI patients (315 men and 85 women) were studied. The correlation between the cumulative ESD and number of cineangiography frames was investigated. The irradiation and overlapping fields were verified using dose-mapping software. A good correlation was found between the cumulative ESD and the number of cineangiography frames. The MSD could be estimated using the proportion of cineangiography frames used for the main angle of view relative to the total number of cineangiography frames and multiplying this by the cumulative ESD. The average MSD (3.0 ± 1.9 Gy) was lower than the average cumulative ESD (4.6 ± 2.6 Gy). This method is an easy way to estimate the MSD during PCI.

Clinical radiation management for fluoroscopically guided interventional procedures

The primary goal of radiation management in interventional radiology is to minimize the unnecessary use of radiation. Clinical radiation management minimizes radiation risk to the patient without increasing other risks, such as procedural risks. A number of factors are considered when estimating the likelihood and severity of patient radiation effects. These include demographic factors, medical history factors, and procedure factors. Important aspects of the patient's medical history include coexisting diseases and genetic factors, medication use, radiation history, and pregnancy. As appropriate, these are evaluated as part of the preprocedure patient evaluation; radiation risk to the patient is considered along with other procedural risks. Dose optimization is possible through appropriate use of the basic features of interventional fluoroscopic equipment and intelligent use of dose-reducing technology. For all fluoroscopically guided interventional procedures, it is good practice to monitor radiation dose throughout the procedure and record it in the patient's medical record. Patients who have received a clinically significant radiation dose should be followed up after the procedure for possible deterministic effects. The authors recommend including radiation management as part of the departmental quality assurance program.

A study of the relationship between peak skin dose and cumulative air kerma in interventional neuroradiology and cardiology

A study of peak skin doses (PSDs) during neuroradiology and cardiology interventional procedures has been carried out using Gafchromic XR-RV2 film. Use of mosaics made from squares held in cling film has allowed doses to the head to be mapped successfully. The displayed cumulative air kerma (CAK) has been calibrated in terms of cumulative entrance surface dose (CESD) and results indicate that this can provide a reliable indicator of the PSD in neuroradiology. Results linking PSD to CESD for interventional cardiology were variable, but CAK is still considered to provide the best option for use as an indicator of potential radiation-induced effects. A CESD exceeding 3 Gy is considered a suitable action level for triggering follow-up of patients in neuroradiology and cardiology for possible skin effects. Application of dose action levels defined in this way would affect 8% of neurological embolisation procedures and 5% of cardiology ablation and multiple stent procedures at the hospitals where the investigations were carried out. A close relationship was observed between CESD and dose-area product (DAP) for particular types of procedure, and DAPs of 200-300  Gy cm(2) could be used as trigger levels where CAK readings were not available. The DAP value would depend on the mean field size and would need to be determined for each application.

Overview of contemporary interventional fluoroscopy procedures

Interventional fluoroscopy procedures are increasingly important in medical practice. As new procedures are introduced and validated, they tend to replace the equivalent surgical procedure. There is wide variation in patient dose, both among procedures and for a specific procedure. Stochastic risk is present, but interventional fluoroscopy procedures may also present deterministic risk. Radiation risk/benefit analyses are different for interventional fluoroscopy procedures than they are for diagnostic imaging procedures. The radiation risk component of an interventional fluoroscopy procedure is substantially less than the other procedural risks, and there is always clear and measurable benefit to the patient from a successful procedure. Optimizing patient dose will require both improvements in equipment technology and greater attention from regulators, accrediting bodies and medical organizations. Ensuring adequate operator training is essential.