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In this Issue: Radiation in the catheterization lab. Patients and practitioners alike are increasingly aware of the benefits attributed to fluoroscopy-guided interventional procedures. This makes the research and review of the occupational health risks associated with the increased use of fluoroscopy, a necessity. This edition of the ThinkRadial newsletter aims to facilitate this process with published articles and relevant tips from the ThinkRadial Board of Advisors about radiation in the cath lab.
Newsletter Table of Contents
- Suggested Relevant Articles – Radiation
- Tips from the Board of Advisors
- Interventional News reports on CIRSE Radial for Peripheral Symposium
- DRAGON Study
- Recorded Tips and Techniques Webinar with Dr. Morton Kern is Available
- South African ThinkRadial Roadshow
- New One-Of-A-Kind Vascular Training Model
- Clinical Radial Team Can Support Radial Transition in Your Cath Lab
- 2016 ThinkRadial Courses
- Register for a Live Webinar – Why Radial for IR with Dr. Darren Klass
Suggested Relevant Articles And Literature
Radiation Exposure During Percutaneous Coronary Interventions and Coronary Angiograms Performed by the Radial Compared With the Femoral Route
Kuipers, PhD, et al. Journal of American College of Cardiovascular Interventions (July 2012)
A comparison of radiation exposure when patients undergoing percutaneous coronary interventions (PCI) and coronary angiograms (CAG) received treatment via the femoral route or the radial route. The study concludes that patients are not subjected to higher radiation exposure when selected procedures are performed using the radial route than when performed by the femoral route.
Occupational Radiation Protection in Interventional Radiology: A Joint Guideline of the Cardiovascular and Interventional Radiology Society of Europe and the Society of Interventional Radiology
Miller, et al. Cardiovascular and Interventional Radiology. (November 2009)
This article serves as an occupational radiation protection guideline, intended to provide guidance and establish procedures to help minimize occupational radiation exposure. A basic review of the medical physics relevant to radiation safety is covered. Occupational dosimetry in the interventional laboratory is examined, including dosimeter use, dose limits, risk estimates and evaluation of personal dosimetry data. The article concludes with discussing radiation protection tools and practical advice to minimize occupational radiation dosage.
Your Lead is Cracked? Radiation Safety Revisited
Morton J. Kern, MD, with several physician contributions. Cath Lab Digest (Nov 2015)
Dr. Morton Kern engages physician colleagues in a discussion about the protocols and processes that protect and monitor radiation in catheterization labs. Specifically: Who is responsible and how do they routinely monitor radiation exposure of lab personnel? Who is responsible and how often do they check the PPE? To whom does your radiation safety officer report to? The article concludes with detailed information about lead aprons, thyroid shields and specific ways to minimize radiation dosage.
Tips from the ThinkRadial Board Of Advisors
We asked our Board of Advisors: What are your top radiation safety tips during radial interventions?
Morton J. Kern, MD, FSCAI, FAHA, FACC, Chief of Medicine, Long Beach Veterans Administration Health Care System, Long Beach, CA; Associate Chief Cardiology, Professor of Medicine, University of California Irvine, CA
Four basic principles about radiation exposure to keep in mind:
- The less exposure, the better. Less exposure reduces chances of absorbed adverse biologic interaction.
- There is no known permissible dose or absolutely safe level of radiation.
- Radiation exposure is cumulative. There is no washout phenomenon. Distance is your friend. Step away whenever possible from the x-ray source.
- Radiation safety is a team sport. All participants in the cardiac catheterization laboratory must actively work to reduce risks to other personnel and themselves. Don’t step on the pedal when someone is near the tube. Be conscientious of when and when not to image.
Mladen I. Vidovich, MD, FACC, Chief of Cardiology at Jesse Brown Veterans Administration Medical Center in Chicago, Illinois
Radial angiography and intervention are associated with a small, but significant increase in radiation to the patient and the operator. This is based on the most contemporary meta-analysis published by Plourde in Lancet (Plourde G. et al. Lancet Sept 25, 2015).
It’s very important to mention that high volume and high experienced operators have lower radiation doses compared to low-volume/less experienced operators.
It is very encouraging that the radiation doses have overall decreased for TRA over the last two decades and the difference between radial and femoral is decreasing.
The most important message to the operators is to use maximum protection (shields, goggles, radiation protection drape, radiation protection boards and similar).
The controversy about left vs. right radial access and importance of radiation is still ongoing.
The modern cardiac catheterization laboratory systems such as Philips Clarity use proprietary algorithms and reduce radiation by up to 75%. It is likely that with this new technology that affords profound dose reductions, the slight increase in radiation with radial approach compared to femoral will become of limited importance.
Mauricio G. Cohen, MD, FACC, FSCAI, Director of the Cardiac Catheterization Laboratory at University of Miami Hospital
There is a small increase in radiation with radial angiography, but the metaregression in the Plourde paper shows that most recent studies have shown a reduction in the differences between radial and femoral, in particular with better understanding of radiation protection.
I use a longer (two feet) tubing extension for the manifold and place the lower part of a lead apron below the patient’s waist to avoid scatter radiation.
In addition, I use a two-piece lead apron, lead goggles, and a leaded hat. It is also important to make sure that the equipment is adjusted to minimize the radiation using lower frames per rate with fluoroscopy (7.5-10 frames/sec).
Punit Ramrakha, MD, MA, BM, BCh, FRCP – Founder of the Chiltern Hills Heart Clinic; Consultant Interventional Cardiologist at Imperial College Healthcare NHS Trust (Hammersmith Hospital), London and Buckshealthcare NHS Trust in Buckinghamshire
In the initial stages there is higher radiation use for a trans-radial case but once the learning curve is overcome the exposure is comparable to transfemoral. Certainly for PCI where the radiation is largely post intubation of the coronary there does not appear to be a significant difference (see reference below as an example).
To minimise the exposure I always advise my juniors:
- Try not to screen the forearm unnecessarily – you might need to screen at the antecubital fossa to negotiate the wire, but with gentle manipulation the catheter can usually be advanced without the need for screening.
- Start screening after the catheter passes the right shoulder.
- Stand back from the catheter once the coronary is intubated – holding on to the catheter is not usually necessary.
- Think of the views that you need to demonstrate the arteries and branch points.
Radiation Exposure During Percutaneous Coronary Interventions and Coronary Angiograms Performed by the Radial Compared With the Femoral Route. Gerritjan Kuipers, PhD, et al. Journal of American College of Cardiovascular Interventions (2012)
Latest News from ThinkRadial
- Standing Room only at CIRSE Radial for Peripheral Symposium: In its November issue, Interventional News reports that transradial access for Interventional Radiologists is gaining traction, but some questions still remain. The article presents discussion of the radial artery approach for interventional radiologists by three IR’s who presented during a symposium sponsored by Merit Medical during the Cardiovascular and Interventional Radiological Society of Europe’s (CIRSE) annual meeting in September – Dr. Christoph Binkert, a professor of Radiology in Zurich, Switzerland; Dr. Aaron Fischman, an Interventional Radiologist and assistant professor of Radiology and Surgery, Mount Sinai Medical Center, New York, USA; and Dr. Darren Klass, Interventional Radiologist, Vancouver Coastal Health, Vancouver, Canada. The physicians outline the benefits and potential complications of radial artery access, radial artery tips and tricks and information to overcome common objections to the radial approach.
Read the full Interventional News article.
- DRAGON Study: In an interview with Healio in October, Dr. Sandeep Nathan, ThinkRadial Course Director, Associate Professor of Medicine and Co-director of the Cardiac Catheterization Laboratory at the University of Chicago Medicine, discussed new data on transradial vs. transfemoral approach for ad hoc PCI from the DRAGON study. Specifically, Dr. Nathan comments that the data demonstrates that transradial in a real-world setting is not inferior to transfemoral approach for ad hoc PCI.
Watch Dr. Nathan’s interview about the DRAGON study.
- Recorded Tips and Techniques Webinar with Morton Dr. Kern is Available to View: ThinkRadial recently hosted a Radial Tips and Techniques webinar with featured presenter Dr. Morton Kern (Chief of Medicine at the Veterans Administration Long Beach Healthcare System in Long Beach, California), who presented his top ten radial techniques including tips for working with your lab to adopt key procedural changes, use of ultrasound and recommendations for which patients to begin with. The webinar includes commentary from panelists Dr. Mladen Vidovich and Dr. Jack Lassetter.
View the recorded webinar.
- South Africa ThinkRadial Roadshow: Interventional Society for Cathlab Allied Professionals (ISCAP) and Merit Medical concluded a South African ThinkRadial Roadshow in Port Elizabeth earlier in December. In total, five ISCAP/Merit Medical ThinkRadial training sessions were conducted and 171 allied professionals were trained this year. The South African ThinkRadial roadshow is designed for cath lab staff to help them understand why and how radial access should be conducted and how to set up the lab. Each training course included a cardiologist, radiographer and a scrub nurse presenter who each gave their perspective on different aspects of radial access. More training is planned for South African physicians in 2016.
- New one-of-a-kind vascular training model: ThinkRadial and Merit Medical recently unveiled a new, one-of-a-kind vascular training model to give interventional cardiologists and radiologists the opportunity to introduce guide wires, diagnostic catheters, guide catheters and interventional devices into the vascular system from several access points—left and right radial, left and right ulnar, as well as femoral. The vascular model travels to symposiums and tradeshows and is used during ThinkRadial courses, in addition to other hands-on training opportunities including a Mentice Simulator and a cadaver lab.
- Merit Medical’s New Level of Support – Clinical Radial Team: As part of Merit Medical’s commitment to the advancement of the radial approach, clinician customers and alumni of the ThinkRadial program have access to Merit’s Clinical Radial team, a team of specialists focused on training and support for the radial approach. Our Specialists can work with you and your lab staff on anything related to the radial approach, including: lab set up for radial access; planning for the latest radial products; training for nurses/technologists; support during early radial cases; and speaking with your hospital administration.
Upcoming Courses and Events
- 2016 US and European ThinkRadial Course Dates: Four 1 1/2-day ThinkRadial courses have been scheduled both in the US and Europe for 2016. Each course will feature an Interventional Cardiologist proctor and an Interventional Radiologist proctor. Space is limited in each course to ensure ample direct contact with proctors and space is filling quickly. Visit ThinkRadial.com/Courses to pre-register for an upcoming course (pre-registration does not guarantee a place in the Course).
|2016 Courses in Salt Lake City, UT||2016 Courses in Maastricht, the Netherlands|
|January 29-30 (Limited space still available for IC’s. Registration closed for IR’s.)||February 25-26|
|April 22-23||May TBA|
|June 17-18||September TBA|
|October 21-22||November TBA|
Why Radial for IR Live Webinar – Monday, January 11, 2016 at 10am PT. Featured presenter, Dr. Darren Klass, will present the benefits of radial approach for peripheral patients, information and data to address common objections and tips for getting started. Following the presentation, questions will be taken from the audience.
About Dr. Darren Klass
Darren Klass is a Clinical Assistant Professor and Interventional Radiologist at Vancouver General Hospital, Vancouver, BC. Dr. Klass performed the first transradial radioembolization and chemoembolization of the liver in Canada and is developing a robust hardware platform for radial access to the liver. He has performed over 400 radial cases. His practice is 90% radial for liver interventions and fibroid embolization.
Please register in advance for the webinar.