How to Reduce The Fluoroscopy Exposure

During TRI Procedure

Li Yue, M.D.
The First Affiliated Hospital of

Harbin Medical University

Vascular Complication

Transradial intervention (TRI)

Radial artery offers an effective (LM, true bifurcation, AMI elderly patients, CTO, etc.) and more safe alternative site for performing diagnostic and interventional coronary procedures.
Yonsei Med J. 2005 Aug 31;46(4):503-10
Yonsei Med J. 2006 Oct 31;47(5):680-7 Chin Med J. 2007 Apr 5;120(7):539-44 Circ J. 2007 Jun;71(6):855-61 Chin Med J. 2007 Apr 5;120(7):598-600

Catheter Cardiovasc Interv. 2007 1;70(5):670-5

J Invasive Cardiol. 2004 Mar;16(3):129-32 Am J Cardiol. 2004 May 15;93(10):1282-5 Am Heart J. 2008 Nov;156(5):864-70 Catheter Cardiovasc Interv. 2009 Jun 1;73(7):883-7

Cardiovasc Revasc Med. 2009 Apr-Jun;10(2):73

Catheter Cardiovasc Interv. 2010 Jun 1;75(7):991-5

Chronic kidney injury

Conclusion: The TRI is associated with less CKD than the TFI.
Heart. 2010 Oct;96(19):1538-42.

Germany

297 cases (Oct. 2000 Mar. 2002)

One invasive cardiologist (H.W.L.) who had vast experience in

radial access catheterization (> 1,500 cases)

Catheter Cardiovasc Interv. 2006 Jan;67(1):12-6

Conclusion: TRI is burdened with a 100% increase in operator radiation exposure during diagnostic coronary catheterization procedures and a 50% increase during coronary interventions.

Eur Heart J. 2008 Jan;29(1):63-70.

Operator

Patient

Conclusion: TRI increase radiation exposure of operators despite extensive use of specic protection devices is currently a growing problem for the interventional cardiologist health.

Radiation exposure during various lesions PCI

CTO

Circ J. 2006 Jan;70(1):44-8

Radiosensitive indicators are arranged on the jacket

Suzuki et al Circ J 2006; 70: 44 48

72 cases
Catheter Cardiovasc Interv. 2008 Feb 1;71(2):160-4

The maximum ESD exceeded 1 Gy in 66 procedures, 3 Gy in 32 procedures, and 5 Gy in 15 procedures. exceed the thresholds for radiation skin injuries in many cases.
The thresholds of transient erythema, permanent epilation, and delayed dermal necrosis are 2, 7, and 12 Gy.

Am J Cardiol. 2010 Oct 1;106(7):936-40

Operator experience

1,813 catheterization cases performed at a high-volume (1400 cases/year) institution between January 2007 and July 2009 by 5 cardiologists.

4 months during which femoral access was the default approach (femoral n = 340)

6 months during which operators transitioned from femoral to radial

access (femoral n = 405, radial n = 280)

6 months during which radial access was the default approach

(femoral n = 103, radial n = 685)

Table 1. Radiation Variables for Diagnostic Angiography

Femoral Access (n = 412)
Fluoroscopy Time Dose Area Product 2.34 min (IQR 1.49-4.18) 1,657 Gy/m2 (IQR 1,064-2,376)

Radial Access (n = 459)

4.43 min (IQR 2.55-8.18) 1,837 Gy/m2 (IQR 1,172-2,783)

P Value
< 0.001 < 0.001

Radial access was associated with almost a doubling of fluoroscopy time and a 20% increase in radiation dose area product compared with femoral access.

Table 2. Radiation Variables for PCI

Femoral Access (n = 436) Radial Access (n = 506) P Value < 0.001 0.08

Fluoroscopy Time
Dose Area Product

9.36 min (IQR 6.13-14.27)

12.02 min (IQR 7.57-17.54)

3,392 Gy/m2 3,682 Gy/m2 (IQR 2,139-5,193) (IQR 2,388-5,314)

For PCI cases, fluoroscopy time also was higher in the radial group vs. the femoral group, but that did not translate into a difference in dose area product.

The authors say that in the initial stages of radial experience, longer [fluoroscopy times] are required to navigate the guidewire to the aortic root, overcoming anatomic variations and loops. Catheter engagement to the coronary ostia may also require more manipulation compared to the femoral approach.

The emphasis should not be on whether there is a slight difference between doing radial and femoral but why there is such broad variability among operators at the same

institution who presumably are doing similar cases.

Catheter Cardiovasc Interv. 2008 Feb 1;71(2):160-4

Archives of Cardiovascular Disease(2009) 102,821-827

Aims - To assess the effectiveness of a dose-reduction programm based on radiation protection training, according to the recommendations of the Euratom Council, the International Commission on Radiological Protection and the French Society of Cardiology.

The radial approach was used in > 80% of the procedures.

Radiation dose-reduction programme

low uoroscopic and cine pulse rates (6.25 and 12.5 frames/second, respectively); a large intensier eld size (23 cm) with an a posteriori numeric magnication; maximal collimation; optimal X-ray tube/patient/image intensier distances (maximal source-patient distance, minimal patient-image intensier distance). Routine left ventriculography was discouraged. The number of runs, choice and angulation of the projections necessary to obtain the best possible analysis of the coronary arteries were not limited.

Conclusion Training in radiation protection were associated with a 50% reduction in radiation exposure to patients undergoing invasive cardiac procedures, without any loss of diagnostic information.

Types of radiation injury

Deterministic injury Occur once a threshold level of exposure has been exceeded. Skin and eye injuries
>2Gyopacity of lens >5Gy, cataracta

Stochastic injury ( Any level of exposure can cause injury Cancer.

 Any

cells that are immature, undifferentiated, and actively

dividing (ie, stomach mucosa, basal layer of skin, stem cells) are

more radiosensitive than mature, nondividing cells.

Radiation effects on the human cell

Direct cellular damage

S-phase cells are particularly radioresistant

Indirect cellular damage through production of reactive oxidative species

Ionizing radiation can cause hydrolysis of water

within the cell, resulting in a hydrogen molecule and hydroxyl (free radical) molecule production. Two-thirds of

radiation-induced DNA damage is a consequence of the

indirect damage done by freely diffusing hydroxyl radicals(.

Radiation-induced skin injuries

The incidence is small when compared with the number of
uoroscopically guided procedures performed, but the consequences can be devastating.

Risk factors

Patient history

Area

of skin exposed (Sensity)

X-ray exposure itself (Dose)

Patient history

1. connective tissue disorders, particularly lupus, scleroderma (), and mixed connective tissue disorder. 2. Ataxia telangiectasia() a rare, autosomal recessive disorder 3. with other cellular DNA repair abnormalities or chromosomal breakage syndromes () 4. Diabetes and hyperthyroidism 5. Chemotherapeutic agents (actinomycin D, doxorubicin, bleomycin,
5-uorouricil, and methotrexate)

6. Obesity: More radiation is necessary to penetrate the body in larger patients

Effective skin dose is determined by BMI (patient) and fluoro time (operator)
Suzuki et al Circ J 2007; 71: 229 233

Differential skin sensity

Care needs to be particularly taken in areas of thinner skin

and extremities. The areas of the body ranked from most to least sensitive are: Anterior neck > antecubital()and popliteal spaces () > exor () surfaces of extremities > chest and abdomen > face > back, extensor () surfaces > nape of neck > scalp () > palms and soles.

Skin entrance dose thresholds for skin injury

Effect Dose(Gy) 2 6 7 10 10 10 12 14 18 15 18 24 Onset Hours 10 days 3 weeks 12 weeks-1 year >1 year >1 year >1 year 4 weeks 4 weeks 8-10 weeks >10 weeks 6 weeks

Early transient erythema Main erythema Permanent epilation Dermal atrophy Induration Telangiectasia Late dermal necrosis Dry desquamation Moist desquamation Late erythema Ischemic dermal necrosis Secondary ulceration

5 Gy skin rash Weeks after procedure resolved after 6 months

20 Gy initial dermatitis 2 months after procedure Image 2 years after

Radiation-induced lens injuries

Manifest as posterior subcapsular opacities(. The latent period between exposure and onset appears to be

inversely related to dose.

The minimum dose required to produce opacities in the lens is

approximately 1.3 Gy for acute exposures, 4 Gy for fractionated exposures.

LONG-TERM CANCER RISK

Am Heart J, 2009; 157: 118-24

In summary, there is some evidence that occupational exposure increases the incidence of cancer, particularly female breast cancer or leukemia, but the evidence is weak at current exposure levels.

How to minimizing X-ray injury to the patient ?

Careful review of the patients history

Position the detector as close to the patient as practicable, with the x-ray tube as far from the patient as possible.

If the detector is positioned far from the patient, the image may be blurred, the uoroscopic machine in ABC (automatic brightness control) mode will automatically increase the kVp or mA, or both, to improve the image brightness, this results in increased radiation dose to the patient.

Use the exposure pedal as sparingly as possible.

Radiation exposure during uoroscopy is directly

proportional to the length of time the unit is activated by the foot pedal switch.

U.S. FDA guidelines require that the total elapsed

uoroscopy time be recorded in the patient record for every patient procedure.
heavy foot on the X-ray pedal

Use a low pulse rate uoroscopy

Decrease from 30 pulses to 15 or 7.5 pulses per second whenever possible.

View and save images with last-image-hold/ fluoro-store.

This allows for storing and reviewing of the last image

without re-exposing the patient to more radiation.

Use magnication only when necessary

In the ABC mode, more radiation is used to brighten and sharpen the image during magnication.
Alter

the position of the beam if possible, particularly

during long cases, to avoid a prolonged exposure to one small area of skin.

Make sure that extraneous body parts are out of the eld. dose given in a short amount of time is more

A large

damaging than the same dose given over a longer period of

time.
Fractionation of the total dose, allowing time for healing between exposures, can increase tissue tolerance.

but do not stop after 60 min fluoro when the case is progressing, all the risk were in vain.

How to minimizing radiation exposure to the staff ?

Time Distance Radiation dose increase or decrease according to the inverse square of the distance from the source.

Graphic representation of the inverse square law ()

Shielding
Lead eye glasses reduces the eye dose to 2% to 3% of

baseline dose, resulting in a few microsieverts of eye

exposure per procedure.