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Gerald S. Werner - Managing radiation for patient and operator safety
- 1. Managing radiation for patient and operator safety Gerald S. Werner, MD, FESC, FACC, FSCAI Klinikum Darmstadt GmbH Darmstadt
- 2. Disclosure • The modified protocols for radiation exposure were implemented in cooperation with Siemens Healthineers, Forchheim, Germany • Speaker’s fees received from Philips • Other speaker’s fees from Abbott Vascular, ASAHI Intecc, Bayer, Biotronik, Pfizer, Shockwave, Terumo
- 3. Complications associated with CTO intervention Patel et al JACC 2013; 71: 160 – 164 Only 7 of 65 studies looked at skin injury
- 4. A 52-year-old patient after a (failed) CTO procedure A LAD CTO was tried mostly in AP cranial with >140 cine runs taken at 25 f/s -> presumed dose >20 Gy Werner GS. EuroInterv 2018; e496-8 LAD successfully opened with 6 p/s and 7.5 f/s, few cine runs, and shallow angles Duration: 212 min Fluouro time: 85.4 min Contrast: 180 cc Dose: 2.2 Gy
- 5. Occupational hazards of doing (complex) PCI
- 6. APCTO Algorithm: Reasons to stop the procedure introduced Harding SA et al. JACC Int 2017;10:2135-43
- 7. Improvement in management is possible but still too much individual variability Werner et al J Inv. Cardiol 2021;33:E146-E154 Changes in ERCTO Registry operators from 2012 - 2017 2017
- 8. You should watch your radiation speed continuously
- 9. Changing angulation influences dose 58 mGy/min LAO 45° 39 mGy/min LAO 30°
- 10. Lower fluoro frame rate 7.5 vs 15, but… Abdelaal et al JACC Interv 2014; 7: 567– 74 Why is there not more of a difference ? • Used 15 f/s for cine • The contribution of cine runs to the total dose should not be underestimated • Avoid cine runs when ever possible, use fluoro storage • Cine at 7.5 f/s Werner et al J Inv. Cardiol 2021;33:E146-E154
- 11. Avoid filming as often as possible Fluoro dose only 2% of cine dose !!!
- 12. A comparison of noise-reduction protocols Werner et al CCI 2021; 97:1196-1206 Dose Rate Index normalizes AirKerma per min Fluoroscopy time
- 13. Is it down to the equipment ? Clarity systems had the lowest DRI But even with an “old” system you could achieve the same range of efficiency It seemed that Clarity limited the outliers Werner et al J Inv. Cardiol 2021;33:E146-E154
- 14. Dramatic changes over time with the same equipment !!! 2011 2017-18 2019-20 Werner et al CRM 2022;36:58-64 • Fluoroscopy was optimized to a high efficiency early on • Further reduction was achieved by reducing cineangiographic exposure
- 15. We exceeded the 5 Gy limit in 10.4 % of patients ! FT 32.7 min CV 204 cc AK 2040 mGy DAP 127 Gy*cm2 Werner et al CCI 2021; 97:1196-1206
- 16. Never exceeded the 5 Gy limit ever again !!! FT 32.7 min CV 204 cc AK 2040 mGy DAP 127 Gy*cm2 FT 34.7 min CV 202 cc AK 655 mGy DAP 37 Gy*cm2 Werner et al CCI 2021; 97:1196-1206
- 17. © Philips - Confidential DoseWise Azurion SpectraBeam filtration with the powerful MRC tube enables: • Enhanced Image Quality at the same patient dose or • Reduced patient dose at the same Image Quality No relation between detector dose and patient dose 17 SpectraBeam Filtration MRC X-ray tube 0.4mm Cu Conventional X-ray tube
- 18. © Philips - Confidential DoseWise Azurion A “speedometer” for dose rate • Actual and predicted air kerma rate. • Operator sees predicted dose rate while selecting views and settings. Operator actions modify the prediction • Operator can modify projection, table height, SID, fluoro mode and other parameters to manage dose rate A “fuel gauge” for accumulated skin dose • Predicted skin dose by body zone • Estimated time until limit is reached 18 Dose information/communication RAO-cranial LAO-cranial RAO-caudal LAO-caudal
- 19. There is never too much protection for the operator RampartIC Zero-Gravity
- 20. Final remark • The potential of further reduction of radiation exposure to the patient and the operator is still not optimized • Operators are still often oblivious of ways to optimize their radiation use • In my own practice, radiation has no longer been a concern for abandoning a procedure, but we constantly aim at optimizing dose efficiency
- 21. Final remark • The potential of further reduction of radiation exposure to the patient and the operator is still not optimized • Operators are still often oblivious of ways to optimize their radiation use • In my own practice, radiation has no longer been a concern for abandoning a procedure, but we constantly aim at optimizing dose efficiency