Radiation exposure and transradial approach - Jim Nolan

1. RADIATION EXPOSURERADIATION EXPOSURE
AND THE TRANSRADIALAND THE TRANSRADIAL
APPROACHAPPROACH
Jim NolanJim Nolan
Professor of CardiologyProfessor of Cardiology
Keele Cardiovascular Research GroupKeele Cardiovascular Research Group
Heart Center,University Hospital of North MidlandsHeart Center,University Hospital of North Midlands
and Keele University, UKand Keele University, UK

2. CONFLICTS OF INTERESTCONFLICTS OF INTEREST
No conflict of interest to declareNo conflict of interest to declare

3. Frau Roentgen’s hand
1895

4. EARLY X-RAY MACHINE

5. Mihran Kassabian (1870-1910)Mihran Kassabian (1870-1910)

6. ADVERSE EFFECTS OF RADIATIONADVERSE EFFECTS OF RADIATIONMILLISEVERT

9. OTHER ENVIRONMENTALOTHER ENVIRONMENTAL
SOURCES OF RADIATIONSOURCES OF RADIATION
 Daily background - 10Daily background - 10μμSVSV
 Sharing a bed – 0.05Sharing a bed – 0.05μμSVSV
 Eating a banana – 0.1Eating a banana – 0.1μμSVSV
 Using a CRT monitor for 12/12 – 1Using a CRT monitor for 12/12 – 1μμSVSV
 Living within 50 miles of nuclear power plantLiving within 50 miles of nuclear power plant
for 12/12 - 1for 12/12 - 1μμSVSV
 Living within 50 miles of a coal power plant forLiving within 50 miles of a coal power plant for
12/12 - 312/12 - 3μμSVSV

10. MEDICALMEDICAL
EXPOSUREEXPOSURE

11. PROCEDURE RELATED PATIENTPROCEDURE RELATED PATIENT
RADIATION EXPOSURERADIATION EXPOSURE
RADIOLOGICALRADIOLOGICAL PATIENT DOSEPATIENT DOSE
BACKGROUND PROCEDUREBACKGROUND PROCEDURE ED (mSv)ED (mSv)
EQUIVALENTEQUIVALENT
CXRCXR 0.020.02 2.5 days2.5 days
BARIUM MEALBARIUM MEAL 2.52.5 0.8 year0.8 year
IVPIVP 3.33.3 1.0 years1.0 years
CACA 55 2.0 years2.0 years
PCI (s)PCI (s) 1010 4.0 years4.0 years
PCI (c)PCI (c) 2525 10.0 years10.0 years

12. PATIENT AND OPERATOR DOSE ARE RELATEDPATIENT AND OPERATOR DOSE ARE RELATED
(Whitby et-al, BJ Radiol, 2003, n=100)(Whitby et-al, BJ Radiol, 2003, n=100)OPERATORDOSE
PATIENT DOSE

13. Late skin reactionsLate skin reactions
Anomalous RCA, 2
prolonged angiograms
attempting visualisation
Image at 2 years, no early
changes reported

14. SKIN INJURY DUE TO CARDIAC INTERVENTIONSKIN INJURY DUE TO CARDIAC INTERVENTION

15. Accessory pathway ablationAccessory pathway ablation
3 weeks
5 months
6.5 months

16. OPERATORS ALSO GET RADIATIONOPERATORS ALSO GET RADIATION
INDUCED SKIN INJURYINDUCED SKIN INJURY

17. Radiation induced lens damage inRadiation induced lens damage in
interventional cardiologistsinterventional cardiologists
(Circj – Bejelac et al, CCI 2010)(Circj – Bejelac et al, CCI 2010)
52
45
9
0
10
20
30
40
50
60
Cardiologists Cath lab nurses Controls
PREVALENCE OF LENS OPACITIES

18. RISK OF DEATH FROM CANCERRISK OF DEATH FROM CANCER
AFTER 100mSV EXPOSUREAFTER 100mSV EXPOSURE

20. BRAIN CANCER MORTALITYBRAIN CANCER MORTALITY
HR = 2.55 ( 1.44 – 4.40 )HR = 2.55 ( 1.44 – 4.40 )
N=90,957

21. DOES RADIAL ACCESSDOES RADIAL ACCESS
INCREASE RADIATIONINCREASE RADIATION
EXPOSUREEXPOSURE

22. EARLY ACCESS SITEEARLY ACCESS SITE
RADIATION LITERATURERADIATION LITERATURE
 Observed increase in radiation measurements inObserved increase in radiation measurements in
radial groupsradial groups
 Observational studiesObservational studies
 Poorly controlledPoorly controlled
 Major differences in patient, procedural andMajor differences in patient, procedural and
operator characteristicsoperator characteristics
 Statistical association is not the same asStatistical association is not the same as
causationcausation

23. PATIENT CHARACTERISTICS AREPATIENT CHARACTERISTICS ARE
IMPORTANTIMPORTANT

24. LEAD SCREENS MAKE A BIGLEAD SCREENS MAKE A BIG
DIFFERENCEDIFFERENCE

25. HOW TO CREATE A RADIATION MYTHHOW TO CREATE A RADIATION MYTH
0
10
20
30
40
50
Fem
Rad
DAPGycm2

27. WHAT DO WE FIND IF WEWHAT DO WE FIND IF WE
DESIGN TRIALS PROPERLY?DESIGN TRIALS PROPERLY?

28.  Minimise patient related variation – first timeMinimise patient related variation – first time
diagnostic angiogram for investigation of chestdiagnostic angiogram for investigation of chest
painpain
 Minimise influence of radiationMinimise influence of radiation
generation/protection protocol – fixed viewgeneration/protection protocol – fixed view
sequence and protection strategysequence and protection strategy
 Match operators expertise ( expert > 1000Match operators expertise ( expert > 1000
cases/95% use; trainee>500cases/mixed use )cases/95% use; trainee>500cases/mixed use )
(AmHeart J 2012 )

29. FLUOROSCOPY TIMEFLUOROSCOPY TIME
EXPERT OPERATOR
minutes
TRAINEE OPERATOR
P = NS P = NS
minutes
0
1
2
3
4
Rad
Fem
0
1
2
3
4
Rad
Fem

30. OPERATOR EXPOSUREOPERATOR EXPOSURE
0
5
10
Rad
Fem
0
5
10
Rad
Fem
μSv
μSv
EXPERT OPERATOR TRAINEE OPERATOR
P=NS P=NS

31. PATIENT EXPOSUREPATIENT EXPOSURE
0
5
10
15
20
25
30
Rad
Fem
0
5
10
15
20
25
30
Rad
Fem
EXPERT OPERATOR TRAINEE OPERATOR
P=NS P=NS
μSv
μSv

32. UHNS RADIAL v FEMORAL STUDYUHNS RADIAL v FEMORAL STUDY
Time to mobilisation (minutes)Time to mobilisation (minutes)
0
50
100
150
200
250
300
Radial
Femoral
19.819.8
263.4263.4

33. IS THIS CONSISTENT WITHIS THIS CONSISTENT WITH
OTHER RECENT LITERATURE?OTHER RECENT LITERATURE?

34. RIVAL TRIAL RADIATIONRIVAL TRIAL RADIATION
SUBSTUDYSUBSTUDY
N=7021 patients randomised to TR or TF accessN=7021 patients randomised to TR or TF access
2569 enrolled in radiation sub study2569 enrolled in radiation sub study
Variable institutional expertise in radial expertiseVariable institutional expertise in radial expertise

35. RIVAL FLUOROSCOPY TIMERIVAL FLUOROSCOPY TIME

36. RIVAL FLUOROSCOPY TIME ISRIVAL FLUOROSCOPY TIME IS
DEPENDENT ON EXPERTISEDEPENDENT ON EXPERTISE

37. RIVAL - PATIENT DOSERIVAL - PATIENT DOSE
(Air kerma, mGy)(Air kerma, mGy)

38. RIVAL PATIENT DOSE ISRIVAL PATIENT DOSE IS
DEPENDENT ON EXPERTISEDEPENDENT ON EXPERTISE

39. COMPARISON OF TRA AND TFA PATIENT RADIATIONCOMPARISON OF TRA AND TFA PATIENT RADIATION
EXPOSURE FOR OPERATORS EXPERIENCED IN BOTHEXPOSURE FOR OPERATORS EXPERIENCED IN BOTH
ACCESS SITESACCESS SITES
(Kuipers et-al, JACCI, 2012, n=3,937)(Kuipers et-al, JACCI, 2012, n=3,937)
P=0.30 P=0.31
Gy.cm
2

40. RADIAL V FEMORAL RADIATIONRADIAL V FEMORAL RADIATION
EXPOSUREEXPOSURE
(Delewi et al, CCI 2013, n=669, 60% TRI)(Delewi et al, CCI 2013, n=669, 60% TRI)
P<0.001
DAP(Gycm2
)

41. (AJC 2016,n=1225(AJC 2016,n=1225))

42. (Clin Res 2016 n=1077)(Clin Res 2016 n=1077)
 99

43. ARE THERE ANY RECENTARE THERE ANY RECENT
RCTs?RCTs?

44. ( JACCi 2015 n=1493 )( JACCi 2015 n=1493 )

45. PATIENT DOSEPATIENT DOSE

46. FLUORO TIMEFLUORO TIME

47. (J Card Thor Res, 2016, RCT n=326)
SINGLE IC EXPERIENCED IN TRA/TFA

48.  Contemporary data from observational andContemporary data from observational and
RCTs indicate no excess radiation hazard for TRRCTs indicate no excess radiation hazard for TR
procedures ( levels may be lower for TRA )procedures ( levels may be lower for TRA )
 Since procedure related doses in cath lab areSince procedure related doses in cath lab are
potentially very high radiation managementpotentially very high radiation management
needs to be optimalneeds to be optimal
 Specific options are available to TR operatorsSpecific options are available to TR operators

49. DOES REDUCING FLUOROSCOPYDOES REDUCING FLUOROSCOPY
FRAME RATE HELP?FRAME RATE HELP?
(Abdelaal et al,JACCi 2014, n=363)(Abdelaal et al,JACCi 2014, n=363)

50. EXTENSION TUBING FOR ENHANCINGEXTENSION TUBING FOR ENHANCING
TRA RADIATION PROTECTIONTRA RADIATION PROTECTION

51. EFFECT OF USING AN EXTENSION TUBEEFFECT OF USING AN EXTENSION TUBE
FROM MANIFOLD TO CATHETERFROM MANIFOLD TO CATHETER

52. NEW PROTECTION OPTIONSNEW PROTECTION OPTIONS

53. Reducing operator radiation exposure –Reducing operator radiation exposure –
effect of additional shieldingeffect of additional shielding
(Behan et-al, CCI 2010)(Behan et-al, CCI 2010)
28
19.5
0
5
10
15
20
25
30
Control Shielding
(Operatorradiationdose,μsv)

54. NEW SHEILDING OPTIONSNEW SHEILDING OPTIONS
(radpad trial CCI 2011)(radpad trial CCI 2011)

60. YOU CAN REDUCE YOUR BRAINYOU CAN REDUCE YOUR BRAIN
DOSEDOSE
(Alazoni et el,CircCI,2015,n=230)(Alazoni et el,CircCI,2015,n=230)

63. RCT n=256

64. CONCLUSIONSCONCLUSIONS
 All cath lab procedures carry an importantAll cath lab procedures carry an important
radiation hazardradiation hazard
 But TRA is not associated with excess radiationBut TRA is not associated with excess radiation
for an experienced operator in contemporaryfor an experienced operator in contemporary
practicepractice
 Mutiple additional simple measures are availableMutiple additional simple measures are available
to greatly reduce your exposureto greatly reduce your exposure