This document provides 10 steps to minimize radiation exposure during percutaneous coronary interventions (PCI). It emphasizes applying the ALARA (as low as reasonably achievable) principle. The most important step is ensuring the procedure is truly necessary. Other key steps include using protective shielding close to the patient's body, positioning the detector closer to minimize scatter radiation, avoiding oblique angles when possible, reducing frame rates, using fluoroscopy instead of cine when able, and stepping back from the patient during imaging. Adopting these good radiation safety habits can reduce radiation dose by 30-80% depending on the technique. The document stresses tailoring dye usage based on kidney function and using superselective injections when possible to minimize dye consumption as well

1. How to minimize
radiation
Nicolaus Reifart
Bad Soden / Wuppertal

2. 10 important steps to lower
radiation exposure in CTO PCI

3. Deterministic & stochastic effect of
radiation
YOUR PATIENT YOU
04.04.2016
By James Heilman, MD - Own work, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=18076961
By Rakesh Ahuja, MD - Own work, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=966501
Important for both of you

4. Golden Rule:
The ALARA principle
AS LOW AS REASONABLY
ACHIEVABLE

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

6. 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

7. 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

9. 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

10. 3.3 mGy/s 2.9 mGy/s
4
Dont forget to collimate
- 12 %
+

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

12. Good radiation habits
04.04.2016
Step back while
filming5
- 80 %
Tube: 1m
Cost: 0.5€

13. 04.04.2016
- 75 %
The fantastic little tube saves you…

14. Fluoroscopy Cine
Fluoro instead of Cine
0.1 mGy/sec 1.0 mGy/sec
- 90 %
6

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

16. 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
04.04.2016
7
- 40 %

17. 04.04.2016
When performing dual injection to
visualize collaterals:
Start with fluoro till the distal
vessel is filled via collaterals,then
inject antegrade and start cine - 50 %
Film runs as short as possible

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

19. Avoid magnification!
Increases radiation for the
patient 2 to 4 fold
04.04.2016
9
- 60%
x 1.6 - 4

20. Reduction in CTO
98 vs 98 patients; single operator 7.5 F/s
04.04.2016
10 p < 0.000002
J. Reifart, DGK Mannheim 2016
- 30 %
-30% off total dose
regardless of user

21. CTOs on your best
machine
• best
resolution
• lowest
exposure
• biplane not
mandatory
04.04.2016
CTO Lab

22. 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)

23. 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

26. €-CTO: Dye Consumption (ml)
2008 2009 2010 2011 2012 2013
Retrograde: 359 ml

27. My basic rules to save dye
• Dye – alert at GFR x 4
• Upper limit of dye: GFR x 6
• Dye dilution 1:1 at 15 frames / min in
patients with GFR<30
• Never inject twice: Store every fluoro-shot
• Superselective injection if possible

28. Checking
collaterals:
10 ml of
dye

29. Super-
selective:
2 ml of dye

30. Severe renal
dysfunction
GFR 28
Dye: NaCl
1:1
Set at high
resolution

31. 5 runs
Total
volume of
Dye:
18 ml

32. Save dye =
save the
kidney
Thankyou
for
considering

39. Thank you
04.04.2016

40. Methods
04.04.2016
We used the doseaware
system to compare
different radiation safety
techniques.

41. Know what you want
to see
5
8 Frames without
information
+

42. Know what you want to see
Time radiation with contrast
application
• start radiation when contrast dye is
already in guide
5
- 20 %
+

43. Fluoroscopy / Procedure (min)

44. Ante - versus Retrograde 2011-13
+120%
+ 77%
+37%

45. Success Antegrade vs Retrograde
75

46. Success Retrograde related to
„accceptance“
%

47. Success Retro related to
experience
%

48. Operators* related Fluoro time
and exposure (cGy) 2012/13
* > 50 cases registrated
>7 Gy
< 0.9 Gy

49. Operators* related Fluoro time
2012/13
* > 50 cases registrated
min

50. cGy per minute Fluoro-Time
Operators with > 50 pts 2012/13
Diff. up to 250%