Coronary Angiography Safety between Transradial and Transfemoral Access
Santosh Kumar SinhaVikas MishraNasar AfdaaliMukesh Jitendra JhaAshutosh KumarMohammad AsifRamesh ThakurC. M. Varma
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Background and Aim. The aim of study was to evaluate safety, feasibility, and procedural variables of transradial approach compared with transfemoral approach in a standard population of patients undergoing coronary catheterization as one of the major criticisms of the transradial approach is that it takes longer overall procedure and fluoroscopy time, thereby causing more radiation exposure. Method. Between January 2015 and December 2015, a total of 1,997 patients in LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, India, undergoing coronary catheterization were randomly assigned to the transradial or transfemoral approach. Result. Successful catheterization was achieved in 1045 of 1076 patients (97.1%) in the transradial group and in 918 of 921 patients (99.7%) in the transfemoral group (Introduction There is an ongoing struggle to understand the potential economic benefits that radial access may offer. Cost savings are thought to primarily occur after the procedure. The aim of our study was to analyze cath lab expenses resulting from transradial (TRA) and transfemoral approaches (TFA). Methods A total of n = 1890 matched pairs of patients were analyzed. A traditional Judkins catheter strategy was pursued for coronary angiography. Three large databases were merged to collect and compare procedural data as material, medication costs and fluoroscopy time. Results Compared to TFA diagnostic catheterization from TRA was associated with significantly lower procedural costs (€181.0 versus €167.5; p<0.001). Extra costs in TFA were primarily produced by frequent use of vascular closure devices (VCDs) in 86% of patients. However, the potential saving amount related to VCD use was only partly realized due to the higher number of extra catheters (0.53 ± 0.9 versus 0.23 ± 0.6; p<0.001) and hydrophilic guidewires (0.088 ± 0.3 versus 0.014 ± 0.1; p<0.001) used in TRA. Weak correlations were observed between the total number of cases and fluoroscopy time (r = −0.13; p<0.001) as well as material costs (r = 0.31; p<0.001). Conclusions Significant cost savings can be realized by TRA at the procedural level even when adhering to a conventional Judkins catheter strategy. Hydrophilic guidewires and additional catheters are the main cost drivers in TRA. In contrast to fluoroscopy time material costs steadily increase during the early stage of the TRA learning curve.
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Radiation awareness has been advocated as a method of decreasing radiation exposure. For fluoroscopy, one indicator of radiation use is fluoroscopy time. We retrospectively reviewed fluoroscopy times on voiding cystourethrography (VCUG) studies performed at a major pediatric center, comparing the average fluoroscopy time of examinations with the fluoroscopy time documented in the report to the average time of those without documentation.A database search of records for the period between June 1, 2002, and March 31, 2009, identified all VCUG examinations and their recorded fluoroscopy time in the radiology information system. Those examinations in which the fluoroscopy time was documented in the radiologist's report were also identified. Average fluoroscopy times were calculated for three groups: all VCUG examinations, examinations without the fluoroscopy time documented in the dictated report, and examinations including the fluoroscopy time in the dictated report.Over the 7-year study period, 10,594 VCUG examinations were performed. The average fluoroscopy time was 47 seconds for all examinations, 50 seconds for examinations without fluoroscopy time reported (n = 8484), and 32 seconds for examinations with fluoroscopy time reported (n = 1979). There was a statistically significant difference between examinations with and without fluoroscopy time reported by the radiologist (p < 0.0001). A decreasing trend in average fluoroscopy time for all VCUG examinations was identified over time (average fluoroscopy time: 65 seconds for 2002-2003 vs 29 seconds for 2008-2009). Radiologists also increasingly reported fluoroscopy time over time (fluoroscopy time reported in 1% of reports in 2002-2003 vs 82% in 2008-2009).Radiologist reporting of fluoroscopy time correlates with a decrease in fluoroscopy time, a surrogate indicator of radiation dose. Our findings suggest that the radiologist's documentation of fluoroscopy time in the report is part of a radiation awareness strategy leading to decreased fluoroscopy times.
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Abstract Objectives : To investigate whether pulsed fluoroscopy reduces a patient's exposure compared with the exposure owing to conventional (continuous) fluoroscopy, we simulated the skin radiation doses of patients at cardiac catheterization facilities with various X‐ray systems used in fluoroscopically guided intervention procedures. Background : Although many reports have noted that “pulsed fluoroscopy” provides important further reductions in radiation exposure, it has been determined that when comparing dose rates between different vendor systems, “pulsed fluoroscopy” does not reduce patients' exposure as compared with “conventional fluoroscopy”. Methods : We examined 13 X‐ray systems; 10 used pulsed fluoroscopy and three used conventional fluoroscopy. The entrance surface doses with fluoroscopy were compared for the 13 X‐ray systems by using acrylic plates (20‐cm thick) and a skin dose monitor. The X‐ray conditions used in the measurements were those normally used in the facilities performing percutaneous coronary intervention. Results : The average surface dose for systems from three different vendors producing conventional fluoroscopy systems was 23.93 ± 2.77 mGy/min vs. an average surface dose of 22.52 ± 4.50 mGy/min from five vendors of pulsed fluoroscopy systems (25, 30, and 50 pulses/sec) ( P = 0.646). The average entrance surface dose was significantly ( P < 0.0001) higher with conventional fluoroscopy and pulsed fluoroscopy at 25, 30, and 50 pulses/sec (23.05 ± 3.78 mGy/min) than with pulsed fluoroscopy at 15 pulses/sec (13.86 ± 3.22 mGy/min). Conclusions : Pulsed fluoroscopy did not in itself reduce radiation exposure. In general, the use of pulsed fluoroscopy at a pulse rate lower than 25 pulses/sec should reduce the skin dose in fluoroscopically guided intervention procedures. Nevertheless, some X‐ray systems are not designed to reduce the dose rate as the number of pulses per second is decreased. Physicians should be aware of the entrance surface dose of the X‐ray system that they use for cardiac IVR. © 2006 Wiley‐Liss, Inc.
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Objective To identify both the procedural and anatomic factors which determine duration of fluoroscopy during elective endovascular aortic aneurysm repair (EVAR). Methods We retrospectively analyzed our prospectively maintained EVAR database for the relationship between fluoroscopy time and both procedural (type of graft, configuration, number of components, surgeon) and anatomic factors reflective of aneurysm complexity (15 variables). Results A total of 128 patients underwent elective EVAR with a mean fluoroscopy time of 5.7 ± 3.4 min. The type of grafts used consisted of 41 (32%) Zenith, 85 (66.4%) Endurant and 2 (1.6%) Anaconda, with 105 (82%) being bifurcated and 23 (18%) being aorto-uni-iliac (AUI) in configuration. Both the surgeon performing the procedure ( p = 0.001) and graft configuration (bifurcated vs. AUI, p = 0.03) were found to be predictive of fluoroscopy time; while procedural and anatomic variables were not. Conclusions The surgeon’s efficiency in the use of fluoroscopy during EVAR is the most important determinant of total fluoroscopy time. Anatomic complexity, make of device, and number of components inserted have minimal impact on duration of fluoroscopy. An endovascular surgeon’s ability to curtail fluoroscopy duration is the key component in minimizing radiation exposure to both the surgical team and the patient.
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Background and objective Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is associated with radiation exposure and related health risks. Either the physician or the radiology technologist can activate fluoroscopy during ERCP. The aim of this study was to determine if physician-controlled fluoroscopy is associated with decreased fluoroscopy time, which may correspond to less radiation exposure to patients and staff. Methods We conducted a single-center, retrospective study; data were collected on ERCP performed using physician-controlled and technologist-controlled fluoroscopy. Fluoroscopy time, procedure complexity level, and Stanford Fluoroscopy Score were compared between the two groups. Results The median fluoroscopy time significantly differed between the two groups with 108 seconds for physician-controlled and 146 seconds for technologist-controlled procedures (p=0.004). The ratio of median fluoroscopy time to procedure complexity level was significantly lower in the physician-controlled group at 73.0 seconds compared to 97.0 seconds in the technologist-controlled group (p=0.002). The ratio of median fluoroscopy time to Stanford Fluoroscopy Score was 25.5 seconds in the physician-controlled group compared to 39.3 seconds in the technologist-controlled group, which was also statistically significant (p<0.001). A subgroup analysis of physicians with advanced training in ERCP also showed a significantly reduced median fluoroscopy time to Stanford Fluoroscopy Complexity Score ratio: 25.5 seconds for physician-controlled versus 35.0 seconds for technologist-controlled (p=0.001). Conclusion The ERCP technique with physician-controlled fluoroscopy may be associated with shorter fluoroscopy time. This may correspond to decreased radiation exposure to patients compared to radiology technologist-controlled fluoroscopy. Further investigations with larger, prospective studies are warranted.
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Abstract Background Fluoroscopy is the imaging modality routinely used for cardiac device implantation and electrophysiological procedures. Due to the rising concern regarding the harmful effects of radiation exposure to both the patients and operation staffs, novel 3D mapping systems have been developed and implemented in electrophysiological procedure for the navigation of catheters inside the heart chambers. Their applicability in cardiac device implantation has been rarely reported. Our aim is to evaluate the feasibility and safety of permanent pacemaker implantation without fluoroscopy. Methods and results From January 2012 to June 2016, six patients (50 ± 15 years, four of six were female, one of who was at the 25th week of gestation) who underwent permanent pacemaker implantation were included (zero‐fluoroscopy group). Data from 20 consecutive cases of implantation performed under fluoroscopy guidance were chosen as a control group (fluoroscopy group). Total implantation procedure time for single‐chamber pacemaker was 51.3 ± 13.1 minutes in the zero‐fluoroscopy group and 42.6 ± 7.4 minutes in the fluoroscopy group (P = 0.155). The implantation procedural time for a dual‐chamber pacemaker was 88.3 ± 19.6 minutes and 67.3 ± 7.6 minutes in the zero‐fluoroscopy and fluoroscopy groups (P = 0.013), respectively. No complications were observed during the procedure and the follow‐up in the two groups, and all pacemakers worked with satisfactory parameters. Conclusion Ensite NavX system can be used as a reliable and safe zero‐fluoroscopy approach for the implantation of single‐ or dual‐chamber permanent pacemakers in specific patients, such as pregnant women or in extreme situations when the x‐ray machine is not available.
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The purpose of this study was to determine if pulsed fluoroscopy reduces radiation exposure to pediatric patients undergoing conventional fluoroscopy. Four hundred one consecutive patients were nonrandomly divided into pulsed fluoroscopy and conventional fluoroscopy study groups. Two control groups were also assembled: 474 patients evaluated with conventional fluoroscopy before the study and 138 patients evaluated with pulsed fluoroscopy after the study. We found no difference in fluoroscopy times across the groups. Although the number of digital spot films was slightly higher for the pulsed fluoroscopy study group than for the conventional fluoroscopy study group, we found no difference in the number of digital spot films for the pulsed fluoroscopy study group and for the conventional fluoroscopy control group. Furthermore, the difference in the number of digital spot films was also insignificant for the pulsed fluoroscopy control group and the conventional fluoroscopy study group. The radiation exposure in the pulsed fluoroscopy study group was 50% lower (mean, 0.6 R) than in the conventional fluoroscopy study group. When using pulsed fluoroscopy in the 7.5 pulses-per-second mode, we were able to reduce radiation exposure by 75% of that from conventional fluoroscopy. Pulsed fluoroscopy reduces fluoroscopic radiation exposure to pediatric patients undergoing conventional fluoroscopy. Despite minor image degradation, pulsed fluoroscopy is the technique of choice at our institution.
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