Pancholy S - AIMRADIAL 2013 - Radiation exposure

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Influence of access-site on radiation exposure in cardiac catheterization

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Pancholy S - AIMRADIAL 2013 - Radiation exposure

  1. 1. Influence of Access-site on Radiation Exposure in Cardiac Catheterization Systematic Review and Meta-Analysis of Observational and Randomized Trials Samir Pancholy, MD, Guillaume Plourde, Imdad Ahmed Sunil Rao, Sanjit Jolly, Sripal Bangalore, Tejas Patel, Olivier Bertrand AimRADIAL2013
  2. 2. Disclosures Research grants: Cordis, Eli-Lilly, Bristol-MyersSquibb, GE Healthcare, Sanofi-Aventis, Eurocor Consultant: Cordis, Astra-Zeneca, Opsens Research-Scholar from Quebec Fund for Health Research
  3. 3. Background Large pool of data comparing TRA vs. TFA radiation exposure However, it remains unclear whether TRA is associated with clinically significant increase in radiation exposure
  4. 4. Background Radiation burden a function of many variables Patient substrate Operator experience Operator awareness Equipment Angiographic routine
  5. 5. Objectives To perform a systematic review and meta-analysis of ALL studies (observational & randomized) comparing radiation exposure between TRA and TFA for:  Diagnostic coronary angiograms (DCA)  Percutaneous coronary intervention (PCI)
  6. 6. Methods Standard PRISMA, QUOROM (randomized) and MOOSE (observational) protocols PubMed, Embase, Cochrane databases using “radial”, “femoral”, “cardiac catheterization”, “radiation exposure”, “fluoroscopy time”, “dose-area-product” Cross-referencing with The Radialist.org Last update: June 26 2013
  7. 7. Outcomes Patient’s radiation exposure  Fluoroscopy time (FT) (minutes)  Dose-area-product (DAP) (Gy ・ cm2) Operator’s radiation exposure  Radiation dose (µSv)
  8. 8. Meta-Analysis Data summarised as the mean difference of continuous variables with 95% confidence intervals Combined using the DerSimonian and Laird random effects model with inverse variance weighting When SD were missing, or data expressed as medians with IQR, authors were contacted Subgroups were based on intervention type (DCA vs. PCI) Separate analyses for randomized and observational studies, and a third combining both
  9. 9. Studies selection Total of 666,765 patients
  10. 10. Studies Characteristics 68 studies (666,765 patients), conducted between 1995-2013 18 randomized trials (n=12,051); 50 observational studies (n=654,714) 60 single-center and 8 multi-center studies In randomized trials, 6,193 TRA and 5,858 TFA
  11. 11. Impact on FT in diagnostic coronary angiograms Randomized Observational
  12. 12. Impact on FT in percutaneous coronary interventions Randomized Observational
  13. 13. Impact on DAP in diagnostic coronary angiograms Randomized Observational
  14. 14. Impact on DAP in percutaneous coronary interventions Randomized Observational
  15. 15. TF vs TR Fluoro time (Diagnostic)
  16. 16. LRA vs RRA Fluoro time (PCI)
  17. 17. Effect of Training
  18. 18. Effect of Training
  19. 19. Effect of Training
  20. 20. Operator Exposure Sciahbasi A
  21. 21. Impact on Operator Dose
  22. 22. Relationship Between Years Since 1992 and Fluoroscopy Time PCI Cohort (Non-randomized) TRA TFA
  23. 23. Non-randomized trials 80 70 60 Dose-Area Product TR TF 50 Linear (TR) Linear (TF) 40 30 20 18 years later 10 0 10 12 14 16 18 20 Years since first descrip on of TRI 22 24
  24. 24. Meta-regression of Fluoroscopy time and Year of Publication since First Description of TRI (1992) (Randomized) 6.00 Difference in means 5.20 P = 0.0001 4.40 3.60 2.80 2.00 1.20 0.40 -0.40 -1.20 -2.00 2.30 4.34 6.38 8.42 10.46 12.50 Years 14.54 16.58 18.62 20.66 22.70
  25. 25. Non-randomized Studies Reporting Fluoroscopy Time (PCI) 10.00 P = 0.0001 Difference in means Fluoroscopy Time 8.60 7.20 5.80 4.40 3.00 1.60 0.20 -1.20 -2.60 -4.00 6.70 8.26 9.82 11.38 12.94 14.50 16.06 17.62 Years since TRI Publication 19.18 20.74 22.30
  26. 26. Conclusion FT and DAP in TRA continues to decrease over the last years TRA, when compared to TFA in the last 5 years, was associated with <1 minute higher FT for DCA and PCI Radiation exposure is moderately increased when initially adopting TRA (like many other skills), with high likelihood of progressive decrease with increasing experience.

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