Portable C-arm Research Articles

Radiation dose during interventional cardiology procedures: portable C-arm vs. a new generation fluoroscopy system

IntroductionOccupational exposure to ionizing radiation poses health risks for veterinary interventionalists. There are limited veterinary studies evaluating radiation dose in the cardiac catheterization laboratory. The purpose of this study was to report direct radiation dose exposure to patients during common interventional cardiology procedures and compare these doses between two fluoroscopy units. AnimalsOne hundred and fifty-four client-owned dogs. Materials and MethodsPatient dose during procedures using a portable C-arm were retrospectively analyzed and compared to those performed in a contemporary interventional suite. Fluoroscopy equipment, procedure type, operator, patient weight, fluoroscopy time, dose area product, and air kerma were recorded and statistically modeled using univariable and multivariable linear regression to evaluate the effect of each factor. ResultsPatient dose population (154 dogs), comprised 61 patent ductus arteriosus occlusions, 60 balloon pulmonary valvuloplasties, and 33 pacemaker implantations. Patient dose was significantly lower in the group utilizing a newer generation fluoroscopy unit vs. the group utilizing an older portable C-arm, positively correlated with patient weight, and highest during balloon pulmonary valvuloplasties compared to patent ductus arteriosus occlusions or pacemaker implantations (all P<0.010). DiscussionNewer fluoroscopy systems can be equipped with technologies that improve image quality while reducing patient dose and radiation exposure to interventional personnel. ConclusionsWe documented a significant reduction in patient radiation dose using a newer fluoroscopy system as compared to an older portable C-arm for interventional cardiology procedures in animals. Improved knowledge of patient radiation dose factors may promote better radiation safety protocols in veterinary interventional cardiology.

Fixed compared to mobile imaging arms for transcarotid artery revascularization.

Transcarotid artery revascularization (TCAR) is a new surgical option for carotid artery stenosis. While this procedure is optimally performed in hybrid operating rooms (OR), it is currently unclear whether it could be safely performed using portable, C-arm fluoroscopy with equivalent results. The aim of this study is to determine whether there are differences in intraoperative and perioperative outcomes stratified by imaging modality. A retrospective review of all TCAR procedures attempted within our health system was performed, capturing all cases between September 2017 and May 2022. Procedures were divided into 2 cohorts, based on whether they were performed in a hybrid OR or with portable, C-arm in a standard OR. Patient demographics, intraoperative results, and postoperative outcomes were compared using univariate strategies. A total of 503 patients were included for review, of which 422 were performed in a hybrid OR (84%) and 81 were performed using a portable C-arm (16%). Intraoperatively, an increased estimated blood loss (47.7 ± 54.7 vs 26.1 ± 26.9mLs, p < 0.01) and operative time was found in the cases performed in a hybrid OR. However, the fluoroscopy time was lower (4.0 ± 2.6 vs 5.2 ± 5.8min, p = 0.01) in the setting of advanced intraoperative imaging. Postoperatively, we found no differences with respect to myocardial infarction (0.2% vs. 0%, p > 0.99), stroke (2.4% vs. 2.5%, p = 0.96), or death (0.7% vs. 2.5%, p = 0.15) between groups. While there are some intraoperative variabilities between TCAR performed in hybrid versus standard ORs, postoperative outcomes are comparable. Therefore, the lack of a hybrid room should not be a deterrent to the adoption of TCAR.

4:12 PM Abstract No. 335 Safety and feasibility of transradial uterine fibroid embolization in an office-based lab

To assess the safety and feasibility of performing transradial uterine fibroid embolization (trUFE) in an office-based lab (OBL). A retrospective review was performed of all patients who underwent transradial uterine fibroid embolization (trUFE) at two office-based labs between June 2018 and July 2019. Data collected included demographic information, pertinent medical history, and procedural details (radiation exposure, length of procedure, time to discharge, complications). All procedures were performed under conscious sedation. Fluoroscopy and digital subtraction radiography were performed utilizing a portable C-arm (Philips Veradius). Ultrasound guidance for radial access was used in all cases. Bilateral Embolization was performed in all cases using embozene 500um and 700 μm particles. Approximately 8 mL of 1% lidocaine was administered to each uterine artery at the end of embolization. Postprocedural pain regimen consisted of fentanyl 25 mcg PRN and oxycodone/acetaminophen 5 mg/325 mg PRN. A total of 9 premenopausal women (mean age, 46.7 ± 4.9 years) underwent trUFE for symptomatic uterine fibroids. The mean procedure time was 68 minutes (range, 53-120) with the average fluoroscopy time of 22.1 minutes (range, 14.2-29.5). The average time to discharge was 4.4 hours. Median follow-up was 4 months. Clinical success measured by subjective relief in symptoms at 2-month follow-up was seen in 9/9 (100%) of the patients. There were no immediate or delayed postprocedural complications. One patient returned to the Emergency room 5 hours after discharge for pain management. Transradial uterine fibroid embolization can be safely performed in an office-based lab.

P1.17-29 8-year Experience of Navigational Bronchoscopy for Preoperative Localization of Subcentimeter Lung Nodules in a Small Community Hospital

With the advent of lung cancer screening, CT imaging has led to the identification of sub-centimeter nodules that are challenging to localize for both diagnosis and resection. The traditional approaches are problematic because biopsies often have poor diagnostic yield, resulting in repeat attempts at tissue collection, delay in time to treatment, and increased cost. Electromagnetic navigation bronchoscopy (ENB) is a newer technology that allows greater precision in preoperative localization of nodules to obtain tissue for diagnosis and fiducial marker placement. Our institution has adopted a practice that combines simultaneous ENB for nodule localization and video-assisted thoracoscopic surgery (VATS) for resection with single anesthetic administration and operating room team. We aimed to evaluate changes in time to treatment, time to surgery, and length of stay. Retrospective review of all patients who underwent nodule localization and VATS or robotic-assisted VATS (RATS) between (May 2011- March 2019). ENB localization was performed with transbronchial injection of ICG and/or placement of gold fiducial markers. A total of 72 patients underwent VATS or RATS. During the first two years of the study period, ENB was performed with portable C-arm fluoroscopic guidance with diagnostic yield of 48%. Surgery was performed on average 29.7 days (4-190 days) after ENB (3 patients had non-diagnostic bronchoscopy and were followed with serial CT scans that resulted in >100 days until surgery). In August 2017 utilization of Cone Beam CT scan began during ENB, which resulted in reduction in time to surgery to average of 20.1 days (1-39 days). After persistent low diagnostic yield with bronchoscopy and demand for expedient diagnosis, in February 2018, ENB and surgical resection were performed simultaneously with single anesthetic administration and OR team. Furthermore, in December 2018 utilization of daVinci Xi robot began for RATS with ICG injection during ENB for intraoperative localization of nodules. The hospital length of stay (LOS) and time to treatment (from the initial identification of a lung nodule to surgery) for Super D bronchoscopy group (SDB) (n=36) is 5.7/63.8 days, SDB-with cone beam technology (n=8) is 4.5/62.8 days, respectively. Transition to simultaneous resection (n=28) resulted in 100% diagnostic yield, further decrease of both hospital LOS and time to treatment, to 3.6 days and 43.7 days, respectively. Our data demonstrates that intraoperative ENB lung lesion localization with simultaneous VATS/RATS resection results in decreased hospital length of stay, reduced time to treatment, and 100% diagnostic yield. Both metrics significantly impact patient satisfaction and healthcare costs.

Retrograde Open Mesenteric Stenting Should Be Considered an Initial Approach to Acute Mesenteric Ischemia

Retrograde open mesenteric stenting (ROMS) is an alternative to traditional bypass in patients who present with acute mesenteric ischemia (AMI). However, there is a paucity of data comparing outcomes of ROMS with other open surgical approaches. This study represents the largest single-institution experience with ROMS and aims to compare outcomes of ROMS with mesenteric bypass. All patients who presented with AMI from 2008 to 2018 and were treated with either ROMS or mesenteric bypass were included in the study. Patient, procedure, and outcome variables were compared (Table). Bypass and ROMS patients were compared using univariate and multivariable analysis. Variables associated with mortality and reintervention were evaluated using multivariable Cox and logistic regression. There were134 patients who presented with AMI. Of these patients, 31 were included in the study; 15 underwent mesenteric bypass, and 16 underwent ROMS. ROMS patients tended to be older and had higher rates of comorbidities and bowel resections than bypass patients. Comparisons of the two surgical groups are summarized in the Table. Bypass patients were more likely to present with acute-on-chronic symptoms (73.3% vs 31.3%; P = .019). Bypass procedures also took longer than ROMS procedures (316 vs 189 minutes; P = .001). The majority of ROMS were performed with a portable C-arm (75%). Of the 10 (62.5%) ROMS patients who survived the hospital stay, stent patency was confirmed with surveillance duplex ultrasound scan and computed tomography angiography. One ROMS stent thrombosed, requiring mesenteric bypass. One bypass conduit thrombosed, resulting in perioperative death; and one bypass anastomosis stenosed, requiring angioplasty. Complication, unanticipated reintervention, and mortality rates were similar between groups (Table). Multivariable Cox regression at 5 years yielded no difference in reintervention-free survival curves between bypass and ROMS patients (log-rank, P = .572). Complication, reintervention, and mortality rates after ROMS are similar to mesenteric bypass in the setting of AMI with no difference in reintervention-free survival. Given similar outcomes and ability to perform these procedures in a conventional operating room with shorter operative times, ROMS should be considered a first-line option in acute situations when the operator is comfortable performing the procedure.TablePatient, procedural, and outcome dataBypass (n = 15)ROMS (n = 16)P valueDemographics Sex (female)10 (66.7)11 (68.8).901 Age73 (68-77)64 (58-70).993 Prior tobacco use13 (86.7)13 (81.3).682 BMI21.5 (17.9-24.9)26.8 (19.9-31.8).944Comorbidities Diabetes5 (33.3)7 (43.8).552 HTN11 (73.3)13 (81.3).598 HLD7 (46.7)11 (68.8).213 ESRD0 (0.0)4 (25.0).038 CHF0 (0.0)2 (12.5).157 COPD3 (20.0)4 (25.0).739 CAD4 (26.7)8 (50.0).183 Stroke or TIA0 (0.0)1 (6.3).325 PVD5 (33.3)7 (43.8).398 Prior SBR3 (20.0)3 (18.8).930Presenting signs and symptoms Lactate1.6 (1.2-3.3)2.9 (1.7-3.4).885 White blood cell count18.2 (11.5-22.8)23.1 (11.5-27.7).868 Albumin2.8 (2.6-3.4)3.8 (3.4-4.1).858 Creatinine elevated from baseline0 (0.0)3 (18.8).078 Pneumatosis4 (26.7)7 (43.8).474 Acute-on-chronic symptoms11 (73.3)5 (31.3).019Intraoperative data SBR9 (60.0)14 (87.5).080 Transfusion8 (53.3)7 (43.8).715 OR time, minutes316 (227-373)189 (141-254).001 Second look10 (66.7)14 (87.5).166In-hospital complications Bleeding3 (20.0)3 (18.8).924 Sepsis5 (33.3)5 (31.3).893 Cardiac2 (13.3)1 (63).501 TIA or stroke0 (0.0)1 (6.3).326 TPN dependent3 (20.0)2 (12.5).624 LOS16 (14-22)16 (7-31).664 In-hospital death5 (33.3)6 (37.5).809Late complications Reintervention for mesenteric ischemia3 (20.0)5 (31.3).474 All-cause mortality10 (66.7)9 (56.25).552BMI, Body mass index; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; ESRD, end-stage renal disease; HLD, hyperlipidemia; HTN, hypertension; LOS, length of stay; OR, operating room; PVD, peripheral vascular disease; ROMS, retrograde open mesenteric stenting; SBR, small bowel resection; TIA, transient ischemic attack; TPN, total parenteral nutrition.Categorical variables are presented as number (%). Continuous variables are presented as median (interquartile range). Open table in a new tab

Radiation exposure in prone vs. modified supine position during PCNL: Results with an anthropomorphic model.

Radiation exposure during urological procedures is still of concern in the urology community. It has been reported that percutaneous nephrolithotomy (PCNL) in supine position has less irradiation, as the puncture is mostly done under ultrasound guidance. However, it can also be done under fluoroscopy guidance. Unfortunately, data on radiation exposure during PCNL is lacking since they are often drawn from generalization and extrapolation, or they do not evaluate new procedures or different positions. The aim of our study was to compare the radiation dose depending on the position of the surgeon during PCNL. A portable C-arm was used in standard mode (32 impulsions/second; 98 kV, 3.8 mA). Specific dosimeters were placed for lens, extremity, and torso. Anthropomorphic models and hand phantom models were used to reproduce the position of surgeon and patient (with same bone density as human) during PCNL in prone and modified supine position. Fluoroscopy time (FT) was six minutes to obtain higher exploitable signal, and the results are given for a FT of three minutes (more realistic). Ten percent of the FT is done with an angulation of 15 degrees and the rest in anteroposterior position. The equivalent doses (ED) are given in uSV (uncertainty k=2). During the modified supine position: neck, lens, right index finger, left thumb, and index finger received EDs of 99 (20%), 62 (18%), 437 (10%), 112 (12%), and 204 (10%), respectively. In a prone position, the phantom received ED on the neck, lens, right thumb and index finger, left thumb and index finger of 85 (20%), 92 (12%), 401 (10%), 585 (10%), 295 (10%), and 567 (10%), respectively. In both positions, the right hand seems more exposed than the left hand. The effective dose is 1.5- and 1.3-fold higher for lens and extremities, respectively, in prone position PCNL compared to modified supine position. Both positions are still well below the recommended limit for professional exposure.

Six years' experience of thoracic endovascular aortic repair in patients with thoracic aortic diseases: A single-center study

Aim: Thoracic endovascular aortic repair (TEVAR) is evolving as a gold standard therapy for treating complex thoracic aortic diseases (TAD). It has evolved as first-line therapy for descending thoracic aortic aneurysms (DTAA) and Type B aortic dissection (TBAD) with reduced morbidity and mortality. The aim of this study is to evaluate clinical profiles, treatment variation, results, and complications of TEVAR. We have also highlighted the feasibility of performing complex procedures under mobile C-arm with certain innovative methods. Materials and Methods: A total of 43 patients (34 men and 9 women), mean age 59 years; age range 23–81 years, with TBAD and DTAA, who underwent TEVAR at tertiary care center from July 2012 to April 2019 were included in the study. Management strategies applied as per existing recommendations requiring TEVAR with or without debranching. The primary endpoints were technical success, 30-day mortality. The secondary endpoints were death, stroke, or spinal cord ischemia (SCI) and graft-related complications such as endoleak, migration, kinking, or thrombosis. Follow-up was done at 1, 3, 6, and 12 months and thereafter yearly. Follow-up events included death from all causes, neurological deficits, malperfusion syndrome, and reintervention. Results: Of 43 patients, 14 had TBAD and 29 had DTAA. Sixteen required hybrid repair and rest underwent TEVAR alone. Primary technical and assisted primary clinical success was 96% and 100%, respectively. Three patients developed Type I endoleak, covered with thoracic extender. The mortality rate was 9.5%. One had minor stroke and no SCI. Conclusion: TEVAR is reliable, stable, and safe for the treatment of TAD. It continues to evolve rapidly and will likely establish itself as the first-line procedure with reduced perioperative morbidity and mortality. Utility of hybrid theaters cannot be overemphasized, and the possibilities of performing TEVAR in with portable C-arm will enable the procedure to be performed in the smaller center also.

Radioprotection Measures during the Learning Curve with Hybrid Operating Rooms

Endovascular procedures come with a potential risk of radiation hazards both to patients and to the vascular staff. Classically, most endovascular interventions took place in regular operating rooms (ORs) using a fluoroscopy C-arm unit controlled by a third party. Hybrid operating rooms (HORs) provide an optimal surgical suit with all the qualities of a fixed C-arm device, while allowing the device to be controlled by the surgical team. The latest studies suggest that an operator-controlled system may reduce the radiation dose. The purpose of the present study is to determine the amount of absorbed radiation using an HOR in comparison with a portable C-arm unit and to assess whether the radioprotection awareness of the surgical team influences the radiation exposure. The primary end point was the effective dose in milliSievert (mSv) for the surgical team and the average dose-area product (ADAP) in Gray-meters squared (Gym2) for patients. The values of absorbed radiation of the surgical team's dosimeters were collected from January 2015 to May 2016. The HOR was installed in June 2015, and a radioprotection seminar was given in October 2015. The HOR-issued radiation, measured by the maximum dose-area product, ADAP, average dose (AD) per procedure, maximum dose per procedure per month, maximum fluoroscopy time, average fluoroscopic time, peak skin dose, and average skin dose (ASD), was collected monthly from September 2015 to July 2016. The timeline was divided into 3 periods: 5months pre-HOR (Pre-HOR), 5months after the HOR installation (PreS-HOR), and 5months after a radioprotection seminar (PostS-HOR). The average number of procedures per month was 22.55 (±4.9), including endovascular aneurysm repair/thoracic endovascular aneurysm repair, carotid, visceral, and upper and lower limb endovascular revascularization. The average amount of absorbed radiation by the surgeons during PreS-HOR was 1.07±0.4mSv, which was higher than the other periods (Pre-HOR 0.06±0.03mSv, P=0.002; PostS-HOR 0.14±0.09mSv, P=0.000, respectively). The ADAP during PreS-HOR was 0.016±0.01 Gym2, which was lower than the PostS-HOR (0.001±0.002 Gym2) (P=0.034). The AD during PreS-HOR was 0.78±0.3Gy and 0.39±0.3Gy during PostS-HOR (P=0.098). The ASD during PreS-HOR was 0.40±0.2Gy and 0.20±0.1Gy during PostS-HOR (P=0.099). In our experience, the HOR increases the amount of absorbed radiation for both patients and surgeons. The radioprotection seminars are of utmost importance to provide a continued training and optimize the use of ionizing radiation while using an HOR. Despite the awareness of the surgical team in the radioprotection field, the amount of absorbed radiation using an HOR is higher than the one using a C-Arm unit.

Radiation Dosimetry for Ureteroscopy Patients: A Phantom Study Comparing the Standard and Obese Patient Models.

To determine the effect of obesity on radiation exposure during simulated ureteroscopy. A validated anthropomorphic adult male phantom with a body mass index (BMI) of approximately 24 kg/m(2), was positioned to simulate ureteroscopy. Padding with radiographic characteristics of human fat was placed around the phantom to create an obese model with BMI of 30 kg/m(2). Metal oxide semiconductor field effect transistor (MOSFET) dosimeters were placed at 20 organ locations in both models to measure organ dosages. A portable C-arm was used to provide fluoroscopic x-ray radiation to simulate ureteroscopy. Organ dose rates were calculated by dividing organ dose by fluoroscopy time. Effective dose rate (EDR, mSv/sec) was calculated as the sum of organ dose rates multiplied by corresponding ICRP 103 tissue weighting factors. The mean EDR was significantly increased during left ureteroscopy in the obese model at 0.0092 ± 0.0004 mSv/sec compared with 0.0041 ± 0.0003 mSv/sec in the nonobese model (P < 0.01), as well as during right ureteroscopy at 0.0061 ± 0.0002 and 0.0036 ± 0.0007 mSv/sec in the obese and nonobese model, respectively (P < 0.01). EDR during left ureteroscopy was significantly greater than right ureteroscopy in the obese model (P = 0.02). Fluoroscopy during ureteroscopy contributes to the overall radiation dose for patients being treated for nephrolithiasis. Obese patients are at even higher risk because of increased exposure rates during fluoroscopy. Every effort should be made to minimize the amount of fluoroscopy used during ureteroscopy, especially with obese patients.

MP17-06 RADIATION DOSES IN PRONE VERSUS SUPINE POSITION DURING PERCUTANEOUS NEPHROLITHOTOMY, RESULTS WITH AN ANTHROPOMORPHIC MODEL

You have accessJournal of UrologyImaging/Radiology: Uroradiology III1 Apr 2015MP17-06 RADIATION DOSES IN PRONE VERSUS SUPINE POSITION DURING PERCUTANEOUS NEPHROLITHOTOMY, RESULTS WITH AN ANTHROPOMORPHIC MODEL Jonathan Cloutier, Jean-Baptiste Terrasa, Luca Villa, and Olivier Traxer Jonathan CloutierJonathan Cloutier More articles by this author , Jean-Baptiste TerrasaJean-Baptiste Terrasa More articles by this author , Luca VillaLuca Villa More articles by this author , and Olivier TraxerOlivier Traxer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.848AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radiation exposure during urologic procedures is still of concern in the urologist's community. There is more surgeon reporting that nephrolithotomy in supine position will have less irradiation as the puncture is almost completely done under ultrasound guidance. However, the puncture on supine position can also be done completely under fluoroscopy guidance. The aim of our study was to compare the radiation dose depending on the position of the surgeon. METHODS A portable C-arm (Siemens, Siremobil Compact L) was used in standard mode (32 impulsions/seconde; 98kV and 3.8mA). Specific dosimeters have been placed for lens and extremity, and on the surgeon. Anthropomorphic models were used to reproduce the position of surgeon and patient (with same bone density than real human) during percutaneous nephrolithotomy in prone and modified supine position. Hand phantom models were placed to represent the extremities. Fluoroscopy time was 6 minutes to have a better precision, and the results are given for a fluoroscopy time of 3 minutes (more realistic). Ten percent of the fluoroscopy time is done with an angulation of 15 degrees and the rest in anteroposterior position. RESULTS The equivalent doses(ED) are given in uSV (uncertainty k=2). During the modified supine position: neck, lens, right index finger, left thumb and index finger received ED of 99 (20%), 62 (18%), 437 (10%), 112 (12%), 204uSV (10%), respectively. In a prone position, the phantom received ED on the neck, lens, right thumb and index finger, left thumb and index finger of 85 (20%), 92 (12%), 401 (10%), 585 (10%), 295 (10%), 567 (10%), respectively. In both position, the right hand seems exposed more than the left hand. The index fingers are 1.5 (right hand) and 1.9 (left hand) fold more exposed than the thumbs. CONCLUSIONS The effective dose is 1.5 and 1.3 fold higher for lens and extremities, respectively, in a prone position percutaneous nephrolithotomy compared to a modified supine position. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e178 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan Cloutier More articles by this author Jean-Baptiste Terrasa More articles by this author Luca Villa More articles by this author Olivier Traxer More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

The impact of x-ray tube configuration on the eye lens and extremity doses received by cardiologists in electrophysiology room

The aim of the study was to analyse the influence of the x-ray tube configuration on the radiation doses to eye lens and extremities of cardiologists performing pacemaker implantation procedures in electrophysiology laboratory. The measurements were performed on one, widely used, portable C-arm system, first with x-ray tube mounted above the patient table and image intensifier below it and then on a reinstalled (but essentially the same) system with under-table x-ray tube configuration. Thermoluminescent dosimeters, placed in various positions near the eye lens, on the hands and ankle, were used during every procedure. The comparison of doses received by cardiologists after changing the x-ray tube configuration from over- to under-table shows statistically significant dose reduction (p < 0.009) for the eye lens closest to the x-ray tube, left finger, left wrist, while for the ankle a dose increase is observed. The corresponding over- to under-table x-ray tube median dose ratios are 4.1 for the right eye, 4.8 for the left finger, 3.0 for left wrist and, finally, 0.13 for the right ankle. Systems with under-table x-ray tube are preferable from a radiation protection point of view. The observed significant increase in doses to the legs should be partially compensated by the use of a protective lead curtain.

Heart Rythm Society expert consensus statement on electrophysiology laboratory standards: process, protocols, equipment, personnel, and safety.

ABBREVIATIONS CIED = cardiovascular implantable electronic device; CT=computed tomography; EP=electrophysiology; FDA= U.S. Food and Drug Administration; ICD=implantable cardioverterdefibrillator; MRI = magnetic resonance imaging; QA = quality assurance; QI = quality improvement; RF = radiofrequency; VT = ventricular tachycardia (Heart Rhythm 2014;11:e9–e51)

MP12-11 INCREASED RADIATION EXPOSURE FROM FLUOROSCOPY WITH FIXED TABLE VERSUS PORTABLE C-ARM

You have accessJournal of UrologyImaging/Radiology III1 Apr 2014MP12-11 INCREASED RADIATION EXPOSURE FROM FLUOROSCOPY WITH FIXED TABLE VERSUS PORTABLE C-ARM Fernando Cabrera, Richard Shin, Giao Nguyen, Chu Wang, Yi Hsuan Chung, Ramy Youssef, Charles Scales, Michael Ferrandino, Glenn Preminger, Terry Yoshizumi, and Michael Lipkin Fernando CabreraFernando Cabrera More articles by this author , Richard ShinRichard Shin More articles by this author , Giao NguyenGiao Nguyen More articles by this author , Chu WangChu Wang More articles by this author , Yi Hsuan ChungYi Hsuan Chung More articles by this author , Ramy YoussefRamy Youssef More articles by this author , Charles ScalesCharles Scales More articles by this author , Michael FerrandinoMichael Ferrandino More articles by this author , Glenn PremingerGlenn Preminger More articles by this author , Terry YoshizumiTerry Yoshizumi More articles by this author , and Michael LipkinMichael Lipkin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.446AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Fluoroscopy is widely used during endourologic procedures and is associated with significant radiation exposure. Our objective was to estimate patient radiation exposure during fluoroscopy with either a fixed table or portable C-arm using a validated anthropomorphic adult male model. METHODS A validated male anthropomorphic model was placed supine on both a cystoscopy operating room table and a fixed fluoroscopy table unit. A GE 9900 C-arm was used to perform fluoroscopy with the cystoscopy table. Metal oxide semiconductor field effect transistor dosimeters were placed at 20 organ-specific locations in the model to measure organ specific dosages. Continuous fluoroscopy was performed for three separate 5-6 minute runs. Measured organ dose rates (mGy/sec) were multiplied by their tissue weighting factor (International Commission on Radiological Protection) and summed to determine effective dose rate (EDR, mSv/sec). Values are reported as mean ± SD. RESULTS The total EDR was significantly higher by an order of magnitude during fixed-table compared with portable C-arm fluoroscopy at 0.0240 ± 0.0019 mSv/sec and 0.0029 ± .0005 mSv/sec, respectively (p = 0.0024) . The organ specific dose rates are presented in the figure. The bone marrow, liver, stomach, spleen, pancreas and gallbladder were all exposed to significantly greater doses with the fixed table compared to the C-arm. CONCLUSIONS Estimated organ doses and EDR are significantly higher during fluoroscopy using fixed-table compared with portable C-arm fluoroscopy. The majority of organs, including the most radio-sensitive organs, are exposed to more radiation using the fixed table. Urologists should be aware of this difference when considering operating room design and purchasing fluoroscopy equipment to perform ureteroscopy or percutaneous nephrolithotomy. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e109 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Fernando Cabrera More articles by this author Richard Shin More articles by this author Giao Nguyen More articles by this author Chu Wang More articles by this author Yi Hsuan Chung More articles by this author Ramy Youssef More articles by this author Charles Scales More articles by this author Michael Ferrandino More articles by this author Glenn Preminger More articles by this author Terry Yoshizumi More articles by this author Michael Lipkin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP73-05 INCREASED RADIATION EXPOSURE DURING URETEROSCOPY IN THE OBESE PATIENT.

You have accessJournal of UrologyStone Disease: Evaluation III1 Apr 2014MP73-05 INCREASED RADIATION EXPOSURE DURING URETEROSCOPY IN THE OBESE PATIENT. Fernando Cabrera, Richard Shin, Giao Nguyen, Chu Wang, Yi Hsuan Chung, Ramy Youssef, Charles Scales, Michael Ferrandino, Glenn Preminger, Terry Yoshizumi, and Michael Lipkin Fernando CabreraFernando Cabrera More articles by this author , Richard ShinRichard Shin More articles by this author , Giao NguyenGiao Nguyen More articles by this author , Chu WangChu Wang More articles by this author , Yi Hsuan ChungYi Hsuan Chung More articles by this author , Ramy YoussefRamy Youssef More articles by this author , Charles ScalesCharles Scales More articles by this author , Michael FerrandinoMichael Ferrandino More articles by this author , Glenn PremingerGlenn Preminger More articles by this author , Terry YoshizumiTerry Yoshizumi More articles by this author , and Michael LipkinMichael Lipkin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2358AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Patients with urolithiasis are at increased risk of significant radiation exposure. We determined the effect of obesity on radiation exposure during ureteroscopy (URS). Effective dose rates were calculated using an obese and non-obese validated phantom model during right and left URS. METHODS A validated anthropomorphic adult male phantom was positioned to simulate URS. Padding with radiographic characteristics of human fat was placed around the phantom to create an obese model. The phantom represents a male with a Body Mass Index (BMI) of approximately 24 kg/m2 and the obese model represents a male with a BMI of 30 kg/m2. Metal oxide semiconductor field effect transistor dosimeters were placed at 20 organ locations in the obese and non-obese model to measure organ dosages. A portable C-arm was used to provide continuous fluoroscopy to simulate a left and right URS for three 5-6 minute runs each. Organ dose rates were calculated by dividing organ dose by fluoroscopy time. Effective dose rate (EDR, mSv/sec) was calculated as the sum of organ dose rates multiplied by a tissue weighting factor (International Commission on Radiological Protection Publication). Values are reported as mean ± SD. RESULTS The mean effective dose rates were higher for the obese model compared with the non-obese model. The mean EDR during left URS was significantly increased in the obese model at 0.0092 ± .0004 mSv/sec compared to 0.0041 ± 0.0003 mSv/sec in the non-obese model (p = 0.006). The mean EDR during right sided URS was 0.0087 ± 0.0044 and 0.0036 ± 0.0003 mSv/sec in the obese and non-obese model, respectively (p = 0.180). The mean organ doses are listed in the table. CONCLUSIONS Fluoroscopy during URS contributes to overall radiation dose. Obese patients are at even higher risk due to increased exposure during fluoroscopy. Efforts should be made to minimize the amount of fluoroscopy used during URS, especially in obese patients. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e866 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Fernando Cabrera More articles by this author Richard Shin More articles by this author Giao Nguyen More articles by this author Chu Wang More articles by this author Yi Hsuan Chung More articles by this author Ramy Youssef More articles by this author Charles Scales More articles by this author Michael Ferrandino More articles by this author Glenn Preminger More articles by this author Terry Yoshizumi More articles by this author Michael Lipkin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Risco da exposição à radiaç ão ionizante durante procedimentos endovasculares

ObjectivesThe resource to endovascular procedures has become progressively more frequent and has increased concerns regarding the deleterious effects from radiation exposure. The purpose of this investigation is to evaluate and quantify scattered radiation exposure to which the patient and the surgical team are exposed, produced by a portable C-arm radioscopy unit during its use in the operating theatre. Material and methodsRadiation dose was measured in a controlled operating room with reproduction of usual conditions experienced during endovascular procedures in our operating theatre. A 15cm polimetilmetacrilate phantom was used as a geometrical simulation of the thorax. The scattered radiation was measured in several positions which were determined according to the usual distribution of the surgical and anesthesiological team in the room and at several heights. Radiation quantification was accomplished with resource to a portable radiation monitor RaySafe Xi Survey Detector, adjusting dose rate in mGy/s. Additionally, a RaySafe Xi R/F detector was used to measure the skin entrance exposure of the simulated patient. Readings were taken in pulsed fluoroscopy mode at a frequency of 4 frames per second (fps), digital subtraction mode and roadmap mode. The different magnifications available (Mag 1, 2 and 3) were also combined with each of these modes. In all situations, x-ray unit radiation dose was setted on level 3 which usually provides the best quality images with automatic real-time control of contrast and brightness. ResultsData analysis determined the distribution of scattered radiation among all elements of the surgical team. Maximum level of exposures was found at a height of 120cm in digital subtraction and roadmap modes. In this setting, surgical team scattered radiation exposure rates relative to patient skin entrance exposure rates were 0.47% for the surgeon, 0.21% for the anesthesiologist, 0.32% for the first assistant and 0.13% for the instrumenting nurse. The use of digital subtraction and roadmap increased levels of radiation exposure to patient and surgical team 5 times in comparison to pulsed fluoroscopy mode at 4fps. When personal radiation protection shielding was used, radiation levels were considerably inferior. ConclusionsProximity to the radiation x-ray tube increases significantly the amount of scattered radiation received. With the use of personal radiation shielding, the exposure is considerably lower and recommended radiation dose limits are not exceeded.

Image fusion for hybrid repair of dislocated superior mesenteric branch of a branched endovascular aortic graft

Recent advances in imaging technology allow the projection of volumetric imaging data from the preacquired computed tomography angiography over live fluoroscopy during interventions. This "fusion" technology is currently underused, although its application carries distinct advantages. We introduce a case in which fusion technology was used for the placement of two thoracic and one branched abdominal aortic endograft and to treat late dislocation of its side branch using a hybrid technique.

The impact of radiological equipment on patient radiation exposure during endovascular aortic aneurysm repair

To compare the patient radiation dose during endovascular aortic aneurysm repair (EVAR) using different types of radiological systems: a mobile fluoroscopic C-arm, mobile angiographic and fixed angiographic equipment. Dose-area products (DAP) were obtained from a retrospective study of 147 consecutive patients, subjected to 153 EVAR procedures during a 3.5-year period. On the basis of these data, entrance surface dose (ESD) and effective dose (ED) were calculated. EVARs were performed using a fluoroscopic C-arm, mobile or fixed angiographic equipment in 79, 26 and 48 procedures, respectively. Fluoroscopy times were essentially equivalent for all the systems, ranging from 15 to 19min. The clinical outcomes were not significantly different among the systems. Statistically significant differences among radiological equipment grouping were found for DAP (mobile C-arm: 32 ± 20Gycm(2); mobile angiography: 362 ± 164Gycm(2); fixed angiography: 464 ± 274Gycm(2); P < 10(-6)), for ESD (mobile C-arm: 0.18 ± 0.11Gy; mobile angiography: 2.0 ± 0.8Gy; fixed angiography: 2.5 ± 1.5Gy; P < 10(-6)) and ED (mobile C-arm: 6.2 ± 4.5mSv; mobile angiography: 64 ± 26mSv; fixed angiography: 129 ± 76mSv; P < 10(-6)). Radiation dose in EVAR is substantially less with a modern portable C-arm than with a fixed or mobile dedicated angiographic system. • Fluoroscopy during endovascular aortic aneurysm repair can impart a substantial radiation dose. • Radiation doses during EVAR are higher when using mobile/fixed angiographic systems. • Mobile C-arm fluoroscopy imparts a lower dose with an equivalent clinical outcome. • Procedures need to be dose-optimised when using mobile/fixed angiographic systems.

1948 ORGAN SPECIFIC RADIATION DOSE RATES AND EFFECTIVE DOSE DURING PERCUTANEOUS NEPHROLITHOTOMY

You have accessJournal of UrologyStone Disease: New Technology/SWL, Ureteroscopic or Percutaneous Stone Removal IV1 Apr 20121948 ORGAN SPECIFIC RADIATION DOSE RATES AND EFFECTIVE DOSE DURING PERCUTANEOUS NEPHROLITHOTOMY Michael Lipkin, John Mancini, Agnes Wang, Greta Toncheva, Colin Anderson-Evans, Michael Ferrandino, Terry Yoshizumi, and Glenn Preminger Michael LipkinMichael Lipkin Durham, NC More articles by this author , John ManciniJohn Mancini Durham, NC More articles by this author , Agnes WangAgnes Wang Durham, NC More articles by this author , Greta TonchevaGreta Toncheva Durham, NC More articles by this author , Colin Anderson-EvansColin Anderson-Evans Durham, NC More articles by this author , Michael FerrandinoMichael Ferrandino Durham, NC More articles by this author , Terry YoshizumiTerry Yoshizumi Durham, NC More articles by this author , and Glenn PremingerGlenn Preminger Durham, NC More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2106AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Fluoroscopy time has been used to report on radiation exposure during urologic procedures. However, it is difficult to determine actual radiation dose delivered to patients based on fluoroscopy time. Effective dose relates absorbed radiation to the risk of developing a malignancy. We determined organ specific dose rates and calculated effective dose rates (EDR) during right and left sided percutaneous nephrolithotomy (PNL) using a validated phantom model. We determined effective dose (ED) for right and left PNL performed at our institution. METHODS A validated anthropomorphic adult male phantom was placed prone on an operating room table. Metal Oxide Semiconductor Field Effect Transistor dosimeters were placed at 20 organ locations to measure the organ dosages. A portable C-arm was used to provide continuous fluoroscopy for three 10 minute runs each to simulate a left and right PNL. Organ dose rate (mGy/s) was determined by dividing organ dose by fluoroscopy time. The organ dose rates were multiplied by their tissue weighting factor and summed to determine EDR (mSv/s). We retrospectively reviewed 210 PNL procedures performed at our institution over a two year period. A total of 20 procedures on non-obese males with information on fluoroscopy time were included. Non-obese males most closely match the physical characteristics of our model. The ED was calculated by multiplying the fluoroscopy time by the EDR. RESULTS The EDR for a left and right sided PNL were 0.021 mSv/s and 0.014 mSv/s, respectively. The skin entrance was exposed to the greatest amount of radiation during left and right PNL, 0.24 mGy/s and 0.26 mGy/s respectively. The stomach was exposed to the second greatest amount of radiation on the left (0.07 mGy/s) and the gallbladder was exposed to the second greatest amount of radiation on the right (0.12 mGy/s). The median fluoroscopy time and ED for left PNL were 386.3 s (142.2–1364.6) and 8.11 mSv (2.99–28.66). The median fluoroscopy time and ED for a right PNL were 545.0 s (236.8–1269.5) and 7.63 mSv (3.32–17.77). CONCLUSIONS The EDR is higher for a left sided PNL compared to a right sided PNL. This is due to the fact that distribution of radiation exposure during PNL is not uniform. The patient ED for left and right PNL in non-obese males is greater than that of a computed tomography of the abdomen/pelvis. This radiation contributes to the overall amount patients with stones are exposed to. Further studies are needed to determine ways to reduce radiation exposure during PNL. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e786 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Lipkin Durham, NC More articles by this author John Mancini Durham, NC More articles by this author Agnes Wang Durham, NC More articles by this author Greta Toncheva Durham, NC More articles by this author Colin Anderson-Evans Durham, NC More articles by this author Michael Ferrandino Durham, NC More articles by this author Terry Yoshizumi Durham, NC More articles by this author Glenn Preminger Durham, NC More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Organ-Specific Radiation Dose Rates and Effective Dose Rates During Percutaneous Nephrolithotomy

Radiation exposure during medical procedures continues to be an increasing concern for physicians and patients. We determined organ-specific dose rates and calculated effective dose rates during right and left percutaneous nephrolithotomy (PCNL) using a validated phantom model. A validated anthropomorphic adult male phantom was placed prone on an operating room table. Metal oxide semiconductor field effect transistor dosimeters were placed at 20 organ locations in the model and were used to measure the organ dosages. A portable C-arm was used to provide continuous fluoroscopy for three 10 minute runs each to simulate a left and right PCNL. Organ dose rate (mGy/s) was determined by dividing organ dose by fluoroscopy time. The organ dose rates were multiplied by their tissue weighting factor and summed to determine effective dose rate (EDR) (mSv/s). Two-dimensional radiation distribution in the abdomen during a left-sided PCNL was visually determined using radiochromic film. The EDR for a left PCNL was 0.021 mSv/s ± 0.0008. The EDR for a right PCNL was 0.014 mSv/s ± 0.0004. The skin entrance was exposed to the greatest amount of radiation during left and right PCNL, 0.24 mGy/s and 0.26 mGy/s, respectively. Radiochromic film demonstrates visually the nonuniform dose distribution as the x-ray beam enters through the skin from the radiation source. The effective dose rate is higher for a left-sided PCNL compared with a right-sided PCNL. The distribution of radiation exposure during PCNL is not uniform. Further studies are needed to determine the long-term implications of these radiation doses during percutaneous stone removal.

Advances in the Endovascular Management of Acute Injury

Traumatic vascular injuries are common in the multi-injured patient. Exposure and repair can often be challenging, particularly in the pelvis, chest, and distal carotid arteries. The explosion of endovascular technology over the last decade has brought innovative strategies to managing vascular trauma in the injured patient.( 1 ) Hybrid operating rooms provide the perfect opportunity to perform arteriography, minimally invasive proximal control, and therapeutic intervention, be it endovascular, open, or a hybrid combination thereof. In the absence of a hybrid operating room, an angiographic table and portable C-arm in the operating room is certainly acceptable. Percutaneous and hybrid techniques to manage nonaortic arterial trauma will be reviewed.