Euro CTO Club – The radiation survey Nicolaus Reifart, Germany The Experts “Live” Workshop 2017 Friday, September 15th, 2017

1. CTO & Radiation
Nicolaus Reifart
Bad Soden / Wuppertal

2. What to expect 2013/2016
50 49
99.8
27.2
61.1
3.7 3.9 6.2
1.25 2.5
0
20
40
60
80
100
120
US 2013/14 Jap. reg ante Jap.reg.retro € CTO ante € CTO retro
Fluoro (min) AK (Gy)

3. Operator Radiation Index
Air Kerma (mGy) / Fluorotime (min)
Mainly influenced by operator habits
and X-ray equipment
ORI

4. What to expect 2013/2016
50 49
99.8
27.2
61.1
3.7 3.9 6.2
1.25 2.5
0
20
40
60
80
100
120
US 2013/14 Jap. reg ante Jap.reg.retro € CTO ante € CTO retro
Fluoro (min) AK (Gy)
62 45 4070 79

5. Room for improvement:
Changes of AirKerma over time per operator
G.Werner

6. 10 important steps to lower
radiation exposure in CTO PCI

7. The most important question:
The indication -
Does this patient need to be
cathed?
04.04.2016
1

8. 04.04.2016
Shield close to patients body and
close to access  -50% scatter
radiation
(Fetterly, Magnuson et al. 2011)
2
- 50 %
Good radiation habits
Disregarded rules at CTO live course 2015….

9. Radioprotection for the operator
Murphy JC, et al Am J Cardiology. 2011;108:1408-1410
RADPAD protection reduces scatter to operator:
Randomized study in 60 patients (40 CTOs)
G.Werner

10. 04.04.2016
Detector closer to patient:
Less scatter radiation
Better image quality
(Haqqani, Agarwal et al. 2011 Vascular Annual
Meeting of the Society for Vascular Surgery)
Also: Table height matters.
3
- 20 %
Good radiation habits

11. 04.04.2016
Avoid strong angulations
Journal of Vascular Surgery 2012 55, 799-805
Worst angulations: LAO lateral, caudal and
cranial. Use PA angulations if possible
(Kuon , JACC 2004)
Avoid “ dark” obstacles: Bones, metal
belly and liver (deep breath)
4
- 80 %
Good radiation habits

12. 3.3 mGy/s 2.9 mGy/s
4
Dont forget to collimate
- 12 %
+

13. Film runs as short as
possible
• 2 heartbeats are sufficient to
visualize lesions
–If you need to visualize late filling:
start with fluoro with cine to follow
(e.g. contralateral injection)
04.04.2016
5
- 40 %

14. 5 heartbeats + panning

15. - 80%

16. Shade the „sunny“ part
• Reduces
radiation
• Improves
picture-quality
04.04.2016
7
- 10 %
+

17. Good radiation habits
04.04.2016
Step back while
filming6
- 80 %
Tube: 1m
Cost: 0.5€

18. 04.04.2016
- 75 %
The fantastic little tube saves you…

19. Fluoroscopy Cine
Fluoro instead of Cine
0.1 mGy/sec 1.0 mGy/sec
- 90 %
7

20. Fluoro
Store/Last
Image Hold for
documentation
Know your machine

21. Frame rate 7.5/s = 1 mGy/sFrame rate 15/s =2.2 mGy/s
8
Reduced frame rate!
- 55 %

22. Avoid magnification!
Increases radiation 2 to 4 fold
04.04.2016
9
- 60%
x 1.6 - 4

23. 98 vs 98 patients; single operator 7.5 F/s
04.04.2016
10
6149
4078
0
1750
3500
5250
7000
mean Dose Area Product in cGy*cm²
AlluraXper Clarity
p < 0.000002
J. Reifart, DGK Mannheim 2016
- 30 %
-30% of total dose
regardless of user
X-ray equipment matters

24. No stump
CTO bend > 45
degr.
Tryed before

25. No stump
CTO bend > 45 degr.
CTO length > 10 cm
Tryed before
JCTO 4

27. Proc. Time 110 min
Fluoro 21.54 min
AK 0.546 Gy
ORI: 25
Dye; 270 ml

28. The 10 + Take home
messages:
1. Proper indication
2. Use all kinds of shielding (transparent,
leaden curtain, legs and abdomen)
3. Adjust detector & table
4. Collimation
5. Avoid magnification
6. Avoid bones, metal and liver (deep breath)

29. The 10 + Take home
messages:
7. Avoid LAO lateral/caudal/ cranial if
possible
8. Keep Cine runs short, Fluoro instead of
Cine
9. 7.5 frames/sec not 15 or 30
10. Step back while filming (tube!)
11.Use optimal equipment