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The Detrimental Impact of Chronic Renal Insufficiency

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									   DOES TRANSRADIAL
  INTERVENTION IMPACT
  RADIATION EXPOSURE

              Dr Jim Nolan
University Hospital of North Staffordshire
    Mihran Kassabian (1870-1910)




7/27/2013                          1
RADIATION EXPOSURE IS IMPORTANT
  Skin injury due to cardiac intervention
          RADIATION EXPOSURE IS IMPORTANT
              Accessory pathway ablation




3 weeks
               5 months

                                6.5 months
OPERATORS ALSO GET RADIATION
     INDUCED SKIN INJURY
RADIATION EXPOSURE AND CANCER RISK
 RADIATION IS IMPORTANT

If radial access is associated with a
    significant increase in radiation
 exposure this will offset some of its
other proven benefits and could limit
             its applicability
  Review of recent literature comparing radiation exposure in transfemoral
                  and transradial cardiac catheterisation



Reference             FA                                    RA

                      No    DAP        FT (min)   Rad Exp   No    DAP         FT (min)   Rad Exp
                            (Gycm2)               (uSv)           (Gycm2)                (uSv)
Mann et al 1996 -     126                         8.8       138                          13.5
PCI
Sandborg et al        40    38±22      4.6±4                36    51±25       7.5±4
2003 -CA
Sandborg et al        42    47±34      12.5±9               24    75±47       18.4±9
2003 –CA+PCI
Sandborg et al        82    43±29      8.6±8                60    61±37       11.9±9
2003 -All
Larrazet et al        184   138        12                   218   175         17
2003 –ad hoc PCI


Geijer et al 2004 -   114   69.8       16.4                 55    70.5        18.1
PCI
Lange et al 2006      103   13.1±8.5   1.7±1.4    32±39     92    15.1±8.4    2.8±2.1    64±55
–CA
Lange et al 2006      48    51±29.4    10.4±6.8   110±115   54    46.3±28.7   11.4±8.4   166±188
-PCI
RADIAL ACCESS INCREASES
RADIATION EXPOSURE FOR
PATIENTS AND OPERATORS
  Review of recent literature comparing radiation exposure in transfemoral
                  and transradial cardiac catheterisation



Reference             FA                                    RA

                      No    DAP        FT (min)   Rad Exp   No    DAP         FT (min)   Rad Exp
                            (Gycm2)               (uSv)           (Gycm2)                (uSv)
Mann et al 1996 -     126                         8.8       138                          13.5
PCI
Sandborg et al        40    38±22      4.6±4                36    51±25       7.5±4
2003 -CA
Sandborg et al        42    47±34      12.5±9               24    75±47       18.4±9
2003 –CA+PCI
Sandborg et al        82    43±29      8.6±8                60    61±37       11.9±9
2003 -All
Larrazet et al        184   138        12                   218   175         17
2003 –ad hoc PCI


Geijer et al 2004 -   114   69.8       16.4                 55    70.5        18.1
PCI
Lange et al 2006      103   13.1±8.5   1.7±1.4    32±39     92    15.1±8.4    2.8±2.1    64±55
–CA
Lange et al 2006      48    51±29.4    10.4±6.8   110±115   54    46.3±28.7   11.4±8.4   166±188
-PCI
           TRANSRADIAL APPROACH
             THE LEARNING CURVE




• Puncture failure, spasm, different guide manipulation
      Is it valid to compare experienced femoral operators with less
                        experienced radial operators
DAP




                     28% reduction in radiation exposure related to
                     learning curve
        Influence of learning curve on radiation
                        exposure
DAP Gycm2
PATIENT CHARACTERISTICS ARE IMPORTANT
FLUOROSCOPY MODE AND PATIENT
  MORPHOLOGY ARE IMPORTANT
PERIPHERAL VASCULAR DISEEASE ALSO IMPACTS
           ON RADIAL OPERATORS
MISMATCH OF PATIENT AND
   OPERATOR VARIABLES
 INVALIDATE THE EXISTING
 OBSERVATIONAL STUDIES
  RANDOMISED COMPARISON OF OPERATOR RADIATION
           EXPOSURE AND ACCESS SITE
           (Lange et al, CCI 2006, n = 297)

                     RADIAL   FEMORAL     P
DIAGNOSTIC STUDIES

FT (mins)              2.8      1.7     <0.001
DAP (Gy.cm2)          15.1      13.1     <0.05
ORE (µSv.cm2)          64        32      <0.001

PERCUTANEOUS

FT (mins)             11.4      10.4     NS
DAP (Gy.cm2)          46.3      51.0     NS
ORE (µSv.cm2)         166       110     <0.05
      USE OF ADDITIONAL RADIATION SCREENING
           (Tift Mann et al, JIC 1996, n = 264)




                FEMORAL       RAD-1        RAD-2


FLUORO TIME       16            19           18
(mins)



OPERATOR DOSE     8.8           13.5         3.3
PER CASE
(mrem/min)
  The inadeqate radiation
protection protocol imposed
   on the radial operators
 invalidates the randomised
             trial
   WHAT CAN AN
EXPERIENCED RADIAL
OPERATOR ACHIEVE?
  TRANSRADIAL PROCEDURES AT UHNS – RADIATION
            PROTECTION PROTOCOL



• Minimise screening and acquisition times,
  and use of oblique views
• Aduct arm after puncture
• Under and over table shields
• Extension tubing from catheter to
  manifold to optimise benefits of inverse
  square law
• Increased operator shielding (shin pads,
  glasses, hat)
FLUOROSCOPY TIMES OF PATIENTS UNDERGOING CA & PCI BY THE RADIAL
         AND FEMORAL ROUTES (UHNS PILOT DATA, N=300)
RADIATION DOSES OF PATIENTS UNDERGOING RADIAL AND
        FEMORAL PCI (UHNS PILOT DATA, N=200)
        Operator radiation exposure and
      access site – UHNS controlled study
      EXPERT OPERATOR          TRAINEE OPERATOR
            P=NS                    P=NS




                         μSv
μSv
PCI OPERATIVE RADIATION EXPOSURE 2003 – 2004
         TLD BADGE READINGS - UHNS
                CONCLUSION

• The existing literature is unreliable and
  invalid
• For an experienced operator employing
  good radiation protection practice……
• There is no radiation hazard to operators
  or patients

								
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