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RADPAD CLI Perspectives: Alternative Access for CTOs in CLI

RADPAD CLI Perspectives: Alternative Access for CTOs in CLI

Posted on September 12, 2016 by in Procedures with no comments

Last year, Cath Lab Digest published an interview covering alternative access for chronic total occlusions in critical limb ischemia. J.A. Mustapha, MD, interviewed Andrej Schmidt, MD, Department of Angiology, Leipzig Heart Center, Leipzig, Germany. 

Read the full article below or click the link for the original publicaiton:

http://www.cathlabdigest.com/article/CLI-PERSPECTIVES-Alternative-Access-CTOs-CLI

 


CLI PERSPECTIVES: Alternative Access for CTOs in CLI

Author(s):

CLI Perspectives is headed by section editor J.A. Mustapha, MD, 

Metro Health Hospital, Wyoming, Michigan. 

 

Topics:
Access
Critical limb ischemia
Chronic total occlusions (CTO)
Issue Number:
Volume 23 – Issue 2 – February, 2015

 

 

 

J. Mustapha: What is your preferred access method for crossing complex superficial femoral artery (SFA) CTOs, with the exception of ostial SFA disease?

A. Schmidt: Most SFA CTO crossing is performed via ipsilateral antegrade approach.

 

 

J. Mustapha: Why do you prefer an ipsilateral antegrade approach?

A. Schmidt: For multiple beneficial reasons, including shortening the distance from the access site to the CTO, enhancement of pushability, and much better wire and catheter torque.

 

J. Mustapha: Do you ever perform a contralateral access approach for SFA CTOs?

 

A. Schmidt: Yes, mostly in patients who are not good candidates for antegrade access such as obese patients, those with proximal disease, ostial SFA disease, or CTOs. Mostly, I prefer antegrade access for SFA CTOs.

 

J. Mustapha: Many of us have seen you perform live cases and have witnessed your excellent techniques in retrograde popliteal and SFA access in complex CTO crossing. Why do you access these segments?

A. Schmidt: We access distal to the CTO cap of the SFA or popliteal CTO only when we fail to cross from antegrade approach first. The reason we access close to the CTO is similar to the reasoning of the antegrade access, close to the CTO cap, which in turns helps with retrograde pushability and torqueability.

J. Mustapha: What advice would you give practitioners who would like to perform similar retrograde access in the SFA/popliteal?

A. Schmidt: Proceed with caution, as this should only be attempted after an antegrade approach fails.  Be sure to have a balloon across the occluded target lesion and the guidewire across the distal access before taking the access catheter out, so that in case a problem (dissection, occlusion) occurs at the distal entrance, balloon angioplasty can be done to fix it. Hemostasis is principally done by external compression.

 

 

J. Mustapha: What is the average time of your balloon inflation?

A. Schmidt: The time depends on the size of the access catheter or the sheath used. Most of the time, we use the smallest catheter possible, .018-inch to .035-inch.  Therefore, we perform a three-minute balloon inflation followed by an angiogram.

 

J. Mustapha: Is this the same for a stick in a stent vs no stent?

A. Schmidt: Yes.

 

J. Mustapha: Do you worry about harming the stent after getting access in it?

A. Schmidt: No. So far, in our experience, we have not had any issues with stents in these situations. Keep in mind, we only get an access in the stent in extreme cases and place the smallest catheter possible.

J. Mustapha: Moving to retrograde tibial access, which access method do you use to enter the artery, angiogram-guided or ultrasound-guided?

A. Schmidt: We use angiogram-guided access.

 

J. Mustapha: Which is your preferred tibial artery for retrograde access and which part of the artery do you like to enter?

A. Schmidt: My preferred artery is the anterior tibial artery and I prefer to enter it proximally.

 

J. Mustapha: Why proximal versus distal?

A. Schmidt: Proximally, because the vessel diameter is larger and accommodates a 4 French sheath if needed.

 

J. Mustapha: How do you get the access?

A. Schmidt: First we position the foot supine and support it with a rolled-up towel, then perform an angiogram in left oblique 30° view, and enter the needle thru the skin into the artery. If no blood returns, we perform an oblique view with repeat angiogram which helps show the tip of the needle and artery.

 

J. Mustapha: How do you obtain hemostasis after the proximal tibial access?

A. Schmidt: Most of the time, we use an external blood pressure cuff.  Occasionally, we use an intra-arterial balloon.

 

J. Mustapha: If needed, what are your tips and tricks for getting distal tibial access?

A. Schmidt: Starting with the dorsalis pedis access, foot positioning is important. First we position the foot supine and support it with a rolled-up towel, then the C-arm is positioned at about 15° ipsilateral and 10° cranial. We then use the quick access needle holder, followed with an angiogram. Also, we can puncture and perform contrast injection simultaneously, as needed.

 

J. Mustapha: Do you recommend road mapping for tibial access?

A. Schmidt: No, side movements of the artery due to puncture needles are not noticed, which may lead to accidental venous access and failed attempts. Also, I don’t recommend coming in from a lateral approach.

 

J. Mustapha: How do you know your needle is in line with the artery?

A. Schmidt: After angiogram is done, make the needle form one line with the artery (Figure 1A-B).

 

J. Mustapha: What do you do in the setting of no blood return?

A. Schmidt: Obtain oblique orthogonal views at 55-65°, load the guidewire into the needle, and perform contrast injection via the proximal sheath and pull back very slowly. Keep testing if the guidewire makes it through. Another method is to pull back slowly and inject contrast from the needle holder until you see contrast in the artery, then advance the guidewire (Figure 2A-G).

 

J. Mustapha: Any tips on how to get peroneal access?

A. Schmidt: Start with an anterior approach. Place the C-arm at ipsilateral LAO 30° (Figure 3A), perform antegrade angiogram, and position the needle in line with the artery.  If no success, then move the C-arm to right anterior oblique (RAO) 70° (Figure 3B) and repeat angiogram. Redirect the needle toward the artery, puncturing the peroneal artery through the membrana interossea.

 

J. Mustapha: Which puncture site is safer?

A. Schmidt: The distal tibial access approach is safer, as it is not associated with compartment syndrome.

 

J. Mustapha: What needles to you use for proximal and distal tibial access?

A. Schmidt: For proximal anterior tibial, posterior tibial, and peroneal access, we use a 7cm, 21g needle. For distal tibials, we use a 4cm, 21g needle.

 

J. Mustapha: Please advise what NOT to do in infrapopliteal retrograde access.

A. Schmidt: One should not access communication arteries, especially those off of the peroneal artery, as shown in Figure 4.

 

J. Mustapha: How do you minimize radiation exposure?

A. Schmidt: My angiographical approach to retrograde pedal and tibial puncture is quick and precise, minimizing radiation exposure. I attribute this to experience and the right equipment (Figure 5A). I wear a ring dosimeter (Figure 5B) to measure my exposure.

Disclosure: Dr. Mustapha reports he is a consultant to Bard Peripheral Vascular, Covidien, Cordis, CSI, Spectranetics, and Boston Scientific. Dr. Schmidt reports occasional consulting for Bard and Medtronic.

Dr. Andrej Schmidt and Dr. J.A. Mustapha can be contacted at jihad.mustapha@metrogr.org

 

WORLDWIDE INNOVATIONS & TECHNOLOGIES, INC. (WIT)

 

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Mounting Evidence That Cath Lab Work Has Radiation-Related Health Effects

Mounting Evidence That Cath Lab Work Has Radiation-Related Health Effects

Posted on September 2, 2016 by in Safety with no comments

A research study was conducted in which 466 scatter radiation exposed hospital staff members were evaluated based on work-related and lifestyle information, current medications and health status. These staff members included interventional cardiologists, electrophysiologists, nurses and technicians, half of which had been working for over ten years. The results of this study concluded almost 3% of the interventional cardiology staff had a history with cancer, compared to less than 1% of unexposed comparison group. Along with that, 8% of lab workers experienced skin lesions, 30% had orthopedic illness and 5% had cataracts. These issues have all been associated with scatter radiation exposure.

McKeown, LA. “Survey Adds to Mounting Evidence That Cath Lab Work Has Radiation-Related Health Effects.”tctmd: Cardiovascular Research Foundation, 13 Apr. 2016. Web. 26 May 2016

See the original article here: http://www.tctmd.com/show.aspx?id=134783

Read the full text below:

 

Survey Adds To Mounting Evidence That Cath Lab Work Has Radiation-Related Health Effects

By L.A. McKeown
Wednesday, April 13, 2016

 

Interventional cardiologists and other personnel who work in environments with fluoroscopy-guided procedures appear to have more health problems than their colleagues in the same field who are not exposed to radiation, a survey suggests. The health problems range from eye, skin, and orthopedic problems to mental health issues, and cancers.

Another View. Survey Adds To Mounting Evidence That Cath Lab Work Has Radiation-Related Health Effects

Researchers led by Maria Grazia Andreassi, MSc, PhD (CNR Institute of Clinical Physiology, Pisa, Italy), say “every effort should be made to raise the radiation awareness in the professional communities of interventional cardiologists and cardiac electrophysiologists, promoting justification of the examination, optimization of the dose, and maximal protection of the radiation workers.”

They surveyed 466 physicians and other staff members with an average of 10 years of experience working in interventional cardiology or electrophysiology laboratories as well as 280 individuals working in the cardiology field but having no exposure, including physicians, researchers, nurses, and administrative staff. All completed a questionnaire about their present and past medical history, medication use, duration of work, and frequency of cigarette and alcohol use. An occupational radiological risk score, which combined length of employment, individual caseload, and proximity to the radiation source, was formulated for each participant.

Physical, Psychological Differences Evident

Reporting their results online April 12, 2016, ahead of publication in Circulation: Cardiovascular Interventions, Andreassi and colleagues found that not only were potential radiation-related health issues such as skin lesions, orthopedic problems (back, neck, knee), cataracts, and cancers more prevalent in radiation-exposed vs unexposed workers, they were also more common among physicians vs technicians and nurses, and among those with longer vs shorter work histories. Across every disease category, those with 16 or more years of working in an environment with fluoroscopy-guided procedures had the highest event rates.

The prevalence of anxiety/depression was also increased among the radiation-exposed group—at a rate 6 times higher than unexposed colleagues, while the rate of thyroid disease was doubled. Radiation-exposed workers also had greater rates of hypertension and hypercholesterolemia, but not of cardiovascular events.

Rates of health problems in the radiation-exposed versus unexposed groups were confirmed in multiple logistic regression analysis.

Table. Survey Adds To Mounting Evidence That Cath Lab Work Has Radiation-Related Health Effects

“Unfortunately, cardiologists pay little heed to monthly or cumulative reports of radiation exposure. And recent studies confirm that simple, effective protection measures—such as a lead curtain, protection glasses and thyroid collars—are not used by the majority of exposed cardiologists,” Andreassi said in a press release.

Exposure-Related Associations Abound

Among the health problems reported in the survey and previously described in the literature, radiation-induced cancer is “the most alarming and serious” of the long-term occupational risks for interventional cardiologists, the study authors write. Concerns of brain cancer on the left side of the head, which is known to be more exposed to radiation and least protected by standard shielding, have been apparent in the literature as far back as 1998, they note.

“Although the evidence supporting an increase in radiation-induced cancer among interventional cardiologists remains inconclusive, molecular studies showed that interventional cardiologists have a two-fold increase of chromosomal damage (surrogate biomarkers of cancer risk) in circulating lymphocytes than clinical cardiologists,” Andreassi and colleagues write. Recently, findings from the International Nuclear Workers cohort showed strong evidence of positive associations between protracted low-dose radiation exposure and leukemia.

Interestingly, Andreassi and colleagues point out that radiation-related increases in hypertension and elevated serum cholesterol concentrations have also been seen in atomic-bomb survivors, more than half of whom were exposed to an average dose of < 50 mSv. In the press release, Andreassi notes that experienced, busy interventional cardiologists and electrophysiologists typically are exposed to about 5 mSv yearly. In a study published last year, her group also found that cath lab workers showed early signs of vascular aging and subclinical atherosclerosis. They suggest that chronic low-dose rate radiation “triggers changes in the endothelial cell biology that induce the onset of premature senescence, and these alterations may in part be responsible for the increased risk of chronic low-dose radiation–associated cardiovascular disease.”

As for the higher incidence of anxiety and depression in the radiation workers, Andreassi and colleagues hypothesize that this may be related to “high stress and psychological strain,” or a direct effect of radiation exposure to the head of the operator, resulting in “hippocampal neurogenesis and neuronal plasticity, with possible negative effects on mood stability and psychiatric morbidity.”

Stress a Likelier Culprit

Commenting for TCTMD, Stephen Balter, PhD, of Columbia University Medical Center (New York, NY), said the biggest flaw with the study is that everything was assumed to stem from radiation.

“It’s a high-stress job and I’m not surprised that there are health risks associated with doing the job, but these things are unlikely to be associated with radiation per se,” Balter said. “I think people trying to do the best they can are stressed out, and that’s reflected in their mental state and in their chemistry.”

Other than cataracts, which have a long, documented history in operators and others routinely exposed to occupational radiation, the other health issues such as cancers have not been substantiated in the literature as related to exposure, he added.

“The message is you have to be careful, but there’s no reason for panic,” Balter commented, adding that enforcing the wearing of radiation protection glasses and other gear among cath lab workers remains a challenge.

Profit Over People

Even though the current study is limited, there is “more than enough information for us to conclude that the interventional catheterization laboratory is not a healthy workplace,” observe Lloyd W. Klein, MD and Mugurel Bazavan, MD (Rush Medical College, Chicago, IL), in an accompanying editorial.

Despite the known risks to operators, the technology used in cath labs has outpaced safety-related changes in cath lab design and personnel protection, they say, primarily due to a profit mentality on the part of administrators that values talented, young, and inexpensive workers who can be readily replaced.

“Certainly, investing money in an innovative cath laboratory design to protect its workers is hardly cost-effective when nurturing a long career is not the goal of management,” Klein and Bazavan write. “We call on industry and hospital administration to provide responsible stewardship, and for physician societies and interventional leaders to advocate visibly and set new priorities, so that those of us who choose to help patients live a longer and healthier life can ourselves enjoy a long and healthy career, one that allows us to use all the magnificent and cherished skills we have dedicated years to master.”


Sources:

  • Andreassi MG, Piccaluga E, Guagliumi G, et al. Occupational health risks in cardiac catheterization laboratory workers. Circ Cardiovasc Interv. 2016;Epub ahead of print.
  • Klein LW, Bazavan M. The economic imperatives underlying the occupational health hazards of the cardiac catheterization laboratory. Circ Cardiovasc Interv. 2016;Epub ahead of print.

Disclosures:

  • Andreassi, Klein, and Bazavan report no relevant conflicts of interest.
  • Balter reports serving on the speakers’ bureau for Mavig, a manufacturer of radiation-protection supplies.

 

WORLDWIDE INNOVATIONS & TECHNOLOGIES, INC. (WIT)
14740 W 101st Terrace
Lenexa, KS 66215
Phone: 913-648-3730
or 1-877-7RADPAD (1-877-772-3723)
Fax: 913-648-0131
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SCAI: Women Undergoing TAVR Have a Different Risk Profile and Greater Survival Rate Than Men

SCAI: Women Undergoing TAVR Have a Different Risk Profile and Greater Survival Rate Than Men

Posted on August 23, 2016 by in Other Stories with no comments

 

image

Although women are more likely to experience vascular complications in the hospital, their one-year survival rate is more favorable than men. 11,808 women and 11,884 men were evaluated over two years and the one-year mortality rate was lower in women, although the in-hospital survival rate was about the same.

Read the full article below, or click the link to see the original posting:

http://www.cathlabdigest.com/content/SCAI-Women-Undergoing-TAVR-Have-Different-Risk-Profile-Greater-Survival-Rate-Men

SCAI: Women Undergoing TAVR Have a Different Risk Profile and Greater Survival Rate Than Men

May 6, 2016 — Orlando, Fla. – Data from one of the largest national registries of transcatheter aortic valve replacement (TAVR) patients shows that although women are more likely to experience vascular complications in the hospital, their one-year survival rate is more favorable than men. This STS/ACC TVT Registry™ analysis was presented today as a late-breaking clinical trial at the Society for Cardiovascular Angiography and Interventions (SCAI) 2016 Scientific Sessions in Orlando, Fla.

Investigators evaluated in-hospital and one-year outcomes for 23,652 TAVR patients, including 11,808 women (49.9 percent) and 11,844 men (51.1 percent), from 2012-2014. Compared to men, women were older, with lower GFR (kidney function) but higher prevalence of porcelain aorta and a higher mean STS adult cardiac surgery risk score (9 percent vs. 8 percent). However, women undergoing TAVR had a lower prevalence of comorbidities, such as coronary artery disease, atrial fibrillation and diabetes.

“Prior to this study, smaller analyses have suggested that men and women have different outcomes following TAVR procedures,” said Jaya Chandrasekhar, MBBS, MRCP, FRACP, a post-doctoral research fellow with Roxana Mehran, MD, FACC, FAHA, FSCAI, at the Icahn School of Medicine at Mount Sinai and the primary author of this report. “We wanted to gain in-depth understanding into the differences between men and women undergoing TAVR procedures from the US national registry and to evaluate the discrepancies by sex in longer-term outcomes.”

The study demonstrated that women were treated more often using non-transfemoral access (45 percent vs. 34 percent) with smaller sheath and device sizes but had a higher valve cover index than men. Post-procedure, women experienced more in-hospital vascular complications than men (8.27 percent vs. 4.39 percent, adj HR 1.70, 95 percent CI 1.34 – 2.14, P < 0.001) along with a trend for more bleeding (8.0 percent vs. 5.96 percent, adj HR 1.19, 95 percent CI 0.98 – 1.44, P = 0.08).

Despite these complications for women, the in-hospital survival rate was the same as men. Additionally, one-year mortality was lower in women (21.3 percent) than in men (24.5 percent).

“These findings are promising for women,” said Dr. Chandrasekhar. “There is a suggestion that the lower rate of coronary artery disease in women undergoing TAVR does put them at an advantage for longer-term survival, compared to men. The next step should be to study quality of life metrics and outcomes beyond one year including causes for death in both men and women. At the same time, frailty should be better defined to allow appropriate selection of patients for this procedure.”

Dr. Chandrasekhar reports no disclosures.

Dr. Chandrasekhar presented “Sex Based Differences in Outcomes With Transcatheter Aortic Valve Therapy: From STS/ACC TVT Registry” on Friday, May 6, 2016, at 9:00 a.m. ET.

For more information about the SCAI 2016 Scientific Sessions, visit www.scai.org/SCAI2016.

###

About SCAI
The Society for Cardiovascular Angiography and Interventions is a 4,500-member professional organization representing invasive and interventional cardiologists in approximately 70 nations. SCAI’s mission is to promote excellence in invasive/interventional cardiovascular medicine through physician education and representation, and advancement of quality standards to enhance patient care. SCAI’s public education program, Seconds Count, offers comprehensive information about cardiovascular disease.

 

WORLDWIDE INNOVATIONS & TECHNOLOGIES, INC. (WIT)
14740 W 101st Terrace
Lenexa, KS 66215
Phone: 913-648-3730
or 1-877-7RADPAD (1-877-772-3723)
Fax: 913-648-0131
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Protecting the Provider:  A Reexamination of Cath Lab Radiation Safety

Protecting the Provider: A Reexamination of Cath Lab Radiation Safety

Posted on July 22, 2016 by in Safety with no comments

Protecting the Health of Cath Lab Technicians

Unlike patients who are only exposed to ionized radiation during their procedure, cath lab technicians are exposed during every procedure they perform. This article discusses health effects associated with radiation exposure in the cath lab along with ways to protect the health of those technicians. Two of those ways are wearing a lead-based shield, and keeping a distance between the operator and the radiation source.

Wohns, David, and Ryan Madder. “Protecting the Provider: A Reexamination of Cath Lab Radiation Safety.” Cath Lab Digest. HMP Communications, Feb. 2015. Web. 26 May 2016.

Read the article in full below, or click the link to see the originally published article at Cath Lab Digest:

http://www.cathlabdigest.com/article/Protecting-Provider-Reexamination-Cath-Lab-Radiation-Safety

 


 

Protecting the Provider: A Reexamination of Cath Lab Radiation Safety

Author(s):

David Wohns, MD, Medical Director, and Ryan Madder, MD, 

Kresge Cardiac Cath Labs, Frederik Meijer Heart & Vascular Institute, 

Spectrum Health, Grand Rapids, Michigan

Topics:
Radiation
Safety
Robotic PCI

In the delivery of high-quality healthcare, patient safety is always a major concern of providers and the public. The safety of healthcare workers frequently receives significantly less attention. Recent events have highlighted this issue and are altering this perspective, with greater recognition of the sacrifices and risks that healthcare workers routinely take to perform their jobs. Patient safety remains the number-one concern of healthcare providers. However, the health and safety of providers should receive equal attention, particularly when novel techniques and strategies can be adopted to mitigate provider risk.

During 2014, the Ebola patients treated within U.S. borders caught the attention of the mainstream media and the public. Besides the public’s general concern for the patients, much attention was devoted to the healthcare workers who were exposed to the virus while caring for Ebola patients. These events raised the public’s awareness of healthcare worker safety and also caused many people to ask: “How do we ensure the safety of healthcare providers who put themselves in harm’s way to look after their patients’ health?

Madder

This increased awareness is especially relevant to interventional cardiologists. Unlike patients, who are only exposed to ionizing radiation during their procedure, interventional cardiologists and other members of the cath lab team are repeatedly exposed to ionizing radiation, subjecting them to potentially serious long-term health issues. Additionally, the physical demands of performing their jobs while wearing heavy protective gear can lead to chronic orthopedic conditions that may prematurely end careers or force change into other fields of medicine.

Wohns

With the increased interest in healthcare worker safety, it is an appropriate time to explore the risks associated with cath lab environments and novel technological solutions available to improve safety.

Assessing cath lab risks

Medical procedures performed in the cath lab are a leading source of occupational ionizing radiation exposure for medical personnel1, due to the use of fluoroscopy and cine angiography during these procedures. This occupational radiation exposure is of particular concern because today’s interventional cardiologists are spending significantly greater time in the cath lab doing more complex and lengthy procedures. Further, the performance of percutaneous coronary intervention (PCI) procedures in cath labs has increased more than 50 percent since 20002, potentially exposing interventional cardiologists to additional radiation.

Although research studies have demonstrated substantial variations in the amount of ionizing radiation to which interventional cardiologists are exposed, a look at the literature reveals the following:

  • One study showed that an interventional cardiologist’s head and neck area are generally exposed to approximately 20 to 30 millisieverts (mSv) per year3, which equates to 2 to 3 rems per year.
  • Another demonstrated that cumulative doses for the average interventional cardiologist after 30 years in the cath lab fall between 50 to 200 mSv, equivalent to 5 to 20 rems, or 2,500 to 10,000 chest x-rays.4
  • A third shows that interventionalists receive approximately 1 to 3 sieverts (Sv) to their head during their career (equivalent to 1,000 to 3,000 mSv, or 100 to 300 rems), which corresponds to about 500mSv to the brain5 (equivalent to 50 rems).
  • A separate study showed that interventional cardiologists have a radiation exposure rate documented to be two to ten times higher than that of diagnostic radiologists.4

 

Adverse health effects

Despite the availability and use of personal protective equipment (PPE), such as lead aprons, leaded glasses and thyroid collars, there are significant radiation exposure risks that have the potential to negatively impact the health of interventional cardiologists and their staff. Below are some findings from recent scientific literature:

  • Cataracts: The Occupational Cataracts and Lens Opacities in Interventional Cardiology (O’CLOC) study revealed that 50 percent of interventional cardiologists and 41 percent of cardiac cath nurses and technologists had significant posterior subcapsular lens changes, a precursor to cataracts, which is typical of ionizing radiation exposure.6
  • Thyroid disease: Studies have reported structural and functional changes of the thyroid as a result of radiation exposure.7 Structural changes such as malignant and benign thyroid tumors develop at a linear rate to dose exposure. Functional changes that would result in hyper- or hypo-thyroidism were noted at elevated doses of external and internal radiation exposure.7
  • Brain tumors and brain disease: A recent study focused on interventionalists who had been diagnosed with a variety of brain tumors. The study revealed that 86% of the brain tumors (where location is known) originated on the left side of the brain.8 This is significant, since interventional cardiologists typically stand with the left side of their body closest to the X-ray source and scattered radiation. In the general population, brain tumors originate with equal frequency on the left and right hemispheres.
  • Cardiovascular changes: Recent studies suggest evidence of a link between low- to moderate-dose radiation exposure and cardiovascular changes, despite personal protective wear.5
  • Reproductive health effects: For males, ionizing radiation has demonstrated a reduction in sperm.9 Additionally, cath lab staff members who may become pregnant while working in the cath lab must also take into consideration the effects that ionizing radiation can have on the developing fetus.

Additionally, there are orthopedic-related consequences from the heavy weight of lead gear worn by interventional cardiologists. The repeated standing and leaning over patients during procedures is fatiguing and commonly leads to chronic orthopedic conditions. A 2006 survey conducted by the Society for Cardiovascular Angiography and Interventions (SCAI) disclosed that interventional cardiologists suffer from a disproportionate amount of back, hip, and knee injuries leading to a significant amount of missed workdays.10 The weight of the personal protective gear is fatiguing, and a physician who is fatigued or experiencing discomfort may be more likely to be distracted or rush through a procedure.

Protecting the health of cath lab employees

There are two traditional techniques used to reduce radiation exposure. One is lead-based shielding, and the second is increasing the distance between the operator and the radiation source.

A relatively new approach to shielding includes devices that support lead aprons that hang from a boom, rather than being worn by clinicians. These hanging aprons provide effective radiation protection with a greater quantity of lead than is traditionally worn by operators. Since the operator is not physically supporting the lead, these devices have the potential to reduce orthopedic injuries and reduce overall operator fatigue.

The advent of robot-assisted percutaneous coronary intervention (PCI) represents another novel approach to reducing radiation exposure to operators. Robotic systems for PCI allow interventional cardiologists to perform procedures remotely, away from the patient’s bedside. Seated in a radiation-protected cockpit, the physician uses digital controls to robotically manage catheters, guide wires, angioplasty balloons, and stents to clear blockages and restore blood flow. These technologies are beneficial in reducing exposure by positioning operators further from the radiation source, but also have the potential to mitigate the impact that wearing PPE has on operators, such as orthopedic pain, missed work and disability.

The robotic-assisted PCI system being used at Spectrum Health is called CorPath (Corindus Vascular Robotics). The CorPath System allows physicians to perform PCI procedures from the comfort of a radiation-shielded cockpit that includes angiographic and hemodynamic monitors. Physicians using the system are able to take measurements, with sub-millimeter accuracy, of relevant anatomy, as well as advance or retract guide wires and/or balloon stent catheters with movements as small as a millimeter. A clinical trial has shown that using the robotic system reduced radiation exposure to the primary operator by more than 95 percent.11

Elevating healthcare worker safety

Interventional cardiology is a uniquely rewarding, highly innovative profession. The bulk of the innovation in our field over the past 3 decades has appropriately been focused on patient care. However, the manner and circumstances with which that care has been delivered in the cath lab has changed little over time. New approaches are now available to begin to mitigate the biomechanical, orthopedic, and radiation risks of working in the cath lab. The CorPath System is an example of a device with tremendous promise to reduce these hazards for interventional cardiologists, contributing to longer, healthier careers. We have been excited to bring this innovative technology to our cath labs as part of the evolution of our environment.

References

  1. Sun Z, AbAziz A, Yusof AK. Radiation-induced noncancer risks in interventional cardiology: optimisation of procedures and staff and patient dose reduction. Biomed Res Int. 2013; 2013: 976962. doi: 10.1155/2013/976962.
  2. Best PJ, Skelding KA, Mehran R, Chieffo A, Kunadian V, Madan M, et al; Society for Cardiovascular Angiography & Interventions’ Women in Innovations (WIN) Group. SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel. Catheter Cardiovasc Interv. 2011 Feb 1; 77(2): 232-241. doi: 10.1002/ccd.22877.
  3. L Renaud. A 5-y follow-up of the radiation exposure to in-room personnel during cardiac catheterization. Health Phys. 1992 Jan; 62(1): 10-15.
  4. Picano E, Andreassi MG, Piccaluga E, Cremonesi A, Guagliumi G. Occupational risks of chronic low dose radiation exposure in cardiac catheterisation laboratory: the Italian Healthy Cath Lab study. EMJ Int Cardiol. 2013; 1: 50-58.
  5. Picano E, Vano E, Domenici L, Bottai M, Thierry-Chef I. Cancer and non-cancer brain and eye effects of chronic low-dose ionizing radiation exposure. BMC Cancer. 2012 Apr 27; 12: 157. doi: 10.1186/1471-2407-12-157.
  6. Vano E, Kleiman NJ, Duran A, Romano-Miller M, Rehani MM. Radiation-associated lens opacities in catheterization personnel: results of a survey and direct assessments. J Vasc Interv Radiol. 2013 Feb; 24(2): 197-204. doi: 10.1016/j.jvir.2012.10.016.
  7. Ron E, Brenner A. Non-malignant thyroid diseases after a wide range of radiation exposures.Radiat Res. 2010 Dec; 174(6): 877-888. doi: 10.1667/RR1953.1.
  8. Roguin A, Goldstein J, Bar O, Goldstein JA.  Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol. 2013 May 1; 111(9): 1368-1372. doi: 10.1016/j.amjcard.2012.12.060.
  9. Burdorf A, Figà-Talamanca I, Jensen TK, Thulstrup AM. Effects of occupational exposure on the reproductive system: core evidence and practical implications. Occup Med (Lond). 2006 Dec; 56(8): 516-520.
  10. Dehmer GJ. Occupational hazards for interventional cardiologists. Catheter Cardiovasc Interv. 2006 Dec; 68(6): 974-976.
  11. Weisz G, Metzger DC, Caputo RP, Delgado JA, Marshall JJ, Vetrovec GW, et al. Safety and feasibility of robotic percutaneous coronary intervention: PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) Study. J Am Coll Cardiol. 2013 Apr 16; 61(15): 1596-1600. doi: 10.1016/j.jacc.2012.12.045.

Disclosure: Dr. Wohns and Dr. Madder report no conflicts of interest regarding the content herein.

The authors can be contacted via David.Wohns@spectrumhealth.org.

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