Impact of access site selection and operator expertise on radiation exposure; a controlled prospective study

doi:10.1016/j.ahj.2012.06.011

American Heart Journal

Volume 164, Issue 4, October 2012, Pages 455-461

https://doi.org/10.1016/j.ahj.2012.06.011 Get rights and content

Background

Published data relating to arterial access site selection and radiation exposure during coronary procedures suggest radial access may lead to increased radiation exposure, but this is based on poorly controlled studies. We sought to measure radiation exposure to patients and operators during elective coronary angiography (CA) according to access site, with other procedure related variables controlled for. We also investigated the specific effect of operator expertise in relation to radiation exposure.

Methods

100 consecutive patients undergoing first time elective CA were recruited prospectively. An expert transradial (TR) and an expert transfemoral (TF) operator performed 25 cases each via their default route. A trainee cardiologist with intermediate experience in both access sites performed 25 cases via each route. Angiographic projections were standardised and optimised radiation protection was utilised for all procedures. The primary endpoints were operator and patient exposure, quantified by effective dose (ED) and dose area product (DAP) respectively. Secondary endpoints included fluoroscopy time (FT) and time to patient ambulation.

Results

The trainee operator recorded higher values for radiation exposure in radial and femoral cases when compared to the expert operators. There were no significant differences in radiation exposure during CA to operator or patient according to access site when standardised by operator experience. For the trainee, ED for TR and TF procedures was 8.8 ± 4.3 μSv and 8.5 ± 6.5 μSv (P = .86) and DAP was 25.4 ± 4.8 Gycm² vs 25.2 ± 8.3 Gycm² (P = .9). For the expert TR and TF operators, ED was 6.4 ± 4.7 μSv vs 6.1 ± 5.6 μSv (P = .85) and DAP was 21.7 ± 6.5 Gycm² vs 22.4 ± 8.0 Gycm², (P = .74). There was no significant difference in FT in relation to access site. Time to ambulation was significantly longer with TF access.

Conclusion

The use of TR access has no adverse effect on radiation exposure or FT for diagnostic CA, but does allow for quicker ambulation compared to TF access. The magnitude of radiation exposure is related to operator expertise for both access sites. The results of previous studies reflect the effect of uncontrolled patient and operator variables and not access site selection.

Section snippets

Study design

In this study we sought to eliminate the effect of non-access site related influences on patient and operator radiation exposure. To minimise the effect of variation in patient related factors and procedural complexity, we studied only patients with symptoms of limiting chest pain undergoing first time elective diagnostic angiography. Patients with acute coronary syndrome (ACS), previous coronary artery bypass grafting (CABG) and undergoing PCI were excluded. All patients were studied using a

Patient characteristics

100 consecutive patients undergoing elective CA comprised the study population. Baseline patient characteristics are detailed in Table I. There was no access failure or access site cross-over in either the radial or femoral groups. The patients investigated by the radial expert operator were significantly older than those investigated by the femoral operator, but all other patient characteristics were similar.

Primary endpoint: radiation exposure

For procedures performed by the expert operator, there were no significant differences

Discussion

This is the first study which attempts to isolate and investigate the role of access site selection in radiation exposure during cardiac procedures whilst tightly controlling for other potential confounding variables. In relation to our first hypothesis, our data indicates that when other variables are controlled for, TR access is not associated with an increase in fluoroscopy time or radiation exposure to operators or patients. We have shown a small (2 to 3 minute) increase in on-table

Conclusions

TR diagnostic CA is not associated with higher radiation exposure to the operator or the patient compared to the TF route when performed by operators of similar experience employing contemporary technique and meticulous radiation protection measures. The time required to patient ambulation is markedly reduced following a TR procedure. Procedures performed by operators with lower levels of experience generate higher radiation exposure regardless of which access site is employed. Careful

Disclosures

Conflict of interest: none declared.

References (40)

C. Lotan et al.
Transradial approach for coronary angiography and angioplasty
Am J Cardiol
(1995)
S.S. Jolly et al.
Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials
Am Heart J
(2009)
M. Brueck et al.
A Randomized Comparison of Transradial Versus Transfemoral Approach for Coronary Angiography and Angioplasty
Am Coll Cardiol Interv
(2009)
E. Kuon et al.
Significant reduction of radiation exposure to operator and staff during cardiac interventions by analysis of radiation leakage and improved lead shielding
Am J Cardiol
(2002)
M.R. Pitney et al.
Modifying fluoroscopic views reduces operator radiation exposure during coronary angioplasty
J Am Coll Cardiol
(1994)
S.W. Miller et al.
Radiation exposure and protection in cardiac catheterization laboratories
Am J Cardiol
(1985)
A. Sciahbasi et al.
Transradial approach (left vs right) and procedural times during percutaneous coronary procedures: TALENT study
Am Heart J
(2011)
M. Mercuri et al.
Radial artery access as a predictor of increased radiation exposure during a diagnostic cardiac catheterization procedure
JACC Cardiovasc Interv
(2011)
K. Ratib et al.
Operator experience and radiation exposure during transradial and transfemoral procedures
JACC Cardiovasc Interv
(2011)
F. Biancari et al.
Meta- analysis of randomized trials on the efficacy of vascular closure devices after diagnostic angiography and angioplasty
Am Heart J
(2010)

B. Freestone et al.

Transradial cardiac procedures: the state of the art

Heart

(2010)

S.C. Eccleshall et al.

Implementation of a diagnostic and interventional transradial programme: resource and organisational implications

Heart

(2003)

T.S.N. Lo et al.

Percutaneous left and right catheterisation in fully anticoagulated patients utilising the radial artery and forearm vein: A Two-Center Experience

J Interv Cardiol

(2006)

T.S.N. Lo et al.

Transradial rescue angioplasty for failed thrombolysis in acute myocardial infarction: reperfusion with reduced vascular risk

Heart

(2006)

S. Kumar et al.

Radial approach to day case intervention in coronary artery lesions (RADICAL): a single centre safety and feasibility study

Heart

(2004)

A. Wiper et al.

Day case transradial coronary angioplasty: a four-year single-center experience

Catheter Cardiovasc Interv

(2006)

Y. Louvard et al.

Feasibility of routine transradial coronary angiography: a single operator's experience

J Invasive Cardiol

(1999)

A.J. Chase et al.

Association of the arterial access site at angioplasty with transfusion and mortality: the M.O.R.T.A.L study (Mortality benefit Of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg)

Heart

(2008)

M.A. Mamas et al.

Influence of access site selection on PCI-related adverse events in patients with STEMI: meta-analysis of randomised controlled trials

Heart

(2012)

M. Hamon et al.

Should radial artery access be the “gold standard” for PCI?

Heart

(2008)

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X-Ray, false friend of the interventional cardiologist - Risks, evaluation, quality improvement - Status report from France-PCI registry
2021, Annales de Cardiologie et d'Angeiologie
Le rayon X est l'allié indispensable de l'angioplasticien, mais l'irradiation du patient et du personnel soignant en salle peut être pourvoyeuse de complications radio-induites (radiodermite, cataracte, tumeur cérébrale, etc.). L'exposition à des doses élevées ou répétées expose à un risque de survenue d'effets déterministes. Et, l'opérateur, et le patient encourent un risque aléatoire d'apparition d'effets stochastiques. Ces risques sont intimement liés à la dose absorbée. Dans ce contexte, la radioprotection constitue un enjeu de santé publique. Elle repose sur le principe ALARA qui consiste à optimiser la dose, c'est-à-dire à utiliser autant de rayonnement utile pour fournir une imagerie adéquate mais pas plus de rayonnement que nécessaire. Ainsi, les mesures et principes de radioprotection, rappelés dans cet article, doivent être maîtrisés par tout cardiologue interventionnel.
Dans une démarche d'amélioration des pratiques, il paraît indispensable d’évaluer et comparer les données dosimétriques liées aux procédures de cardiologie interventionnelle. Le registre France-PCI a permis de recueillir, sur l'année 2020, les données dosimétriques de 55 783 procédures coronaires menées dans 30 centres français. En moyenne, une coronarographie diagnostique nécessitait un temps de scopie de 4,4 minutes, un PDS de 1 767cGy.Cm2 et un Air Kerma de 257 Gy. Ces doses sont doublées voire triplées pour les procédures d'angioplasties. Enfin les traitements des occlusions chroniques apparaissaient comme responsables d'une irradiation plus de deux fois supérieures aux angioplasties conventionnelles. On constate par ailleurs une importante disparité des doses moyennes par procédure selon les centres considérés.
Although indispensable, radiation exposure during cardiac catheterization procedures can cause specific radiation-induced diseases. These affect the patient but also the interventional cardiologist. Exposure to high or repeated radiation doses causes deterministic effects. Moreover, even low-dose exposure, especially when repeated, produces a risk of stochastic effets. In that respect, it is crucial to improve the radiation safety of cardiac angiography and interventions, to promote radiation protection and to maintain this exposure « As Low As Reasonably Achievable ». Thus, there is a necessity to spread knowledge about safety standards and recommandations to reduces the dose among interventionalists.
Data collection and comparaison of practices are precious to this quality improvement process. For the year 2020, France-PCI registry had collected dosimetric datas related to 55 783 coronary angiographic and interventional procedures from 30 centers in France. Mean fluoroscopy time was 4,4 minutes for diagnostic procedures. Mean PDS was 1 767cGy.Cm2 and mean Air Kerma de 257Gy. Coronary percutaneous angioplasty procedures were related to approximately two to three times higher mean exposures. Mean exposure related to chronic coronary total occlusion treatment procedures was also two times higher than exposure related to non-CTO interventions. These data also highlighted wide disparities between centers.
Radial Versus Femoral Arterial Access for Interventional Procedures: Is There a Preference Among Nursing Care Providers?
2020, Journal of Radiology Nursing
Citation Excerpt :
In fact, a subset analysis of the international RIVAL trial, the largest randomized trial comparing radial versus femoral access outcomes, found that radiation exposure was only nominally higher in TRA than TFA and that this difference was only present in lower-volume centers and operators (Jolly et al., 2013). This is consistent with the findings of other studies that illustrate similar or lower radiation exposures and procedure times associated with TRA compared with TFA performed by a proficient operator (Jolly et al., 2013; Lo et al., 2012). It also implies that the learning curve associated with TRA may be the primary barrier to its implementation.
The purpose of this study was to examine preference for radial or femoral access for visceral arterial interventions among nursing staff responsible for postprocedural care at a single institution. In September 2018, 100 surveys were sent to nurses in the Cardiac and Interventional Radiology Recovery Unit, 48 of whom completed the survey. On a 5-point Likert scale, nurses responded to whether they disagree or agree with 10 encouraging statements regarding radial arterial access. An average of these 10 scores was calculated and an average score >4 for a nurse was considered to be favorable for radial access. Surveyed nurses had an average of 16.7 years of experience with a standard deviation of 10.2 years. The mean value for 7 of 10 statements regarding radial access was >4.5; the mean value was a 4.1 for the statement “radial access requires less nursing care.” Nurses responded most favorably to the statements “radial access is less embarrassing” and “radial access lets patients go home sooner," with 93% (43/47) of nurses either strongly agreeing or agreeing. Among the 48 nurses, 40 nurses had a cumulative average score >4. A chi-square test of radial favorability versus level of experience yielded a chi-square statistic of 1.2 and a p-value of .273 (not significant at p < .05). Nurses tend to prefer radial over femoral access when caring for patients who have undergone interventional radiology procedures, independent of years of experience. Nursing care is not likely to be an impediment in the initiation of a radial access program.
Barriers for transradial coronary angiography and interventions in 2016
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Radial versus femoral access for coronary angiography and intervention is associated with lower patient radiation exposure in high-radial-volume centres: Insights from the RAY'ACT-1 study
2017, Archives of Cardiovascular Diseases
Citation Excerpt :
The first clinical implication of this study is that it confirms, in a multicentre setting and in a country where radial access is common, that exposure with radial access is modulated by the volume of transradial procedures. The learning curve, the experience and the high volume of operators for radial access have been underlined as key factors in radiation dose reduction [12–14,18]. In the RadIal Versus femorAL (RIVAL) randomised trial [13], KAP was not significantly different between radial and femoral access, while fluoroscopy time and the radiation dose (measured by the total air Kerma calculated at the interventional reference point) were higher in transradial procedures.
Literature suggests that radial access is associated with higher radiation doses than femoral access.
To compare patient radiation exposure during coronary angiography (CA) and percutaneous coronary intervention (PCI) with radial versus femoral access.
RAY’ACT is a nationwide, multicentre, French survey evaluating patient radiation in interventional cardiology. Variables of patient exposure from 21,675 CAs and 17,109 PCIs performed at 44 centres during 2010 were analysed retrospectively.
Radial access was used in 71% of CAs and 69% of PCIs. Although median fluoroscopy times were longer for radial versus femoral access (CA, 3.8 vs 3.5 minutes [P < 0.001]; PCI, 10.4 vs 10.1 minutes [P = 0.001]), the Kerma-area product (KAP) was lower with radial access (CA, 26.8 vs 28.1 Gy·cm²; PCI, 55.6 vs 59.4 Gy·cm²; both P = 0.001). Differences in KAP remained significant in the multivariable analysis (P < 0.01), and in a propensity score-matched analysis (P = 0.01). A significant interaction was found between KAP and the percentage of procedures with radial access by centre (P < 0.001). KAP was higher by radial versus femoral access in low-radial-volume centres, and lower in high-radial-volume centres. Radiation protection techniques, such as the use of low frame rates (7.5 frame/s), were used more frequently in high-radial-volume radial centres.
In this multicentre study, radial access was associated with lower radiation doses to patient than femoral access in high-radial-volume centres. Provided that radioprotection methods are implemented, radial access could be associated with lower patient radiation exposure.
La voie radiale est considérée comme plus irradiante pour les patients que la voie fémorale pour les coronarographies (CA) et les angioplasties coronaires (PCI)
Cette étude a comparé l’exposition des patients lors de CA et PCI réalisées par voie radiale et fémorale.
RAY’ACT est une étude française multicentrique évaluant l’exposition des patients aux rayons x lors des procédures de cardiologie interventionnelle coronaire, qui a analysé rétrospectivement les paramètres d’exposition pour 21 675 CA et 17 109 PCI réalisées dans 44 centres en 2010.
La voie radiale a été utilisée dans 71 % des CA et 69 % des PCI. Bien que le temps de scopie médian soit plus long pour la voie radiale versus fémorale (CA, 3,8 vs 3,5 minutes [p < 0,001] ; PCI, 10,4 vs 10,1 minutes [p = 0,001]), le produit dose-surface (KAP) était inférieur pour la voie radiale (CA, 26,8 vs 28,1 Gy·cm² ; PCI, 55,6 vs 59,4 Gy·cm² ; tous p = 0,001). Les différences de KAP restaient significatives en analyse multivariée (p < 0,01), et par analyse stratifiée sur un score de propension (p = 0,01). Une interaction significative a été observée entre le KAP et le pourcentage de procédures par voie radiale des centres (p < 0,001). Le KAP était plus élevé par la voie radiale vs fémorale dans les centres à faible volume pour la voie radiale, et inférieur dans les centres à haut volume pour cette voie. Les techniques de radioprotection, telles que les cadences faibles (7,5 images/s), étaient plus souvent utilisées dans les centres à haut volume pour la voie radiale.
Dans cette étude multicentrique, la voie radiale était associée à une irradiation du patient inférieure à la voie fémorale, globalement et particulièrement dans les centres à haut volume de voie radiale. Sous réserve de la mise en place de méthodes de radioprotection, la voie radiale pourrait être associée à une irradiation du patient réduite.
Radiation exposure in relation to the arterial access site used for diagnostic coronary angiography and percutaneous coronary intervention: A systematic review and meta-analysis
2015, The Lancet
Transradial access for cardiac catheterisation results in lower bleeding and vascular complications than the traditional transfemoral access route. However, the increased radiation exposure potentially associated with transradial access is a possible drawback of this method. Whether transradial access is associated with a clinically significant increase in radiation exposure that outweighs its benefits is unclear. Our aim was therefore to compare radiation exposure between transradial access and transfemoral access for diagnostic coronary angiograms and percutaneous coronary interventions (PCI).
We did a systematic review and meta-analysis of the scientific literature by searching the PubMed, Embase, and Cochrane Library databases with relevant terms, and cross-referencing relevant articles for randomised controlled trials (RCTs) that compared radiation parameters in relation to access site, published from Jan 1, 1989, to June 3, 2014. Three investigators independently sorted the potentially relevant studies, and two others extracted data. We focused on the primary radiation outcomes of fluoroscopy time and kerma-area product, and used meta-regression to assess the changes over time. Secondary outcomes were operator radiation exposure and procedural time. We used both fixed-effects and random-effects models with inverse variance weighting for the main analyses, and we did confirmatory analyses for observational studies.
Of 1252 records identified, we obtained data from 24 published RCTs for 19 328 patients. Our primary analyses showed that transradial access was associated with a small but significant increase in fluoroscopy time for diagnostic coronary angiograms (weighted mean difference [WMD], fixed effect: 1·04 min, 95% CI 0·84–1·24; p<0·0001) and PCI (1·15 min, 95% CI 0·96–1·33; p<0·0001), compared with transfemoral access. Transradial access was also associated with higher kerma-area product for diagnostic coronary angiograms (WMD, fixed effect: 1·72 Gy·cm², 95% CI −0·10 to 3·55; p=0·06), and significantly higher kerma-area product for PCI (0·55 Gy·cm², 95% CI 0·08–1·02; p=0·02). Mean operator radiation doses for PCI with basic protection were 107 μSv (SD 110) with transradial access and 74 μSv (68) with transfemoral access; with supplementary protection, the doses decreased to 21 μSv (17) with transradial access and 46 μSv (9) with transfemoral. Meta-regression analysis showed that the overall difference in fluoroscopy time between the two procedures has decreased significantly by 75% over the past 20 years from 2 min in 1996 to about 30 s in 2014 (p<0·0001). In observational studies, differences and effect sizes remained consistent with RCTs.
Transradial access was associated with a small but significant increase in radiation exposure in both diagnostic and interventional procedures compared with transfemoral access. Since differences in radiation exposure narrow over time, the clinical significance of this small increase is uncertain and is unlikely to outweigh the clinical benefits of transradial access.
None.
A comparison of radial and femoral access for cardiac catheterization
2015, Trends in Cardiovascular Medicine
Over the past several years, the transradial approach (TRA) for cardiac catheterization has become increasingly adopted in the United States. The increased utilization of the TRA is grounded on 2 decades of research, showing reduced bleeding and vascular complications to complement improved patient quality of life. However, the concern over cost, radiation exposure, and acknowledged “learning curve” has kept the transfemoral approach (TFA) the mainstay of most US catheterization laboratories. More recent larger multi-centered randomized studies have aimed to address outcomes and these concerns between the TR and TF approaches. This article will review the changing trends in TRA in the US, discuss clinical (bleeding and mortality) and non-clinical (quality of life and cost) outcomes from recent randomized studies, and finally discuss certain aspects when it comes to adopting TRA.

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Transradial Angiography and interventionImpact of access site selection and operator expertise on radiation exposure; a controlled prospective study

Background

Methods

Results

Conclusion

Section snippets

Study design

Patient characteristics

Primary endpoint: radiation exposure

Discussion

Conclusions

Disclosures

Am J Cardiol

Am Heart J

Am Coll Cardiol Interv

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

JACC Cardiovasc Interv

JACC Cardiovasc Interv

Am Heart J

Transradial cardiac procedures: the state of the art

Heart

Implementation of a diagnostic and interventional transradial programme: resource and organisational implications

Heart

Percutaneous left and right catheterisation in fully anticoagulated patients utilising the radial artery and forearm vein: A Two-Center Experience

J Interv Cardiol

Transradial rescue angioplasty for failed thrombolysis in acute myocardial infarction: reperfusion with reduced vascular risk

Heart

Radial approach to day case intervention in coronary artery lesions (RADICAL): a single centre safety and feasibility study

Heart

Day case transradial coronary angioplasty: a four-year single-center experience

Catheter Cardiovasc Interv

Feasibility of routine transradial coronary angiography: a single operator's experience

J Invasive Cardiol

Association of the arterial access site at angioplasty with transfusion and mortality: the M.O.R.T.A.L study (Mortality benefit Of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg)

Heart

Influence of access site selection on PCI-related adverse events in patients with STEMI: meta-analysis of randomised controlled trials

Heart

Should radial artery access be the “gold standard” for PCI?

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Transradial Angiography and intervention
Impact of access site selection and operator expertise on radiation exposure; a controlled prospective study