International Atomic Energy Agency


Can cardiac procedures be
 graded in complexity and
    related with dose?
          ...
Educational Objectives


               1. Complexity related factors in
                  cardiac interventions
         ...
factors determining patient’s exposure


  adequacy of equipment
  fluoroscopy time
  cine-angiography time




       ...
simple case
straightforward right




                                     fluoro time: 1 m’ 20 sec
                      ...
difficult case
extreme vessel tortuosity




                                      fluoro time: 20 m’
                    ...
complexity related factors

         • age
         • number of vessels treated
         • occluded vessels
         • pre...
Clinical and technical determinants of the
   complexity of PTCA procedures. Analysis in
            relation to fluorosco...
PTCA characteristics
n 402, 21/06/96-08/05/98 (50% of tot)



  350                                                       ...
patients’ characteristics
n 402, M 72 % age 62±11



                                                                     ...
clinical factors tested

    • age
    • sex
    • single or multivessel disease
    • EF
    • previous CABG
            ...
Weight (seconds)       score
                Constant                      159                -
          lesion B2 (AHA) ...
complexity index/fluoro time correlation
         most significant & less operator-dependent variables

                  ...
complexity index-based stratification
fluoro time

                        2000
                        1800
             ...
complexity index-based stratification
cine frames

                      2500
                                            ...
complexity index-based stratification
total DAP

                     250

                     200
                      ...
procedural success rate
(402 cases, 50% of total activity)



              98                      97,6                  ...
fluoro time in different diagnostic
procedures (844)
          7

          6                                             ...
conclusions (I)

     •     In our experience, fluoroscopy time and total DAP
           were directly related to technica...
conclusions (II)


  • Comparison of different centers and
         operators for quality control
         assessment, as ...
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International Atomic Energy Agency Can cardiac procedures be ...

  1. 1. International Atomic Energy Agency Can cardiac procedures be graded in complexity and related with dose? L 8.3
  2. 2. Educational Objectives 1. Complexity related factors in cardiac interventions 2. Relationship of patient dose with technical and clinical factors 3. Development of complexity index and its utility Radiation Protection in Cardiology Lecture 8.3: Complexity 2
  3. 3. factors determining patient’s exposure  adequacy of equipment  fluoroscopy time  cine-angiography time operator’s experience procedure complexity Radiation Protection in Cardiology Lecture 8.3: Complexity 3
  4. 4. simple case straightforward right fluoro time: 1 m’ 20 sec total DAP: 102 dGy Radiation Protection in Cardiology Lecture 8.3: Complexity 4
  5. 5. difficult case extreme vessel tortuosity fluoro time: 20 m’ total DAP: 1074 dGy Radiation Protection in Cardiology Lecture 8.3: Complexity 5
  6. 6. complexity related factors • age • number of vessels treated • occluded vessels • previous CABG • poor Ejection Fraction quantification never proposed Radiation Protection in Cardiology Lecture 8.3: Complexity 6
  7. 7. Clinical and technical determinants of the complexity of PTCA procedures. Analysis in relation to fluoroscopy time (Cathet Cardiovasc Intervent 2000; 51:1-9) Radiation Protection in Cardiology Lecture 8.3: Complexity 7
  8. 8. PTCA characteristics n 402, 21/06/96-08/05/98 (50% of tot) 350 mean fluoro 300 one-lesion time 11,5’ ± 8,6’ multi-lesion 250 multivessel 200 150 76.3% 100 success 96.5 % 50 15.4% 8.2% 0 Stenting 49% (x procedure) Radiation Protection in Cardiology Lecture 8.3: Complexity 8
  9. 9. patients’ characteristics n 402, M 72 % age 62±11 one vessel 31% two vessels three vessels 34.9% 34.1% 6% previous CABG mean EF 58% ± 10 Radiation Protection in Cardiology Lecture 8.3: Complexity 9
  10. 10. clinical factors tested • age • sex • single or multivessel disease • EF • previous CABG no significant correlation with fluoro time or exposure parameters Radiation Protection in Cardiology Lecture 8.3: Complexity 10
  11. 11. Weight (seconds) score Constant 159 - lesion B2 (AHA) 151 - lesion > B2 (AHA) 400 1 IVUS 315 - simple stenting 157 - bifurcation stenting 331 1,5 ostial stenting 346 0,8 occlusion 3 months 943 2,8 moderate tortuosity 234° - severe tortuosity 1471 4,9 double balloon technique 350* - double wire technique 140* - p< 0.001, p<0.01*, p<0.005° Radiation Protection in Cardiology Lecture 8.3: Complexity 11
  12. 12. complexity index/fluoro time correlation most significant & less operator-dependent variables 7 6 Complexity Index 5 4 3 r = 0.576 2 P < 0.0001 1 0 0 1000 2000 3000 4000 5000 Fluoro time (sec) Radiation Protection in Cardiology Lecture 8.3: Complexity 12
  13. 13. complexity index-based stratification fluoro time 2000 1800 1600 P < 0.0001 Fluoro time (sec) 1400 1200 1000 800 600 400 200 215 119 68 0 simple medium complex CI = 0 CI 1.5 CI > 1.5 Radiation Protection in Cardiology Lecture 8.3: Complexity 13
  14. 14. complexity index-based stratification cine frames 2500 P = 0.001 2000 Cine frames (n) 1500 1000 P = ns 500 P = 0.0377 215 119 68 0 simple medium complex CI = 0 CI 1.5 CI > 1.5 Radiation Protection in Cardiology Lecture 8.3: Complexity 14
  15. 15. complexity index-based stratification total DAP 250 200 P < 0.0001 Gy * cm2 150 100 P = 0.0015 50 215 119 68 0 simple DAP medium complex CI = 0 CI 1.5 CI > 1.5 Radiation Protection in Cardiology Lecture 8.3: Complexity 15
  16. 16. procedural success rate (402 cases, 50% of total activity) 98 97,6 P = 0.00787 96 94 93,3 % 92 90 89,7 88 86 84 simple medium complex Radiation Protection in Cardiology Lecture 8.3: Complexity 16
  17. 17. fluoro time in different diagnostic procedures (844) 7 6 6.8±7.1 5 6.1±4.9 minutes 6.1±6.0 4 3 65% 2 2.6±3.4 2.7±2.3 1 0 Coro only Coro + LV Right cath. Graft Aortogr Radiation Protection in Cardiology Lecture 8.3: Complexity 17
  18. 18. conclusions (I) • In our experience, fluoroscopy time and total DAP were directly related to technical and not to clinical factors • The weight of these factors can be quantified in order to anticipate the radiation dose needed to treat patients undergoing complex procedures Radiation Protection in Cardiology Lecture 8.3: Complexity 18
  19. 19. conclusions (II) • Comparison of different centers and operators for quality control assessment, as well as the definition of appropriate fluoroscopy time and DAP doses, should take into account complexity indexes • Further studies in different institutions are warranted to corroborate this data Radiation Protection in Cardiology Lecture 8.3: Complexity 19

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