Operator Radiation Exposure Research Articles

First case report of a percutaneous coronary intervention with intracoronary lithotripsy in a heavily calcified and tortuous right coronary artery using the R-One+ robotic system

Abstract Background Advancement in interventional techniques has significantly improved the ability of percutaneous coronary intervention (PCI) to treat complex coronary artery disease. Despite these advancements, coronary artery calcification poses a substantial challenge during PCI, contributing to increased risks of procedural complications, prolonged procedure duration, an increase in radiation exposure dose for both patients and physicians. Recently, robotic PCI has emerged, allowing physicians to remotely control and deliver wires and catheters, leading to a notable reduction of the operator radiation exposure and a decrease in the risk of operator physical injuries such as back pain. Case summary We report the first robotic PCI with the R-One+™ robotic system using intracoronary lithotripsy for lesion preparation of two heavily calcified lesions in a tortuous right coronary artery of a 60-year old male patient followed by double drug-eluting stent implantation. Discussion Robotic PCI with the R-One+™ system can not only manage wires, balloons or stent systems but can also precisely position more bulky catheters such as intracoronary lithotripsy catheters to the target site even in the presence of a tortuous access.

Robotic spinal angiography: A single-center experience.

Robotic neurointervention enhances procedural precision, reduces radiation risk, and improves care access. Originally for interventional cardiology, the CorPath GRX platform has been used in neurointerventions. Recent studies highlight robotic cerebral angiography benefits, but information on spinal angiography is limited. While a new generation of robotic solutions is on the horizon, this series evaluates our experience with the CorPath GRX in spinal angiographic procedures, addressing a key gap in neurointerventional research. In this single-center retrospective case series, we analyzed 11 patients who underwent robotic-assisted diagnostic procedures with the CorPath GRX system from February 2022 to March 2023 at our institution. A descriptive synthesis was performed on the demographic, baseline, surgical, and postoperative data collected. The average age of the 11 patients was 54 ± 20.34 years, with six (54.55%) female. The mean body mass index was 29.58 ± 7.86, and 7 (63.64%) were non-smokers. Of the 11 procedures using the CorPath GRX system, four (36.36%) were partially converted to manual technique. General anesthesia was used in nine cases (81.82%), and right-side femoral access in ten (90.91%) patients. Mean fluoroscopy time was 24.81 ± 10.19 min, contrast dose 174.09 ± 57.31 mL, dose area product 472.23 ± 437.57 Gy·cm², and air kerma 2438.84 ± 2107.06 mGy. No robot-related complications and minimal procedure-related complications were reported. The CorPath GRX system, a robotic-assisted platform, has proven reliable and safe in spinal angiography, evidenced by its enhanced procedural accuracy and reduced radiation exposure for operators.

RAdiation Dose Attenuation using RADPAD in CATH lab for primary and secondary operators - RADAR-CATH STUDY.

Radiation injury is an important concern for interventional cardiologists and needs to be addressed. RADPAD is a radiation protection drape that has been shown to reduce the radiation exposure of the primary operator (PO). While Indian data on radiation exposure of the PO in the cath lab are scarce, the exposure of the secondary operator (SO) is even less well studied. The aim of this study was to evaluate the efficacy of RADPAD drapes in reducing radiation doses in the cath lab for the primary as well as the secondary operator. A total of 160 patients (40 patients each with single vessel disease [SVD], double vessel disease [DVD] and triple vessel disease [TVD] undergoing coronary angioplasty, and 40 patients undergoing balloon mitral valvuloplasty [BMV]) were randomised in a 1:1 pattern to undergo a procedure with or without the use of RADPAD. For patients with SVD, DVD and TVD undergoing percutaneous coronary intervention (PCI) and those undergoing BMV, the % reduction with the use of RADPAD reduced the PO's received dose (in mrem) by 65%, 54%, 28% and 67%, respectively, as compared to without RADPAD. The % reduction in relative operator exposure for the PO for the 4 groups was 55%, 34%, 18% and 75%, respectively, with the use of RADPAD. The corresponding % reduction for the SO's received dose (in mrem) was 80%, 63%, 33% and 69% and for relative operator exposure was 74%, 46%, 23% and 76% in the 4 groups, respectively. RADPAD significantly reduces the radiation exposure of the primary and secondary operator during prolonged complex PCI and BMV procedures.

Autonomous navigation of catheters and guidewires in mechanical thrombectomy using inverse reinforcement learning

PurposeAutonomous navigation of catheters and guidewires can enhance endovascular surgery safety and efficacy, reducing procedure times and operator radiation exposure. Integrating tele-operated robotics could widen access to time-sensitive emergency procedures like mechanical thrombectomy (MT). Reinforcement learning (RL) shows potential in endovascular navigation, yet its application encounters challenges without a reward signal. This study explores the viability of autonomous guidewire navigation in MT vasculature using inverse reinforcement learning (IRL) to leverage expert demonstrations.MethodsEmploying the Simulation Open Framework Architecture (SOFA), this study established a simulation-based training and evaluation environment for MT navigation. We used IRL to infer reward functions from expert behaviour when navigating a guidewire and catheter. We utilized the soft actor-critic algorithm to train models with various reward functions and compared their performance in silico.ResultsWe demonstrated feasibility of navigation using IRL. When evaluating single- versus dual-device (i.e. guidewire versus catheter and guidewire) tracking, both methods achieved high success rates of 95% and 96%, respectively. Dual tracking, however, utilized both devices mimicking an expert. A success rate of 100% and procedure time of 22.6 s were obtained when training with a reward function obtained through ‘reward shaping’. This outperformed a dense reward function (96%, 24.9 s) and an IRL-derived reward function (48%, 59.2 s).ConclusionsWe have contributed to the advancement of autonomous endovascular intervention navigation, particularly MT, by effectively employing IRL based on demonstrator expertise. The results underscore the potential of using reward shaping to efficiently train models, offering a promising avenue for enhancing the accessibility and precision of MT procedures. We envisage that future research can extend our methodology to diverse anatomical structures to enhance generalizability.

Comprehensive radiation shield minimizes operator radiation exposure in coronary and structural heart procedures

ObjectivesThis study evaluated the efficacy of a novel comprehensive shield designed to minimize radiation exposure (RE) to Physicians performing coronary and structural heart procedures. BackgroundThe Protego™ radiation shielding system (Image Diagnostics Inc., Fitchburg, Ma) is designed to provide comprehensive protection from RE and has been State certified sufficient to allow operators to perform procedures without orthopedically burdensome lead aprons. MethodsThis single center two-group cohort study assessed the efficacy of this shield in a large number of cardiac procedures (coronary and structural), comparing operator RE compared to standard protection methods (personal lead apparel and “drop down” shield). ResultsThe Protego™ system reduced operator RE by 99 % compared to Standard Protection. RE was significantly lower at both “Head” level by thyroid median dose 0.0 (0.0, 0,0) vs 5.7 (2.9, 8.2) μSv (p < 0.001), as well as waist dose 0.0 (0.0, 0.0) vs 10.0 (5.0, 16.6) μSv (p < 0.001). “Zero” Total RE was documented by Raysafe™ in 64 % (n = 32) of TAVR cases and 73.2 % (n = 183) of the coronary cases utilizing Protego™. In contrast, standard protection did not achieve “Zero” exposure in a single case. These dramatic differences in RE were achieved despite higher fluoroscopy times in the Protego™ arm (11.9 ± 8.6 vs 14.3 ± 12.5 min, p = 0.015). Per case procedural exposure measured by Dose Area Product was higher in the Protego™ group compared to standard protection (115.4 ± 139.2 vs 74.9 ± 69.3, p < 0.001). ConclusionThe Protego™ shield provides total body RE protection for operators performing both coronary and structural heart procedures. This shield allows procedural performance without the need for personal lead aprons and has potential to reduce catheterization laboratory occupational health hazards.

Assessment of Area Radiation Dose for the National Cyclotron and PET Centre at Chulabhorn Hospital in Thailand.

The National Cyclotron and PET Centre at Chulabhorn Hospital offers nuclear medicine diagnostic services using state-of-the-art digital PET/CT and PET/MRI machines as well as other related devices. Additionally, the center plays a vital role by having a cyclotron to produce radiopharmaceuticals, which are used both in-house and in other hospitals throughout the country. Despite the center's strict adherence to international standards regarding the use of radioactive substances in patients, there remains a potential risk of radiation exposure for operators, workers, and the public due to radioactive contamination and emissions from unsealed sources. Hence, it is imperative to assess and continuously monitor radiation levels in the work area to ensure the utmost level of safety for personnel. Methods: This study used optically stimulated luminescence dosimeters to measure radiation levels in 17 areas, consisting of 9 controlled and 8 supervised areas. Over a 3-mo period, the average monthly radiation dose was recorded for each location. Results: The PET/CT room registered the highest radiation dose within the controlled area, with a monthly average of 1.81 ± 0.29 mSv, equivalent to an annual dose of 21.72 mSv. This higher dose can be attributed to the significant number of patients served in this room. In supervised areas, the nursing counter located between the examination room and the patient waiting area exhibited the highest radiation exposure. The average monthly dose measured at this location was 0.085 ± 0.019 mSv, resulting in an annual dose of 1.015 mSv. Conclusion: The evaluation of radiation dose in controlled and supervised areas indicated that the overall radiation level remains within the prescribed limits. However, the slight excess that was observed at the nursing counter indicates the need for improvement to ensure compliance with the as-low-as-reasonably-achievable principle. Continuous monitoring of radiation levels should be conducted annually to maintain safety standards and minimize the risk that workers and the general public will be exposed to radioactivity.

Role of Different Adjunctive Protective Devices to Reduce Operator Radiation Exposure in Percutaneous Coronary Procedures: The RAPTOR Study

Objective. To compare the relative effectiveness of different anti‐Rx devices in terms of radiation dose absorbed by operators during percutaneous coronary procedures (diagnostic or interventional). Background. Direct comparisons among different adjunctive anti‐Rx devices during percutaneous coronary procedures to reduce operator radiation exposure are lacking. Methods. We retrospectively analyzed the last 200 percutaneous procedures performed by a single operator according to the use of adjunctive protective devices (group 1) or standard anti‐Rx setting (group 2). Subsequently, the procedures in group 1 have been divided according to the protective device utilized (homemade pelvic drape with under‐table curtain, or RADPAD drape, or the STAR System device, or the Rampart shield). The primary endpoint was the operator radiation dose at the thorax. Results. Groups 1 and 2 did not show significant differences in terms of anthropometric data or cardiovascular risk factors. The use of adjunctive anti‐Rx devices was associated with a significant reduction in operator radiation exposure compared to standard radioprotection (12.8 μSv [7–21] and 22.6 μSv [11–36], respectively; p &lt; 0.0001). Globally, the anti‐Rx devices utilized were associated with a reduced operator radiation exposure (11.7 μSv [2–19] for homemade drapes, 13.5 μSv [9–29] for RADPAD drape, 15 μSv [11–30] for STAR Board System, and 8 μSv [5–19] for Rampart; p &lt; 0.0001) with the homemade drapes and the Rampart system showing a lower operator exposure. Conclusions. The use of anti‐Rx devices during percutaneous coronary procedures is associated with a significant lower operator radiation exposure with the greater effect obtained with pelvic drapes and the Rampart system.

Emergent Applications of Machine Learning for Diagnosing and Managing Appendicitis: A State-of-the-Art Review.

Background: Appendicitis is an inflammatory condition that requires timely and effective intervention. Despite being one of the most common surgically treated diseases, the condition is difficult to diagnose because of atypical presentations. Ultrasound and computed tomography (CT) imaging improve the sensitivity and specificity of diagnoses, yet these tools bear the drawbacks of high operator dependency and radiation exposure, respectively. However, new artificial intelligence tools (such as machine learning) may be able to address these shortcomings. Methods: We conducted a state-of-the-art review to delineate the various use cases of emerging machine learning algorithms for diagnosing and managing appendicitis in recent literature. The query ("Appendectomy" OR "Appendicitis") AND ("Machine Learning" OR "Artificial Intelligence") was searched across three databases for publications ranging from 2012 to 2022. Upon filtering for duplicates and based on our predefined inclusion criteria, 39 relevant studies were identified. Results: The algorithms used in these studies performed with an average accuracy of 86% (18/39), a sensitivity of 81% (16/39), a specificity of 75% (16/39), and area under the receiver operating characteristic curves (AUROCs) of 0.82 (15/39) where reported. Based on accuracy alone, the optimal model was logistic regression in 18% of studies, an artificial neural network in 15%, a random forest in 13%, and a support vector machine in 10%. Conclusions: The identified studies suggest that machine learning may provide a novel solution for diagnosing appendicitis and preparing for patient-specific post-operative complications. However, further studies are warranted to assess the feasibility and advisability of implementing machine learning-based tools in clinical practice.

Autonomous exploration for radioactive sources localization based on radiation field reconstruction

In recent years, unmanned ground vehicles (UGVs) have been used to search for lost or stolen radioactive sources to avoid radiation exposure for operators. To achieve autonomous localization of radioactive sources, the UGVs must have the ability to automatically determine the next radiation measurement location instead of following a predefined path. Also, the radiation field of radioactive sources has to be reconstructed or inverted utilizing discrete measurements to obtain the radiation intensity distribution in the area of interest. In this study, we propose an effective source localization framework and method, in which UGVs are able to autonomously explore in the radiation area to determine the location of radioactive sources through an iterative process: path planning, radiation field reconstruction and estimation of source location. In the search process, the next radiation measurement point of the UGVs is fully predicted by the design path planning algorithm. After obtaining the measurement points and their radiation measurements, the radiation field of radioactive sources is reconstructed by the Gaussian process regression (GPR) model based on machine learning method. Based on the reconstructed radiation field, the locations of radioactive sources can be determined by the peak analysis method. The proposed method is verified through extensive simulation experiments, and the real source localization experiment on a Cs-137 point source shows that the proposed method can accurately locate the radioactive source with an error of approximately 0.30 m. The experimental results reveal the important practicality of our proposed method for source autonomous localization tasks.

Comprehensive Shielding System Enhances Radiation Protection for Structural Heart Procedures

BackgroundThis study of radiation exposure (RE) to physicians performing structural heart procedures evaluated the efficacy of a novel comprehensive radiation shield compared to those of traditional shielding methods. A novel comprehensive shielding system (Protego, Image Diagnostics Inc) has been documented to provide superior RE protection during coronary procedures compared to that provided by a standard “drop down” shield. The purpose of this study was to assess the efficacy of this shield in transcatheter aortic valve replacement (TAVR) procedures, which are associated with disproportionate RE to operators. MethodsThis single-center, 2-group cohort, observational analysis compared RE to the primary physician operator performing TAVR using the Protego shield (n = 25) with that using a standard drop-down shield with personal leaded apparel (n = 25). RE was measured at both thyroid and waist levels with a real-time dosimetry system (RaySafe i3, RaySafe) and was calculated on a mean per case basis. Data were collected on additional procedural parameters, including access site(s) for device implantation, per case fluoroscopy time, air kerma, and patient factors, including body mass index. Between-group comparisons were conducted to evaluate RE by group and measurement sites. ResultsThe Protego system reduced operator RE by 99% compared to that using standard protection. RE was significantly lower at both the thyroid level (0.08 ± 0.27 vs 79.2 ± 62.4 μSv; P < .001) and the waist level (0.70 ± 1.50 vs 162.0 ± 91.0 μSv, P < .001). “Zero” total RE was documented by RaySafe in 60% (n = 15) of TAVR cases using Protego. In contrast, standard protection did not achieve zero exposure in a single case. ConclusionsThe Protego shield system provides superior operator RE protection during TAVR procedures. This shield allows operators to work without the need for personal lead aprons and has potential to reduce catheterization laboratory occupational health hazards.

Assessing lead curtains’ impact on radiation protection in coronary interventions

The objective of this investigation is to assess the impact of supplementary lead curtains on the reduction of radiation dose exposure to operators during coronary interventional procedures. Seven standard positions during coronary angiography (foot, right foot, head, left foot, left lateral, left head, and right lateral) were simulated on a standard anthropomorphic phantom with radial artery access. Measurements were taken at two different heights, 125 cm and 155 cm, and dosimeters were used to measured surface incident dose rates for the first and second operators, both with and without additional lead curtains at various positions. Each position was measured 20 times, and arithmetic means were computed. A t-test was utilised to compare dose rates with and without supplementary lead curtains, as well as dose rates with additional lead curtains at varying heights. The finding indicate that the dose rates of the first operator with supplementary lead curtains were not significantly lower compared to those without, except for the 125 cm head and left foot positions and the 155 cm head position with the additional lead curtain edge 10 cm below the umbilical level (t umbilical = 0.9, 0.4, 0.5, P > 0.05). The dose rates of the second operator with additional lead curtains were significantly lower than those without, with statistically significant differences (P < 0.05). The arithmetic mean dose rates for the first and second operators at each position were lowest when the upper edge of the additional lead curtain was situated 10 cm above the umbilical level. Employing supplementary lead curtains during coronary interventions effectively reduces radiation doses received by operators. The protective effect is enhanced when the additional lead curtain is closer to the irradiation field. Hence, it is recommended that additional curtains be employed judiciously, while ensuring that clinical procedures are not impeded, in order to effectively mitigate the radiation exposure of operators.

Operator radiation exposure during radioembolisation of the liver: transfemoral versus transradial access using real-time dose monitoring.

In this study, operator radiation exposure is compared utilising transradial access (TRA) versus transfemoral access (TFA) during transarterial radioembolisation (TARE) of liver tumors. Patients who underwent Y90 TARE between May 2017 and April 2018 were included. Electronic medical records and interventional data were collected and the following parameters evaluated: technical success, fluoroscopy time, operator radiation exposure and rate of operator radiation exposure per fluoroscopy time. Statistical analysis was performed with the Wilcoxon rank-sum test. A total of 22 patients (12 males, 10 females) underwent 22 procedures. A total of 12 procedures were performed via TFA and 10 via TRA. Technical success was 100% in both groups. Median fluoroscopy time (10minutes for TRA vs 6.4minutes for TFA, p=0.082) was not statistically different. Both operator radiation exposure (49 vs 4.2μSv, p=0.00016) and rate of operator exposure (4.9 vs 0.71μSv per min, p=0.00021) were significantly higher in the TRA versus TFA groups, respectively.

Zero or near-zero x-ray pacemaker implantation in paediatric patients. dream or reality?

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Transvenous implantation of pacemaker is performed with fluoroscopy for leads’ insertion and implantation in the heart. This implies radiation exposure for patients and operators. Fluoroscopy allows a two-dimensional view of lead movements, and sometimes it is difficult to implant lead in the complex heart anatomy, or in alternative right ventricular (RV) pacing sites, that often requires higher radiation doses. These alternative pacing sites may prevent pacing-induced ventricular dysfunction. They are his bundle pacing area (HBP), ventricular septum close to the conduction system area (VS), RV outflow tract (RVOT). The use of three-dimensional-electroanatomic mapping system (3D-EAM) may reduce fluoroscopy and guide lead implantation. Published median fluoroscopy data for similar procedure are: 6 mGy (1), 13 mGy and 231 microGy/m2 (2). Purpose of this study is to seek out if a 3D-EAM-guided transvenous implantation into RV alternative sites pacing in paediatric patients can be accomplished with zero or near-zero X-rays. Methods Retrospective analysis of children and adolescents with congenital or acquired (idiopathic) complete atrioventricular block (CAVB) without other congenital heart defects who underwent 3D-EAM-guided pacing in alternative RV sites. The implant procedure was divided in 4 steps: 1-contrast venography; 2- 3D mapping: with a steerable catheter (femoral vein), the 3D-EAM acquired geometric reconstruction of the right heart and a pacing map identified RV sites with narrower paced QRS; 3-axillary vein puncture; 4-lead and pacemaker implantation: 3D-EAM guided stylet-directed screw-in lead implantation toward desired RV sites. Data are reported as median (25th-75th centiles). Results 54 CAVB patients (42 females), underwent 3D EAM-guided pacing (27 VVIR, 27 DDD) at age 11.5 (7.7-14) years, weight 42 (26-54) kg. Pacing sites were: 10 HBP, 4 RVOT, 40 VS (Figure 1). Procedure time was 170 (143-193) min, total fluoroscopy exposure and that of the 4 steps are reported in Table 1. The lowest exposures were: 0.2 mGy, 8 microGy/m2 (VVIR) and 0.6 mGy, 15 microGy/m2 (DDD). Paced QRS was 115 (100-120) ms. Conclusions 3D-EAM-guided alternative RV pacing sites was accomplished with very low fluoroscopic exposure, close to zero in some cases. Therefore, with 3D-EAM we can significantly reduce radiological doses also in difficult pacing procedures in paediatric patients, thus reducing radiological risks and preserving ventricular function. The dream is becoming reality.

Prospective Assessment of Direct Measurements of Absorbed Radiation Exposure in Operators and Patients Undergoing Fenestrated and Branched Endovascular Aortic Repair

To analyze the direct dose of absorbed radiation exposure of the primary operator and the patient during fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). Patients treated by FB-EVAR for CAAAs and TAAAs were prospectively enrolled between March and December 2022. Measurements of direct dose of absorbed radiation exposure were obtained using nanodots sensors (Landauer Inc., Glenwood, IL) positioned in standard location within unprotected skin area of the primary operator and patient face and periorbital area. The primary operator was positioned in the right femoral access site. Measurements of direct dose of absorbed radiation exposure (mGy) were compared with recorded metrics of the imaging unit including total radiation dose (mGy), dose area product (DAP) (mGy·cm2) and fluoroscopy time (minutes). There were 48 patients (75% male; mean age, 73 ± 9 years) enrolled in the study and treated by FB-EVAR for TAAAs in 38 patients (79%), CAAAs in 8 (17%), and arch aneurysms in 2 (4%). As shown in the Figure, measurements of DDRAE was three-fold higher for the patient compared to the primary operator (0.34 ± 0.27 vs 0.09 ± 0.06 mGy; P < .001). The left side of the primary operator face and periorbital artery was exposed to five-fold higher DDRAE compared to the right side (0.16 ± 0.12 vs 0.03 ± 0.004 mGy; P < .001). For the patient, the left side was exposed to significantly higher DDRAE as compared to the right side (0.42 ± 0.34 vs 0.32 ± 0.33 mGy; P < .001). All three recorded metrics (total radiation dose, DAP, and fluoroscopy time) had significant linear correlation with DDRAE measurements for the primary operator (P < .001). However, for the patient a linear correlation with DDRAE measurements was observed only for fluoroscopy time (P = .002) and not for total radiation dose (P = .28) or DAP (P = .49). Patients treated by FB-EVAR have on average five-fold higher dose of absorbed radiation in the unprotected face and periorbital areas as compared to their primary operators, with significantly higher doses in their left side as compared to the right side. For the primary operator, the left side of the face and periorbital area are exposed to three-fold more absorbed radiation that the right side. When compared to metrics provided by the imaging unit, measurements of DDRAE had linear correlation with fluoroscopy time, total radiation exposure and DAP for the primary operator, but only fluoroscopy time for the patient.

Radioprotective Effects of a Semicircular X-ray Shielding Device for Operators During CT Fluoroscopy-Guided Interventional Procedures: Experimental and Clinical Studies

To evaluate, experimentally and clinically, the radioprotective effects of a semicircular X-ray shielding device for operators during CT fluoroscopy-guided IR procedures. During experimentation, the reduction rates of scattered radiation rates from CT fluoroscopy were evaluated using a humanoid phantom. Two shielding device positions were tested: "shielding close to the CT gantry" and "shielding close to the operator". The scattered radiation rate without shielding was also evaluated. The clinical study retrospectively evaluated the operator's radiation exposure during 314 CT-guided IR procedures. With a semicircular X-ray shielding device (with shielding group, n = 119) or without it (no shielding group, n = 195), CT fluoroscopy-guided IR procedures were performed. Radiation dose measurements were taken using a pocket dosimeter placed near the operator's eye. For shielding and no shielding groups, the procedure time, dose length product (DLP), and the operator's radiation exposures were compared. Experimentation revealed the respective mean reduction rates of "shielding close to the CT gantry" and "shielding close to the operator" as 84.3% and 93.5% compared with the no-shielding setting. Although no significant differences were found in the procedure time and the DLP between "no shielding" and "with shielding" groups in the clinical study, the operators' radiation exposure in the "with shielding" group (0.03 ± 0.04mSv) was significantly lower than in the "no shielding" group (0.14 ± 0.15mSv; p < .001). The semicircular X-ray shielding device provides valuable radioprotective effects for operators during CT fluoroscopy-guided IR.

Comprehensive Radiation Shield Minimizes Operator Radiation Exposure and Obviates Need for Lead Aprons.

The catheterization laboratory predisposes to occupational health hazards. Chronic radiation exposure (RE) direct injuries include a predilection to cataracts and concerns for cancers. Indirectly adverse effects underly the prevalence of orthopedic maladies in interventionists, linked to the burden of mandatory protective lead aprons. A novel comprehensive shielding system (Protego, Image Diagnostics Inc) has been validated in early studies to provide excellent radiation protection. The system is designed to reduce operator RE sufficient to eliminate the need for personal lead aprons. Recent system refinements offer potentially even greater degrees of protection. This clinical study evaluated the efficacy of this system. This single-center 2-group cohort study compared physician operator RE utilizing the latest iteration of the Protego shield (n = 25 cases) or standard protection (personal leaded apparel and drop-down shield, n = 25 cases) during routine cardiac catheterization procedures. RE at both thyroid and waist levels were measured with a real-time dosimetry system (Raysafe) and calculated on a mean per case basis at both thyroid and waist levels. Additional parameters collected included procedure type, access site, per case fluoroscopy time, and patient factors including body mass index. Between-group comparisons were conducted to evaluate RE by group and measurement sites. Protection with Protego was superior to standard methods. Protego showed markedly lower RE at both the thyroid level (0.36 ± 0.86 vs 58.5 ± 50.2 μSv; P < .001) and the waist level (0.84 ± 2.99 vs 121.4 ± 171.2 μSv; P < .001. "Zero" total RE was documented in 68% (n = 17) of Protego cases; in contrast, standard protection did not achieve "zero" exposure in a single case. The Protego shield system provides excellent RE protection to the physician operator, achieving "zero" RE in two-thirds of cases. RE was superior to standard protection methods. The magnitude of protection achieves state regulatory standards sufficient to allow operators to perform procedures without orthopedically burdensome lead aprons. This shield system has the potential to reduce occupational health hazards.

Outcomes of Right Versus Left Upper Extremity Access For Fenestrated Branched Endovascular Aortic Repair (F-BEVAR)

Objective: Upper extremity (UE) access is associated with an increased risk of peri-operative strokes and transient ischaemic attacks (TIAs) after F-BEVAR. Left sided UE access avoids crossing the arch and the origin of the supra-aortic vessels, which could reduce cerebral embolisation and the risk of peri-operative cerebrovascular events. Although right UE access is convenient, ergonomic, and may reduce operator radiation exposure, whether it results in increased risk of peri-operative cerebrovascular events has not been established. The purpose of this study was to assess the peri-operative cerebrovascular events after F-BEVAR using right versus left side upper extremity access.

Branched Endovascular Thoracoabdominal Aneurysm Repair Under Electromagnetic Guidance in an in Vitro Model.

We report a new approach to perform endovascular treatment of thoracoabdominal aneurysms under electromagnetic navigation guidance using a modified system (IOPS; Centerline Biomedical, Inc., Cleveland, OH, USA) and a modified branched endograft (E-nside TAAA Multibranch Stent Graft System; Artivion Inc., Kennesaw, GA, USA). We performed this case in an aortic in vitro model made from transparent polyurethane in our research hybrid room (Discovery IGS 730; GE HealthCare, Chicago, IL, USA). While the implantation of this device typically involves several challenging steps, including precise endograft implantation, snaring of preloaded guide wires, and cannulation of target visceral arteries, all were successfully performed using electromagnetic navigation guidance. Our preliminary experience suggests that endograft implantation under electromagnetic navigation guidance in an integrated hybrid operating room is an innovative option to address technical challenges and reduce patient and operator radiation exposure associated with complex endovascular surgery. Most steps of a branched endografting procedure can be performed without X-Ray exposure when using electromagnetic navigation guidance and a modified branched endograft.

Best crossing of peripheral chronic total occlusions.

Together with colleagues from different disciplines, including cardiologists, interventional radiologists and vascular surgeons, committee members of the of the German Society of Angiology (Deutsche Gesellschaft für Angiologie [DGA]), developed a novel algorithm for the endovascular treatment of peripheral chronic total occlusive lesions (CTOs). Our aim is to improve patient and limb related outcomes, by increasing the success rate of endovascular procedures. This can be achieved by adherence to the proposed crossing algorithm, aiding the standardization of endovascular procedures. The following steps are proposed: (i) APPLY Duplex sonography and if required 3D techniques such as computed tomography or magnetic resonance angiography. This will help you to select the optimal access site. (ii) EVALUATE the CTO cap morphology and distal vessel refilling sites during diagnostic angiography, which are potential targets for a retrograde access. (iii) START with antegrade wiring strategies including guidewire (GW) and support catheter technology. Use GW escalation strategies to penetrate the proximal cap of the CTO, which may usually be fibrotic and calcified. (iv) STOP the antegrade attempt depending on patient specific parameters and the presence of retrograde options, as evaluated by pre-procedural imaging and during angiography. (v) In case of FAILURE, consider advanced bidirectional techniques and reentry devices. (vi) In case of SUCCESS, externalize the GW and treat the CTO. Manage the retrograde access at the end of the endovascular procedure. (vii) STOP the procedure if no progress can be obtained within 3 hours, in case of specific complications or when reaching maximum contrast administration based on individual patient's renal function. Consider radiation exposure both for patients and operators. In this manuscript we systematically follow and explain each of the steps (i)-(vi) based on practical examples from our daily routine. We strongly believe that the integration of this algorithm in the daily practice of endovascular specialists, can improve vessel and patient specific outcomes.

Integrity of personal radiation protective equipment (PRPE): a 4-year longitudinal follow-up study

BackgroundPersonal radiation protective equipment (PRPE) such as lead aprons minimises radiation exposure of operators using X-ray systems. However, PRPE might be prone to cracks in the attenuating layer resulting in inadequate radiation protection. This study aims to investigate the prevalence, qualification and quantification of PRPE integrity during a longitudinal follow-up study.MethodsAll PRPE of a large, general hospital was evaluated yearly in the period 2018–2021. The equipment was inspected on a tele-operated X-ray table, and tears were qualified and quantified using an X-ray opaque ruler. Rejection criteria of Lambert & McKeon, with an extra rejection criterion of 15 mm2 for individual tears, were applied to accept or reject further use of the PRPE.ResultsOver the 4-year follow-up period, a total of 1011 pieces of PRPE were evaluated. In total, 47.3% of the PRPE showed tears of which 31% exceeded the mentioned rejection criteria. Remarkably, of the 287 newly registered pieces of PRPE, 6.0% showed tears in the first year of use of which 88.2% needed to be rejected. Also, 48% of the repaired PRPE was rejected again in the consecutive year.ConclusionsPRPE is prone to cracks. Up to 50% of PRPE showed tears and cracks resulting in 31% rejections. Newly purchased PRPE is not guaranteed to remain free of cracks and tears in the first year of use. Repair does not guarantee a long-term solution for prolonging the lifespan. Regular X-ray-based integrity analysis of PRPE is needed to ensure adequate radioprotection for operators using X-ray systems.