Euro CTO Club – The radiation survey

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

Health & Medicine

CTO & Radiation
Nicolaus Reifart
Bad Soden / Wuppertal

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)

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

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

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

10 important steps to lower
radiation exposure in CTO PCI

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

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….

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

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

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

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

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 %

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

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

04.04.2016
- 75 %
The fantastic little tube saves you…

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

Fluoro
Store/Last
Image Hold for
documentation
Know your machine

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

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

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

No stump
CTO bend > 45
degr.
Tryed before

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

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

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)

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

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Live Cases from Florence and Rome From Tor Vergata Hospital, Rome Operators: Andrea Gagnor (Turin), Mohaned Egred (Newcastle - UK), Daniela Benedetto (Rome) From Careggi University Hospital, Florence Operators: Masahisa Yamane (Tokyo - J), Stelios Pyxaras (Furth - D), Carlo Di Mario (Florence) Flash Highlights 8:30 Tips & tricks on radial CTO-PCI Francesco Burzotta (Rome) ___________________________________________ PLENARY SESSION Live Cases from Florence and Rome + Flash Highlights Auditorium Zubin Mehta - Saturday 8:30 - 10:00 Coordinator: Roberto Garbo (Turin) Chairpersons: Heinz Joachim Büttner (Bad Krozingen - D), Roberto Diletti (Rotterdam - NL) Discussants: Michael Behnes (Mannheim - D), Giacomo Boccuzzi (Turin), Alexander Bufe (Krefeld - D), Salvatore Colangelo (Turin) Challengers: Paul Knaapen (Amsterdam - NL), Gioel Gabrio Secco (Alessandria) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

Kambis Mashayekhi: EuroCTO Consensus on treatment of Calcified CTO lesion Eur...

Euro CTO Club

Emmanouil S. Brilakis - CTO PCI Outcome associated with poor quality of the d...

Euro CTO Club

16:53 CTO PCI Outcome associated with poor quality of the distal target vessel Emmanouil Brilakis (Minneapolis - USA) _____________________________________________ PARALLEL SESSION Interventional CTO & Chip Research Best CTO Publications 2022-23 (selected by the Editors of the Cardiology Interventional journals) Auditorium Zubin Mehta - Friday 16:30 - 17:16 Chairpersons: Davide Capodanno (Catania), Carlo Di Mario (Florence), Giuseppe Tarantini (Padua) Panelist: Roberto Diletti (Rotterdam - NL), Giovanni Esposito (Naples), Paul Knaapen (Amsterdam - NL), Maksymilian Opolski (Warsaw - PL) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

Mario Iannaccone - 2 EuroCTO Consensus on Guide Catheter Extensions JACC Card...

Euro CTO Club

16:33 EuroCTO Consensus on Guide Catheter Extensions JACC Cardiovasc Interventions Mario Iannaccone (Turin) _____________________________________________ PARALLEL SESSION Interventional CTO & Chip Research Best CTO Publications 2022-23 (selected by the Editors of the Cardiology Interventional journals) Auditorium Zubin Mehta - Friday 16:30 - 17:16 Chairpersons: Davide Capodanno (Catania), Carlo Di Mario (Florence), Giuseppe Tarantini (Padua) Panelist: Roberto Diletti (Rotterdam - NL), Giovanni Esposito (Naples), Paul Knaapen (Amsterdam - NL), Maksymilian Opolski (Warsaw - PL) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

Javier Escaned: 3 Low contrast complex and CTO PCI

Euro CTO Club

Flash Highlights 15:00 3 Low contrast complex and CTO PCI Javier Escaned (Madrid - Spain) ___________________________________________ PARALLEL SESSION Live Cases from Rome + Flash Highlights Auditorium Zubin Mehta - Friday 15:00 - 16:30 Coordinator: Andrea Gagnor (Turin) Chairpersons: Roberto Diletti (Rotterdam - NL), Bernward Lauer (Jena - D) Discussants: Alessio Gaetano La Manna (Catania), Eugenio Stabile (Potenza) Challengers: Paul Knaapen (Amsterdam - NL), Alessio Mattesini (Florence) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

Giuseppe Tarantini: Protect IV and PROTECT-Europe trial

Euro CTO Club

11:35 Protect IV and PROTECT-Europe trial Giuseppe Tarantini (Padua) _____________________________________________ PARALLEL SESSION Cto & Chip Regitries & Trials Auditorium Zubin Mehta - Friday 11:00 - 12:00 Chairpersons: Paul Knaapen (Amsterdam - NL), Gennaro Sardella (Rome) Discussants: Björn Billmann (Wolfenbuettel - D), Laurent Drogul (Nice - F), Sergey Furkalo (Kiev - UA), Maciej Lesiak (Poznan - PL) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

Paul Knaapen: The PROCTOR randomized trial

Euro CTO Club

11:28 The PROCTOR randomized trial Paul Knaapen (Amsterdam - NL) _____________________________________________ PARALLEL SESSION Cto & Chip Regitries & Trials Auditorium Zubin Mehta - Friday 11:00 - 12:00 Chairpersons: Paul Knaapen (Amsterdam - NL), Gennaro Sardella (Rome) Discussants: Björn Billmann (Wolfenbuettel - D), Laurent Drogul (Nice - F), Sergey Furkalo (Kiev - UA), Maciej Lesiak (Poznan - PL) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

John Davies: Update on the ORBITA - CTO trial

Euro CTO Club

11:21 Update on the ORBITA - CTO trial John Davies (Basildon - UK) _____________________________________________ PARALLEL SESSION Cto & Chip Regitries & Trials Auditorium Zubin Mehta - Friday 11:00 - 12:00 Chairpersons: Paul Knaapen (Amsterdam - NL), Gennaro Sardella (Rome) Discussants: Björn Billmann (Wolfenbuettel - D), Laurent Drogul (Nice - F), Sergey Furkalo (Kiev - UA), Maciej Lesiak (Poznan - PL) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

Masahisa Yamane: The Complex CTO Japanese Registry

Euro CTO Club

11:14 The Complex CTO Japanese Registry Masahisa Yamane (Tokyo - J) _____________________________________________ PARALLEL SESSION Cto & Chip Regitries & Trials Auditorium Zubin Mehta - Friday 11:00 - 12:00 Chairpersons: Paul Knaapen (Amsterdam - NL), Gennaro Sardella (Rome) Discussants: Björn Billmann (Wolfenbuettel - D), Laurent Drogul (Nice - F), Sergey Furkalo (Kiev - UA), Maciej Lesiak (Poznan - PL) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

Kambis Mashayekhi: Trends and spin-offs from the EuroCTO Registry

Euro CTO Club

11:00 Trends and spin-offs from the EuroCTO Registry Kambis Mashayekhi (Lahr - D) _____________________________________________ PARALLEL SESSION Cto & Chip Regitries & Trials Auditorium Zubin Mehta - Friday 11:00 - 12:00 Chairpersons: Paul Knaapen (Amsterdam - NL), Gennaro Sardella (Rome) Discussants: Björn Billmann (Wolfenbuettel - D), Laurent Drogul (Nice - F), Sergey Furkalo (Kiev - UA), Maciej Lesiak (Poznan - PL) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

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Euro CTO Club – The radiation survey

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

26.

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

Editor's Notes

Alaswad et al. CCI 2015; 85: 1123-29 Japanese retrograde registry 2017
Alaswad et al. CCI 2015; 85: 1123-29 Japanese retrograde registry 2017
Wörtlich: With contemporary powerful X ray equipment you might be able to document coronary arteries with fluoro only especially in non obese patients.
Some machines even store the last run and you can save it or have it replaced by the following run. Very useful to document balloon or stent positioning
Always return tu low framerate
Dont use magnification if you dont need to

Euro CTO Club – The radiation survey

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Editor's Notes