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One-Third of Patients With Low Flow Aortic Stenosis Do Not Improve With TAVR, Research Finds

One-Third of Patients With Low Flow Aortic Stenosis Do Not Improve With TAVR, Research Finds

Posted on October 27, 2016 by in Procedures with no comments

Aortic Stenosis, the narrowing of the aortic valve in the heart, causing restricted blood flow, is one of the most common and serious valve disease problems. A TAVR procedure is the best option for treating this disease, but recent studies have shown that approximately one-third of low flow AS patients continue to suffer with low flow AS after the procedure.

Read the full article on the Radpad blog below, or see the original publication here: http://www.cathlabdigest.com/content/One-Third-Patients-Low-Flow-Aortic-Stenosis-Do-Not-Improve-TAVR-Research-Finds

One-Third of Patients With Low Flow Aortic Stenosis Do Not Improve With TAVR, Research Finds

Patients who do not improve with TAVR are found to have worse clinical outcomes at one year


June 16, 2016 – Aortic stenosis (AS), the narrowing of the aortic valve in the heart which causes restricted blood flow, is one of the most common and serious valve disease problems. For patients with one type of AS — low flow — transcatheter aortic valve replacement (TAVR), a minimally invasive procedure which corrects the damaged aortic valve, is often the best option for restoring the heart’s normal pumping function. However, approximately one-third of low flow AS patients treated with TAVR continue to suffer persistent low flow AS even after the procedure, ultimately increasing their risk of death. Now, researchers from the Perelman School of Medicine at the University of Pennsylvania have examined this high-risk patient population to determine the cause of this persistent low flow AS and to evaluate their risk of dying during the year following the procedure. Their findings are detailed in a paper published in the Journal of the American Medical Association – Cardiology.

“There has been a lot of interest in these patients with low flow AS, as their surgical mortality is higher than other patients. TAVR is often a good option, but not all of them will be able to normalize flow following the procedure and these persistently low flow patients have a 60 percent higher rate of mortality at one year,” said Howard C. Herrmann, MD, FACC, MSCAI, John W. Bryfogle Professor of Cardiovascular Medicine and Surgery, and director of Penn Medicine’s Interventional Cardiology Program. “Low flow before TAVR is one of the most important predictors of mortality following TAVR, but it is one of the harder qualities to measure. This presents a challenge to properly treating patients with low flow AS, and can leave some patients at higher risk.”

To better understand the potential benefits of TAVR for low flow AS, researchers conducted an analysis of 984 patients with low flow AS from the PARTNER trial and continued access registry from April 2014 through January 2016. A baseline and follow-up echocardiogram, evaluation of post-TAVR hemodynamics — blood flow — and one year outcomes were assessed.

Through this analysis, researchers identified the large subgroup of patients who, following TAVR, failed to regain normal flow despite a successful procedure. In the first six months following TAVR, flow improved in roughly 66 percent of the patients evaluated. However, those with severe low flow AS had the highest mortality rate — 26 percent — at one year, as compared to approximately 20 percent for those with moderate low flow and even less for those with normal flow.

“Unfortunately, many centers do not routinely measure flow, but rather focus more on a patient’s pressure gradient or valve area when evaluating aortic stenosis pre-and post-TAVR,” said Herrmann. “While low flow is more challenging to monitor, this measurement can better inform the patient’s risk of mortality, and in turn lead to better treatment.”

The researchers noted that the identification of remedial, or treatable, causes of persistent low flow following TAVR, such as severe mitral regurgitation and atrial fibrillation, may represent an opportunity to improve the outcomes of these patients.

Journal Reference:

  1. Venkatesh Y. Anjan, MD; Howard C. Herrmann, MD; Philippe Pibarot, PhD; William J. Stewart, MD; Samir Kapadia, MD; E. Murat Tuzcu, MD; Vasilis Babaliaros, MD; Vinod H. Thourani, MD; Wilson Y. Szeto, MD; Joseph E. Bavaria, MD; Susheel Kodali, MD; Rebecca T. Hahn, MD; Mathew Williams, MD; D. Craig Miller, MD; Pamela S. Douglas, MD; Martin B. Leon, MD. Evaluation of Flow After Transcatheter Aortic Valve Replacement in Patients With Low-Flow Aortic Stenosis: A Secondary Analysis of the PARTNER Randomized Clinical Trial. Journal of the American Medical Association — Cardiology, June 2016 DOI: 10.1001/jamacardio.2016.0759
alternate access for CTOs by RADPAD
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:



CLI PERSPECTIVES: Alternative Access for CTOs in CLI


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

Metro Health Hospital, Wyoming, Michigan. 


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




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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



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:


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.


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BRAIN Study Confirms Higher Radiation Dose to Cardiologists’ Left Side

BRAIN Study Confirms Higher Radiation Dose to Cardiologists’ Left Side

Posted on July 29, 2016 by in Safety, Uncategorized with no comments

BRAIN Study Confirms Higher Radiation Dose to Cardiologists’ Left Side:

This study was conducted by Ethisham Mahmud, MD, of University of California, San Diego, along with 7cardiology fellows and 4 physicians as they performed diagnostic and interventional cardiovascular procedures to show the attenuation of radiation by using a lead-free cap. Dr. Mahmud discusses the significant amount of exposure the left time of the cranium receives compared to the right during these procedures. Dr. Mahmud says that we need to do a lot more to further understand the equipment being used and the dangers of radiation in the lab. He notes that lead-free caps are a great way to reduce scatter radiation.

Contact us for a No Brainer surgical cap sample


Read the full article below or see the original piece here:



BRAIN Study Confirms Higher Radiation Dose to Cardiologists’ Left Side

Key Points:

  • Single-center study looks at whether protective cap can limit radiation exposure during interventional procedures
  • Exposure consistently greater on left side of head; secondary operators receive more radiation than primary

By Yael L. Maxwell
Tuesday, August 18, 2015

Radiation exposure to the cranium is higher on the left than on the right side for cardiologists doing invasive procedures, though this difference can be attenuated by wearing a nonlead-based cap in the cath lab, according to a study published in the August 17, 2015, issue of JACC: Cardiovascular Interventions.

Implications: BRAIN Study Confirms Higher Radiation Dose to Cardiologists’ Left Side

For the BRAIN (Brain Radiation Exposure and Attenuation During Invasive Cardiology Procedures) study, Ehtisham Mahmud, MD, of the University of California, San Diego (La Jolla, CA), and colleagues assessed 7 cardiology fellows and 4 attending physicians (mean age 38.4 years; all men) at their institution as they performed diagnostic and interventional cardiovascular procedures (mean 66.2 cases per operator; mean fluoroscopy time 14.9 minutes).

Each participant wore a lightweight XPF attenuating cap (BLOXR; Salt Lake City, UT) containing barium sulfate and bismuth oxide. All caps were fitted with 6 dosimeters to measure radiation exposure on the outside and inside of the cap.

A Little More on the Left

Total exposure on the outside of the cap was numerically higher on the left than center location (106.1 vs 83.1 mrad; P = .075), but exposure in both areas was higher than on the right side (50.2 mrad; P < .001 for both). Total exposure inside the cap was similar for all 3 locations—ranging from 41.8 to 42.3 mrad—and was only slightly higher than that measured by the ambient controls (38.3 mrad; P = .046).

After accounting for the ambient radiation, outside left exposure was 16 times higher than exposure on inside left and 4.7 times higher than that on the outside right (P < .001 for both). Exposure on the outside center was 11 times higher than on the inside center of the cap (P < .001), but no difference was seen between outside and inside doses on the right side.

Among a variety of factors—including patient weight, patient BMI, operator height, operator weight, percentage of radial cases, fluoroscopy time, and dose area product—only operator training level (fellow in training or attending cardiologist) predicted the extent of radiation exposure on the outside left and center locations.

Attending cardiologists—who tend to stand in the secondary position farther from the radiation source—received more outside left and center radiation than did fellows, who usually stand in the primary position (P = .002 and P = .01, respectively). “Despite the decreased exposure to the second operator as explained by the inverse square law, the optimal use of shielding in favor of the primary operator may overcome the protection offered by the increased distance,” Dr. Mahmud and colleagues suggest.

The Cap is Only the Beginning

In a telephone interview with TCTMD, Dr. Mahmud said the value of the study is “not as much about the cap as the concept.” Regardless of what protection operators may or may not use, “the most important message of this paper is that the left side of the brain gets tremendously greater exposure to radiation,” he said.

“We’re not doing a whole lot to protect ourselves… whether it’s in the primary or secondary position,” Dr. Mahmud continued. “One option is this cap, but the reality is we need to do a lot more to further understand and design equipment… or to look at alternative ways to do the procedure.”

Stephen Balter, PhD, of Columbia University Medical Center (New York, NY), told TCTMD in a telephone interview that the overall exposure reported outside the cap in the study is “reasonable” and well within the regulatory guidelines of 15,000 total mrad per year.

That said, using the cap “certainly doesn’t hurt,” he commented, and the fact that it can be used multiple times makes it less expensive than other options.

It is well known that radiation exposure is greater on the left than right side of cath lab operators, Dr. Balter explained. “It’s just how they stand and how they look at the monitors.” But “tracking people and understanding what’s happening is very relevant,” he said, adding that more specific results should come in time with theoretical modeling studies.

There will never be enough epidemiological research to show whether the XPF cap and other protections are increasing safety, Dr. Balter said. “There is a theoretical gain based on the radiobiology of models,” he added. “But it’s a small gain based on these numbers.”

All About Education

Dr. Mahmud said his team is planning another study, known as BRAIN 2, to further examine the phenomenon of how operator position affects radiation exposure. “The primary position is actually often better protected than the secondary position, where you’re a little bit further away but you might get more exposure to scatter,” he explained. “This is probably the first time this has ever been measured and ascertained.”

The second study will assess the validity of the difference between positions, Dr. Mahmud said. “We’re actually going to measure in a very systematic manner the radiation exposure for operators in the primary and secondary positions and behind and in front of shields.” BRAIN 2 will require the operators to stay in the same position throughout the course of each procedure, he explained.

But all of these studies, present and future, are meant to educate, Dr. Mahmud observed. “I am always shocked as to how few people seem to even admit that [radiation] is an issue. So I think it’s going to take more and more information, knowledge, and dissemination,” about the potential risk and any preventative options available, he said.


Reeves RR, Ang L, Bahadorani J, et al. Invasive cardiologists are exposed to greater left sided cranial radiation: the BRAIN study (Brain Radiation Exposure and Attenuation During Invasive Cardiology Procedures). J Am Coll Cardiol Intv. 2015;8:1197-1206.


  • Dr. Mahmud reports receiving clinical trial support from Boston Scientific, Corindus, and Gilead; serving as a consultant to The Medicines Company; and serving on the speakers bureau of Medtronic.
  • Dr. Balter reports no relevant conflicts of interest.




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:




Protecting the Provider: A Reexamination of Cath Lab Radiation Safety


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

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

Spectrum Health, Grand Rapids, Michigan

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?


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.


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.


  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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The Physical Stress of Working in a Cath Lab

Posted on July 16, 2016 by in Safety with no comments

Heavy Lead Aprons Causing Pain for Cath Lab Professionals

A survey was published in March of 2015 exhibiting musculoskeletal pain caused by work-related stress due to lead aprons. In order to protect from scatter radiation, cath lab professionals are required to wear heavy lead aprons. A survey was emailed to 2,682 cardiology and radiology employees at 6 Mayo Clinic facilities in the U.S. and received responses from 57%. Of these responses, 62% of techs, 60% of nurses, 44% of attending physicians and 19% of trainees reported work-related pain. Dr. Singh recommends that these employees be rotated out of the cath lab suites more frequently to reduce stress. Additionally, he recommends lighter-weight or non-lead-based protective wear.

Dalton, Kim. “Survey Puts Spotlight on Physical Stress of Working in a Cath Lab.” Tctmd: Cardiovascular Research Foundation, 23 Feb. 2015. Web. 26 May 2016.

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




Survey Puts Spotlight on Physical Stress of Working in a Cath Lab

By Kim Dalton
Monday, February 23, 2015

Cath lab personnel who spend long hours wearing heavy lead aprons to protect against radiation exposure are more likely to experience musculoskeletal problems than colleagues who work in other hospital settings, according to the results of a survey published in the March 3, 2015, issue of the Journal of the American College of Cardiology. Cath lab staffers did not report more radiation-related cataracts and cancers, although the low prevalence of such conditions and the study’s cross-sectional design may have hampered its ability to detect a difference.

According to an accompanying editorial by James A. Goldstein, MD, of the Beaumont Health System (Royal Oak, MI), years of such physical stress can result in “missed days of work, surgery, and, in some cases, curtailed careers.”


Investigators led by Mandeep Singh, MD, of the Mayo Clinic (Rochester, MN), emailed surveys to 2,682 cardiology and radiology department employees at 6 Mayo Clinic facilities across the country and received responses from 57% (n = 554 in cardiology and 989 in radiology; average age 43 years; 33% male). Respondents were divided into cath lab workers (n = 1,042) and controls (n = 499) based on whether they reported being engaged in procedures involving radiation.

The most common occupations of respondents were:

  • Technician/technologist: 54.3% (mean 15.5 years in position)
  • Registered nurse: 18.3% (mean 16.1 years)
  • Physician: 13.4% (mean 18.8 years)
  • Other: 9.3% (mean 11.3 years)
  • Resident/fellow: 4.7% (mean 4.0 years)

Clinical employees with exposure to procedures involving radiation that required wearing a lead apron were more likely to have experienced work-related pain and to have sought medical care for it than the control group. In addition, they were more likely to report pain at the time of the survey (table 1).

Table 1. Work-Related Pain by Job

However, there was no difference between the groups in objective assessment scores for current pain, recent use of pain medication, missed workdays, or use of disability.

The association between work-related pain and lead apron wearing remained after adjustment for age, sex, body mass index, preexisting musculoskeletal conditions, years in the profession, and job description (adjusted OR 1.67; 95% CI 1.32-2.11).

Cath lab employees who reported a history of work-related pain were more likely to be female, spent more time each week exposed to radiation, and wore a lead apron more often than controls (all P < .001). Tactics aimed at reducing musculoskeletal pain were also more common in those who reported work-related pain and included:

  • Prompt removal of the lead apron after procedures
  • Stretching/exercising before or after procedures
  • Wearing soft-soled shoes

There was no relationship between risk of injury and the type of lead apron worn (1 piece vs 2 pieces) or use of a glass shield or eye protection.

The likelihood of experiencing work-related pain varied by job description, with the highest incidence reported by techs (62%) and nurses (60%), followed by attending physicians (44%) and trainees (19%; P for trend < .001). Although techs and nurses were more likely than attending physicians to be female, the findings were similar when the analysis was restricted to men or women.

Cath lab workers exposed to radiation did not report more cancers, cataracts, hypothyroidism, or nephrolithiasis than employees not so exposed and showed no difference in rates of a composite endpoint including these conditions and musculoskeletal pain (P = .26).

Focus on Relieving Physical Stress

According to the authors, this is the first study to show that techs and nurses have a higher prevalence of work-related musculoskeletal pain than attending physicians despite being younger and having fewer years in the cath lab.

One reason for the discrepancy may be that physicians regularly rotate out of the cath lab while nurses and tech personnel do not, they suggest. Another possible contributor is that staff perform physically stressful tasks, like transferring patients on and off the table and applying compression after sheath removal.

According to Dr. Singh and colleagues, ongoing efforts should be made to provide regular ergonomic evaluations, periodic rotations out of the cath lab suite, and lighter-weight, non–lead-based protective wear. In addition, they say, robotic interventional equipment and remote monitoring technologies may help reduce both the number of personnel needed to care for the patient and their proximity to the radiation source, thereby diminishing the time spent wearing a lead apron.

The researchers acknowledge that these data cannot resolve questions about cancer risk from radiation exposure, in part because the incidence of the disease in younger cath lab personnel is low. Moreover, staffers diagnosed with cancer may transfer to a job that does not expose them to radiation or retire, and thus their cases would not be captured in this cross-sectional survey.

In the editorial, Dr. Goldstein calls the findings “alarming and sobering.” But, he adds, given the growth in the volume, complexity, and length of interventional procedures, the “escalating epidemic of occupational-induced orthopedic afflictions” should not be surprising.

Dr. Goldstein observes that innovative equipment that facilitate quality imaging with lower doses is helping to minimize radiation exposure, and measures like ceiling-suspended lead aprons, shielded gloves and scrub caps for cranial protection, and vascular robotic technology can help reduce orthopedic problems.

‘Take Care of Yourself’

But in a telephone interview with TCTMD, Craig St. George, RT, director of online education for the American Society of Radiologic Technologists (Albuquerque, NM), said that  over 6 years working at the Mayo Clinic in Jacksonville, FL, he cannot recall anyone complaining of a work-related injury.

However, he noted, many of his colleagues exercised, stretched, and practiced yoga, which likely helped counter the stress of wearing a lead apron day after day. Another important factor in minimizing aches and pains, he suggested, was that each person was custom-fitted for an apron. And they could choose from different versions, including a wraparound model with a waist belt that took much of the weight off the shoulders. They also stood on ergonomic pads near the table to help cushion their feet during long hours. In addition, the strain of transferring patients to and from the table was mitigated by working in teams.

As for any radiation concerns, Mr. St. George said he relied on his training—making sure he was properly shielded and standing in the right place to minimize exposure—and oversight by the hospital’s radiation safety officer.

“I know people who have been technologists for 20 or 30 years, and I’ve never heard anyone say, ‘This is really wearing on me,’ he commented, adding, “You go into the profession because you want to take care of patients, and to do that you have to take care of yourself.”

1. Orme NM, Rihal CS, Gulati R, et al. Occupational health hazards of working in the interventional laboratory: a multisite case control study of physicians and allied staff. J Am Coll Cardiol. 2015;65:820-826.
2. Goldstein JA. Orthopedic afflictions in the interventional laboratory: tales from the working wounded [editorial]. J Am Coll Cardiol. 2015;65:827-829.


  • Dr. Singh reports no relevant conflicts of interest.
  • Dr. Goldstein reports owning equity in a company developing radiation shielding equipment.
  • Mr. St. George reports no relevant conflicts of interest.






Copyright AP Radiation protection
Cath Lab Workers May Be Harmed by Radiation

Cath Lab Workers May Be Harmed by Radiation

Posted on July 1, 2016 by in Safety with no comments

This article discusses a study comprising 466 hospital staff members, including interventional cardiologists, electrophysiologists, nurses and technicians who are exposed to radiation regularly. Additionally, 280 staffers who were not exposed to radiation in the cath lab were interviewed. This study gathered work-related and lifestyle information, current medications and health status for these workers. Almost three percent of interventional cardiology staff had a history of cancer, compared to less than one percent of the unexposed group. Eight percent of lab workers had experienced skin lesions, 30 percent experienced orthopedic illness and five percent had cataracts, compared to two, five, and less than one percent of the unexposed group.

See the full article below or read the original by clicking the link below:


Cath Lab Workers May Be Harmed by Radiation
Wednesday, 13 Apr 2016 08:53 AM

Copyright AP Radiation protection
Healthcare workers in labs where patients undergo heart procedures guided by X-rays may be at higher risk for cataracts, skin lesions, bone disorders or cancer than other healthcare workers, according to a new study.

Procedures in the “cath lab” – named for the catheters threaded into the heart – are done for all forms of cardiac disease, like congenital heart defects, ischemic heart disease or heart arrhythmias, said lead author Maria Grazia Andreassi of the CNR Institute of Clinical Physiology in Pisa, Italy.
“These procedures, highly effective and often life-saving, require substantial radiation exposure to patients,” Andreassi told Reuters Health by email.

But staff members, too, are exposed to radiation. In particular, for the cardiologists and electrophysiologists who work near the patient and the radiation source, “the cumulative dose in a professional lifetime is not negligible,” Andreassi said.

The researchers used questionnaires to gather work-related and lifestyle information, current medications and health status for 466 exposed hospital staff, including interventional cardiologists, electrophysiologists, nurses and technicians, half of whom had been working for at least 10 years. They also surveyed 280 staffers who had not been exposed to radiation in the cath lab.

Almost 3 percent of interventional cardiology staff had a history of cancer, compared to less than 1 percent of the unexposed comparison group. Eight percent of lab workers had experienced skin lesions, 30 percent had an orthopedic illness and five percent had cataracts, compared to two percent, five percent and less than one percent of the unexposed group, respectively.

Doctors had higher risks than nurses or technicians, and risk was higher for those who had been working more than 16 years, as reported in Circulation: Cardiovascular Interventions.

Stroke and heart attack risk were similar in the radiation and non-radiation exposure groups.

“Compared to healthcare professionals not exposed to radiation, workers with more than 16 years of occupational work are approximately 10 times more likely to experience cataracts and eight times more likely to have cancer after adjusting for other confounders,” like age and smoking status, Andreassi said.

Protective measures like leaded aprons, thyroid collars, leaded glasses, and overhead radiation shields can reduce the radiation dose to the operators, but are still not used regularly in every laboratory, Andreassi said.

Healthcare workers in the cath lab “sort of know there is a risk but it’s typically presented to young people as something to know about and not to worry about,” said Dr. Lloyd Klein of Advocate Illinois Medical Center in Chicago, who coauthored an editorial accompanying the new study.
“Everyone wears lead aprons, and increasingly, lead caps,” Klein told Reuters Health by email. “We are careful about unnecessary exposure.”

But wearing lead creates orthopedic problems and doesn’t completely protect against the effects of radiation, he said.

The Occupational Safety and Health Administration and federal and state agencies probably need to get more involved than they already are, he said.

“Unfortunately, interventional cardiologists are often inadequately trained in radiation safety and radiobiology, and hospitals have few training programs regarding radiation risk and exposure,” Andreassi said.
© 2016 Thomson/Reuters. All rights reserved.


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Radiation Safety for the Interventional Cardiologist

Posted on June 23, 2016 by in Safety with no comments

Protecting Ourselves from the Dangers of Ionizing Radiation:

Patient exposure has significantly decreased over the past decade by reducing procedure time and improved imaging quality and equipment. Despite these improvements, procedure personnel still remain at high risk of radiation exposure. Interventional cardiologists are so commonly concerned with their patient’s safety that they forget they too are at risk. These health care professionals need to know the dangers and risks associated with radiation in order to properly take charge and protect their lives. There are many hazards towards the human body with radiation exposure. These hazards include brain tumors, cataracts, thyroid disease, cardiovascular effects, and reproductive system effects. Along with that, some effects from radiation can be stochastic, like developing a malignancy, and some can be deterministic, like a skin burn. Procedure professional should be aware of their dose limits and way to reduce exposure in the lab.

The following informative article by the American College of Cardiology addresses radiation safety for the Interventional Cardiologist. Read the full text below or link to the article here:


Radiation Safety for the Interventional Cardiologist—A Practical Approach to Protecting Ourselves From the Dangers of Ionizing Radiation

Jan 04, 2016   |  Gautam Kumar, MD, FACC; Syed Tanveer Rab, MBBS, FACC

Editorial Comment From George W. Vetrovec, MD, MACC, Editorial Team Lead for Invasive Cardiovascular Angiography and Intervention Clinical Topic Collection, ACC.org

Radiation safety is the concern of all health care providers who perform procedures associated with radiation imaging, whether for diagnostic purposes or therapeutic procedures. Appropriately, there has been increasing public and societal interest in limiting patient radiation. Likewise, laboratory personnel are at risk for radiation compounded by long procedures and multiyear careers using radiation procedures.

Over the years, there have been various equipment modifications. The initial focus was to improve image quality by increasing radiation intensity. However, there is now a greater focus on limiting patient exposure in the setting of often prolonged procedures, such as complex multivessel and chronic total occlusion (CTO) revascularization procedures. X-ray systems are able to provide excellent image quality with lower X-ray exposure.

However, despite these improvements, radiation remains a risk for procedure personnel. Unfortunately, the focus on the complexity and intensity of the procedure itself often overshadows attention to personal optimal “self-radiation” protection. The following article not only describes these risks but also, importantly, enumerates the specific operator and personnel approaches to minimize radiation risk. A review of these preventive strategies is important to re-emphasize the personnel opportunities and responsibilities for radiation protection. Finally, the authors describe some of the evolving opportunities to more dramatically reduce radiation exposure. This article is an excellent refocus on an important issue for the interventional community.

Ionizing radiation in the form of X-rays is used extensively in the modern cardiac catheterization laboratory. Unlike patients who receive a dose of ionizing radiation during their procedure, interventional cardiologists and cardiac catheterization laboratory personnel are repeatedly exposed to ionizing radiation in the course of their duties. This issue has been magnified with increased exposure in the long duration of structural or complex adult congenital heart disease intervention and CTO cases. Personnel not previously exposed to ionizing radiation such as echocardiographers, ultrasound technologists, cardiac surgeons, and anesthesiologists are frequently close to the X-ray field. Therefore, minimizing radiation exposure is of utmost importance.

Understanding the Hazards

Significant radiation exposure has the potential to impact the health and well-being of interventional cardiologists in the following ways:

  • Brain Tumors: A case report of brain tumors in 2 Canadian interventional cardiologists1 first raised this concern. There were three additional cases identified in a study from Sweden in physicians who had worked with fluoroscopy.2 The left-sided predisposition of these tumors raised further alarm when four additional cases were reported from France and Israel.3 Active case findings from this group highlighted this concern further when they identified that 22 of 26 cases (85%) had a left-sided distribution of brain tumors, which is a phenomenon that is not noted in the general population.4 In a study of 11 cardiologists performing invasive (diagnostic and interventional) procedures, radiation exposure to the outside left side and outside center of the head was significantly greater than the outside right side of the head (106.1 +/- 33.6 and 83.1 +/- 18.9 vs. 50.2 +/- 16.2 mrad, p < 0.001). This was significantly attenuated by the usage of a radiation protection cap (42.3 +/- 3.5 and 42.0 +/- 3.0 vs. 41.8 +/- 2.9 mrad) and only slightly higher than ambient control (38.3 +/- 1.2 mrad, p = 0.046).5
  • Cataracts: Higher incidence of cataracts (specifically posterior subcapsular) has been reported in interventional cardiologists in a large French multicenter observational study.6 Similar results were also noted in a separate study of both interventional cardiologists and CCL nurses and technicians. Fortunately, this risk appeared to be mitigated in those who wore lead-lined glasses.7
  • Thyroid Disease: Structural and functional changes as a result of radiation exposure have been reported in the thyroid gland. The degree of exposure has been correlated with a linear increase in the development of both benign and malignant thyroid neoplasms.8,9
  • Cardiovascular Effects: Exposure to radiation has been associated with both macrovascular and microvascular abnormalities. The occupational significance of this is not well-identified presently.10
  • Reproductive System Effects: Although exposure to ionizing radiation reduces both sperm count and quality, the occupational effects of this have not been determined.11 A study of 56,436 female radiology technicians in the United States revealed 1,050 cases of breast cancer and concluded that daily low-dose radiation exposure over several years may increase the risk of developing breast cancer.12 It is concerning that in the small series reported by the “Women in Innovation” group for safety, two cardiologists and one nurse with breast cancer had left-sided tumors.13Radiation safety for the pregnant interventional cardiologist and/or cardiac catheterization laboratory nurse/technician is a pressing issue. US federal law prohibits discrimination against the pregnant worker, but pregnancy should be declared to the employer as early as feasible so that adequate fetal protection can be undertaken. Protective garments must provide at least 0.5 mm lead-equivalent protection throughout the entire pregnancy, and an additional monthly fetal dose-monitoring badge should be issued and worn at waist level under the protective garment.14

Understanding Adverse Effects of Radiation Exposure

The adverse risks of radiation exposure may be described in terms of stochastic and deterministic effects.

The stochastic effect is the non-threshold biologic effect of radiation that occurs by chance to a population of persons whose probability is proportional to the dose and whose severity is independent of the dose. Developing malignancy due to radiation exposure is a stochastic risk.

The deterministic effect is a dose-dependent direct health effect of radiation for which a threshold is believed to exist. Developing a skin burn as a result of a prolonged case is a deterministic effect.

Dose exposure is usually described in terms of the following parameters:

  1. Fluoroscopic Time (min): This is the time during a procedure that fluoroscopy is used but does not include cine acquisition imaging. Therefore, considered alone, it tends to underestimate the total radiation dose received.
  2. Cumulative Air Kerma (Gy): The cumulative air kerma is a measure of X-ray energy delivered to air at the interventional reference point (15 cm from the isocenter in the direction of the focal spot). This measurement has been closely associated with deterministic skin effects.
  3. Dose-Area Product (Gy.cm2): This is the cumulative sum of the instantaneous air kerma and the X-ray field area. This monitors the patient dose burden and is a good indicator of stochastic effects.

The annual occupational dose limits for catheterization laboratory personnel are as follows:

Area Maximum Dose/Year
Whole body 50 mSv
Eye lens 150 mSV
Skin or extremities 500 mSv
Fetus 0.5 mSv/month or 5 mSv/pregnancy

Tissue Reactions

Radiation-induced hair loss and injuries of the skin and subcutaneous tissues are collectively termed “tissue reactions” and are rare complications of prolonged fluoroscopic procedures. Tissue reactions may be graded; this is influenced by biological variability. In general, Grade 1 reactions are visible but seldom clinically important, but Grade 2 reactions may be clinically important. Grades 3 and 4 tissue reactions are usually considered to be clinically important.15,16

Notification levels are intended to make the operator aware, during the procedure, of the cumulative radiation used. This happens at 3 Gy. The substantial radiation dose level is a trigger level for certain processes and follow-up measures and happens at 5 Gy. It is not an indicator of a tissue reaction or a predictor of the risk of a stochastic effect but is intended to alert providers to the possibility of a tissue reaction. The following process should be followed when a substantial radiation dose level is reached:

  1. At the end of the procedure, the primary operator documents the clinical necessity for exceeding any substantial radiation dose level in the medical record.
  2. Patients are promptly informed when substantial amounts of radiation were used for their procedures and the necessity for this.
  3. Patients receive follow-up to determine whether tissue reactions occurred.
  4. If a tissue reaction is identified, the patient should be referred to an appropriate provider for management. In general, biopsies of these areas must be avoided.
  5. These results are reported to and reviewed by the interventional service quality assurance and peer review committees.

Minimizing X-ray Exposure

This is enshrined in the “as low as reasonably achievable” (ALARA) principle. The level of protection should be the best under the prevailing circumstances, maximizing the margin of benefit over harm. Imaging requirements depend on the specific patient and the specific procedure. Although better-than-adequate image quality subjects the patient to additional radiation dose without additional clinical benefit, reducing patient radiation dose to the point at which images are inadequate is counterproductive and results in radiation dose to the patient without any clinical benefit.17Using an anthropomorphic phantom, significant differences were identified between different manufacturers in terms of radiation doses in comparable views.18

Commonly employed strategies to minimize radiation exposure are summarized below and also in Figures 1 and 2.19

Figure 1

Figure 1

Figure 2

Figure 2

Precautions to Minimize Exposure to Patient and Operator

  • Utilize radiation only when imaging is necessary to support clinical care. Avoid allowing the “heavy foot,” to step on the fluoroscopy pedal while not looking at the image.
  • Minimize use of cine. “Fluoro-save” has a <10% radiation exposure of cineangiography.
  • Minimize use of steep angles of X-ray beam. The left anterior oblique (LAO) cranial angulation has the highest degree of scatter exposure to the operator.
  • Minimize use of magnification modes. Most modern systems have software magnification algorithms that allow for magnification without additional radiation. In modern machines, there is a “Live Zoom” feature without significant degradation of the image. For example, in lieu of magnification, an 8-inch field of view with a zoom factor of 1.2 results in a 6.7-inch field of view without added radiation.
  • Minimize frame rate of fluoroscopy and cine. Ensure that CTOs and other long cases are performed on the 7.5 frames/sec fluoroscopy setting. A reduction of the fluoroscopic pulse rate from 15 frames/sec to 7.5 frames/sec with a fluoroscopic mode to low dose reduces the radiation exposure by 67%.
  • Keep the image detector close to the patient (low subject-image distance).
  • Utilize collimation to the fullest extent possible. In a room with a peripheral-compatible large flat panel detector, ensure that this is collimated to the field of view adequate for coronary procedures.
  • Monitor radiation dose in real time to assess the patient’s risk/benefit ratio during the procedure.

Precautions to Specifically Minimize Exposure to Operator

  • Use and maintain appropriate protective lead garments. We recommend a full protective suit with thyroid collar and additional head protection. However, 49% of active interventional operators report at least one orthopedic injury.20 Consideration should be given to ceiling suspension or floor-mounted personal radiation shielding for enhancing radiation protection and preventing orthopedic issues. For women, we also suggest additional protection to the breast with sleeves, which ensure full coverage of this area, in addition to dedicated breast shields. In view of the concern about brain tumors, protective hats are recommended, especially for the primary operator.
  • Maximize distance of operator from X-ray source and patient.
  • Keep above-table (hanging) and below-table shields in optimal position at all times. A larger ceiling-mounted shield with attached lamellae, used in combination with a drape, decreased exposure to the operator by half.21
  • Use additional disposable shielding material for protection from scatter radiation.
  • Keep all body parts out of the field of view at all times. When it is unavoidable that a body part would be exposed to radiation, consider usage of radiation attenuating gloves (for example, for an echocardiographer imaging during cardiac biopsies) or attenuating cream (for example, for an electrophysiologist attempting to perform device implantation).
  • A robotic percutaneous coronary intervention (PCI) system may be considered as a viable alternative for both radiation protection and occupational hazard mitigation because lead shielding need not be worn when seated in the interventional cockpit during PCI procedures.

Precautions to Specifically Minimize Exposure to Patient

  • Keep table height as high as comfortably possible for the operator.
  • Every 30 minutes, vary the imaging beam angle to minimize exposure to any specific skin area
  • Minimizing steep LAO and anteroposterior cranial angles
  • Keep the patient’s extremities out of the beam.


A radiation safety program is an essential part of the quality administration for the catheterization laboratory. This should be a collaborative effort involving physicians, staff, medical or health physicists, quality assurance personnel, and hospital administration. Interventional cardiologists are an essential part of this process and need to ensure the best possible outcomes for ourselves and for our patients.

As a profession, interventional cardiologists need to be conscious of their own radiation safety. Improved wall hanging or floor-mounted personal shielding and robotic cardiac catheterization laboratories need to become a standard of care and not a luxury. The high prevalence of orthopedic issues among catheterization laboratory professionals and subsequent disability should prompt governmental oversight agencies like the Occupational Safety and Health Administration to mandate these types of procedures and equipment. We need to continue pursuing research and development of customized radiation safety equipment for peripheral interventions and structural procedures.


  1. Finkelstein MM. Is brain cancer an occupational disease of cardiologists? Can J Cardiol 1998;14:1385-8.
  2. Hardell L, Mild KH, Påhlson A, et al. Ionizing radiation, cellular telephones and the risk for brain tumours. Eur J Cancer Prev 2001;10:523-9.
  3. Roguin A, Goldstein J, Bar O. Brain tumours among interventional cardiologists: a cause for alarm? Report of four new cases from two cities and a review of the literature. EuroIntervention 2012;7:1081-6.
  4. Roguin A, Goldstein J, Bar O, et al. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol 2013;111:1368-72.
  5. Reeves RR, Ang L, Bahadorani J, et al. Invasive cardiologists are exposed to greater left sided cranial radiation: The BRAIN study (Brain Radiation Exposure and Attenuation during Invasive Cardiology Procedures). JACC Cardiovasc Interv 2015;8:1197-206.
  6. Jacob S, Boveda S, Bar O, et al. Interventional cardiologists and risk of radiation-induced cataract: results of a French multicenter observational study. Int J Cardiol 2013;167:1843-7.
  7. Vano E, Kleiman NJ, Duran A, et al. Radiation-associated lens opacities in catheterization personnel: results of a survey and direct assessments. J Vasc Interv Radiol 2013;24:197-204.
  8. Ron E, Brenner A. Non-malignant thyroid diseases after a wide range of radiation exposures. Radiat Res 2010;174:877-88.
  9. Schneider AB, Ron E, Lubin J, et al. Dose-response relationships for radiation-induced thyroid cancer and thyroid nodules: evidence for the prolonged effects of radiation on the thyroid. J Clin Endocrinol Metab 1993;77:362-9.
  10. Picano E, Vano E, Domenici L, et al. Cancer and non-cancer brain and eye effects of chronic low-dose ionizing radiation exposure. BMC Cancer 2012;12:157-69.
  11. Burdorf A, Figà-Talamanca I, Jensen TK, et al. Effects of occupational exposure on the reproductive system: core evidence and practical implications. Occup Med (Lond) 2006;56:516-20.
  12. Doody MM, Freedman DM, Alexander BH, et al. Breast cancer incidence in U.S. radiologic technologists. Cancer 2006;106:2707-15.
  13. Buchanan GL, Chieffo A, Mehilli J, et al. The occupational effects of interventional cardiology: results from the WIN for Safety survey. EuroIntervention 2012;8:658-63.
  14. Best PJ, Skelding KA, Mehran R, et al. SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel. Catheter Cardiovasc Interv 2011;77:232-41.
  15. Balter S, Hopewell JW, Miller DL, et al. Fluoroscopically guided interventional procedures: a review of radiation effects on patients’ skin and hair. Radiology 2010;254:326-41.
  16. National Council on Radiation Protection and Measurements. Radiation Dose Management for Fluoroscopically Guided Interventional Medical Procedures, NCRP Report No. 168. Bethesda: NRCP Publications; 2010.
  17. Cousins C, Miller DL, Bernardi G, et al. ICRP PUBLICATION 120: Radiological protection in cardiology. Ann ICRP 2013;42:1-125.
  18. Christopoulos G, Christakopoulos GE, Rangan BV, et al. Comparison of radiation dose between different fluoroscopy systems in the modern catheterization laboratory: results from bench testing using an anthropomorphic phantom. Catheter Cardiovasc Interv 2015;86:927-32.
  19. Chambers CE, Fetterly KA, Holzer R, et al. Radiation safety program for the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2011;77:546-56.
  20. Klein LW, Tra Y, Garratt KN, et al. Occupational health hazards of interventional cardiologists in the current decade: results of the 2014 SCAI membership survey. Catheter Cardiovasc Interv 2015;86:913-24.
  21. Gilligan P, Lynch J, Eder H, et al. Assessment of clinical occupational dose reduction effect of a new interventional cardiology shield for radial access combined with a scatter reducing drape. Catheter Cardiovasc Interv 2015;86:935-40.

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Lenexa, KS 66215
Phone: 913-648-3730
or 1-877-7RADPAD (1-877-772-3723)Fax: 913-648-0131
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New Technique to Cardiac Catheterization Procedure

Posted on June 3, 2016 by in Procedures with no comments


Interventional cardiologist Dr. John Wang, chief of the Cardiac Catheterization Lab at MedStar Union Memorial Hospital in Baltimore, Maryland demonstrates a new technique to cardiac catheterization procedure by using transradial access.

Patients may need a cardiac catheterization if they are experiencing cholesterol narrowing’s in the blood vessels which may result in chest pain or even a heartattack. This procedure is typically performed through the femoral artery, but there is sufficient collateral blood flow to the hand to make the wrist an accessible location for catheterization. There is no risk of bleeding complications where the catheter is inserter so this technique is used to increase patient comfort and experience a quicker recovery. If the patient is in need of a stent, this can be placed through the wrist as well.

Link to demonstration video:

Dr. John Wang also discusses the benefits of transradial cardiac catheterization:



14740 W 101st Terrace
Lenexa, KS 66215
Phone: 913-648-3730
or 1-877-7RADPAD (1-877-772-3723)Fax: 913-648-0131


Specialty Microcatheters to Facilitate Antegrade Crossing for CTO Revascularization

Posted on May 27, 2016 by in Safety with no comments

“Chronic total occlusions are difficult to treat and only a small number of patients receive percutaneous treatment due to risks including time, complications, and amount of scatter radiation.”

Cath Lab Digest recently published an article regarding the difficulties in treating chronic total occlusions. One of the challenges in the procedure is the level of scatter radiation, which is why our team at RADPAD® found the article so relevant:


Orlando Marrero, RCIS, MBA, Tampa, Florida, Zaheed Tai, DO, FACC, FSCAI, Winter Haven Hospital, Winter Haven, Florida

Chronic total occlusions (CTO)
Read the article on Cathlabdigest.com


Despite advances in wire and stent technology, chronic total occlusions (CTOs) remain a difficult lesion subset to treat. CTOs are present in about 20% of patients undergoing cardiac catheterization; however, only a small percentage are offered percutaneous treatment.1,2 There are several reasons for this. Time and resource constraints, complications risk, and variations in technical expertise are some of the reasons for inconsistent attempt rates. The current hybrid algorithm approach to CTO percutaneous coronary intervention (PCI) uses a combination of antegrade and retrograde techniques to facilitate wire crossing and procedural success.3 In the early stages of adopting this approach, some operators may use an antegrade-only approach.4 The use of specialty catheters and wires may facilitate engagement and crossing of the proximal cap. We present two case examples using the SuperCross microcatheters (Vascular Solutions) to perform CTO revascularization via an antegrade approach.

Case #1

This is a 62-year-old male with recent admission to another outside hospital with positive troponins, and cardiac catheterization revealing a CTO of the circumflex artery and right coronary artery (RCA). He had ventricular tachycardia and had a subsequent revascularization at the hospital twice which was unsuccessful. He was then referred to our institution for bypass. Given that there was no involvement of the left anterior descending coronary artery (LAD), he was referred by surgery for possible CTO revascularization. Repeat angiography revealed a CTO of the circumflex artery (left-left collaterals) with a CTO of the RCA as well, with what appeared to be filling via right-to-right collaterals (Figures 1-2). Based on the angiogram and his clinical presentation, it was decided to fix the circumflex CTO first.

The right radial was accessed with a 6/7 GlideSheath Slender (Terumo) and the left radial was accessed with a 6 French sheath.  A Q 3.5 guide catheter (Boston Scientific) was used to engage the left coronary system and an Amplatz right (AR) mod guide catheter (Cordis) was used to engage the RCA in order to perform dual angiography.

The left main was calcified and bifurcated into the LAD and circumflex artery. The LAD was patent with mild angiographic disease and no focal obstructions. It gave rise to a diagonal and there was some evidence of left-to-left collaterals. The circumflex artery was 100% occluded after what appeared to be a high atrioventricular (AV) groove. It was a short occlusion and then reconstituted into obtuse marginal branches (OM)1 and a large OM2. There is calcification noted in the occlusion. The RCA was a large-caliber artery. It was occluded distally at the crux, and had some late right-to-right collaterals.

Heparin was administered, and using a Turnpike Gold catheter (Vascular Solutions) and a Runthrough wire (Terumo), we got into the circumflex and then exchanged out for a Gaia guidewire (Asahi Intecc) to penetrate the proximal cap. The Turnpike Gold catheter, unfortunately at this point, was downward and therefore, did not allow engagement of the proximal cap (Figure 3). The catheter was changed for a SuperCross 90-degree catheter (Vascular Solutions), which pointed the wire up towards the blunt cap of the CTO and away from the bifurcation (Figure 4). We then used the Gaia wire to penetrate the proximal cap and gain some purchase. We advanced the 90-degree SuperCross catheter, but it  would not penetrate the cap. We were able to get the guidewire to gain some more purchase and then switched out for the Turnpike Gold catheter. Using the Turnpike Gold in a clockwise manner permitted advancement into the proximal cap and advancement of the guidewire distally. Once we confirmed it was luminal, we tried to advance the Turnpike Gold to switch out the wire, but we could not advance completely without the guide catheter backing out. well as the calcification of the vessel. We switched the wire out to a Pilot 200 wire (Abbott Vascular) and were able to wire both branches, OM1 and OM2, to confirm there was no subintimal wire placement. Given that OM2 was a larger branch, we placed the wire distally, confirmed that we were luminal (Figure 5), and then, in a counter-clockwise manner, removed the Turnpike Gold catheter. A 0.9 mm laser (Spectranetics) was used to perform laser athrectomy at the setting of 40/60 initially, then at 60/80, as multiple passes were made to create a pilot channel (Figure 6). A 2.0 x 15 mm AngioSculpt balloon (Spectranetics) was successfully advanced and predilated the lesion (Figure 7). After significant predilation at 10 atmospheres for 1 minute, we were able to wire a Runthrough wire into the OM1. We ballooned with a 2.25 x 20 mm balloon and switched out the Pilot wire for a second Runthrough wire (Figure 8). We advanced a 2.5 x 26 mm Resolute stent (Medtronic) favoring the OM2, which was a larger branch, and inflated at nominal pressure. We removed the Runthrough wire from the OM1 and using the Turnpike Gold as support, rewired the OM with a Sion wire (Asahi Intecc). We ballooned with a 2.0 x 20 mm balloon in the OM1 and in the ostium, and predilated the OM2 circumflex stent with a 2.5 mm Quantum balloon (Boston Scientific). A low-pressure inflation of the OM1 was performed with a 2.0 mm balloon at 4 atmospheres, and after intracoronary nitroglycerin (NTG), final angiography revealed TIMI-3 flow without dissection, embolization, or perforation, with an excellent angiographic result (Figure 9). The patient was staged for the RCA CTO 4 weeks later and had successful PCI using a SuperCross catheter and a Twin-Pass catheter (Vascular Solutions) to complete the procedure.

Case #2

A 70-year-old male with a history of coronary artery bypass graft surgery (CABG) x 3 in 2000 and an implantable cardioverter defibrillator (ICD) (for inducible ventricular tachycardia [VT] in 2006) presented with chest pain and precordial ST depression and positive troponins. He was taken to the lab urgently for ongoing chest pain and a left heart catheterization was performed, revealing a patent left internal mammary artery-left anterior descending coronary artery (LIMA-LAD), occluded saphenous vein graft-right coronary artery (SVG-RCA) (with collateral filling of the native RCA via left-to-right collaterals) and an occluded SVG to the obtuse marginal (OM) (Figures 10-11). The SVG-OM was the culprit based on the angiogram, electrocardiogram (EKG), and clinical presentation.

It was decided to revascularize the native OM instead of an occluded 16-year old graft. Given the patient’s height (6 feet, 9 inches), it was decided to access the right brachial for secondary access (guide length can be an issue from the radial). The femoral sheath was upsized to an 8 French with an Extra Backup (EBU) 3.75 guide (Medtronic). From the brachial approach, an Amplatz left (AL) 1 was used to engage the SVG-OM, and a wire passed distally to mark and control the distal vessel (Figure 12). The proximal cap was defined, but the branch came off at an angle. Initial attempts were made to wire with a Turnpike catheter (Vascular Solutions), and Fielder XT (Abbott Vascular) and Pilot wire (Abbott Vascular). The angle made it difficult to engage the cap (Figure 13) and a SuperCross 120 catheter allowed us to engage with a Fielder XT and maintain the “CTO bend” on the wire (Figure 14). The wire was “knuckled” and advanced through the occlusion into the true distal lumen (Figures 15-16). Excimer laser, intravascular ultrasound (IVUS), and stenting were performed on the native vessel with placement of a 2.5 x 38 mm and a 3.0 x 16 mm Synergy stent (Boston Scientific) (Figure 17). There was a wire perforation noted of no hemodynamic or clinical consequence. The patient was discharged home the following morning.


There are several factors that favor an antegrade-only approach to CTO revascularization (for those not adopting the hybrid algorithm):

1) Well-visualized proximal cap;

2) Presence of a microchannel;

3) Minimal calcification;

4) Occlusion <20 mm;

5) No angulation >45 degrees; and

6) A good distal target.4

In addition to wire selection, microcatheter support can enhance “pushability” and facilitate lesion crossing. There are several microcatheters available and the most commonly used ones in the United States include the Corsair (Asahi Intecc), Finecross (Terumo), and Turnpike (Vascular Solutions). These are straight-tip catheters and therefore, may not provide the best approach for an angled proximal cap.

The SuperCross catheters are a series of microcatheters used for guidewire support and directional wiring. In addition, they can be utilized for subselective delivery of diagnostic and therapeutic agents. The coronary catheters are available in straight, flexible, and angled versions (Figures 18-19). The angled-tip catheters are available in a 45, 90, 120 and 90 XT (extended degree tip for secure cannulation). The inner layer is PTFE and the outer layer is hydrophilic.  They have a 0.71 mm outer diameter (OD) and 0.43 mm inner diameter (ID), and are 6 French compatible. We have used these catheters to access side branches, as wire support for an angulated left circumflex off the left main, and, as in the above cases, to engage a difficult proximal cap. Once we have gained purchase into the CTO, the microcatheter is usually changed to a Corsair, Turnpike, or Finecross to navigate the remainder of the occlusion. When the wire is able to cross, but the microcatheter cannot follow, a catheter such as the Tornus (Asahi Intecc) or Turnpike Gold may be able to advance through the occlusion (other options, if available, include laser atherectomy or exchanging the wire for rotational atherectomy). A full discussion about antegrade crossing of CTOs is beyond the scope of this article. For more information, visit ctofundamentals.org.


  1. Fefer P, Knudtson ML, Cheema AN, Galbraith PD, Osherov AB, Yalonetsky S, et al. Current perspectives on coronary chronic total occlusions: The Canadian Multicenter Chronic Total Occlusions Registry. J Am Coll Cardiol. 2012; 59:991-997.
  2. Grantham JA, Marso SP, Spertus J, House J, Holmes DR Jr., Rutherford BD. Chronic total occlusion angioplasty in the United States. JACC Cardiovasc Interv. 2009; 2: 479–486.
  3. Brilakis ES, Grantham JA, Rinfret S, Wyman RM, Burke MN, Karmpaliotis D, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012; 5: 367– 379.
  4. Rinfret S, Joyal D, Spratt JC, Buller CE. Chronic total occlusion percutaneous coronary intervention case selection and techniques for the antegrade-only operator. Catheter Cardiovasc Interv. 2015 Feb 15; 85(3): 408-415.

Disclosures: Orlando Marrero reports he is a consultant for Boston Scientific. 

Dr. Zaheed Tai reports the following: Terumo (proctor for transradial course), Spectranetics (proctor for laser course, speaker, advisory board member), and Boston Scientific (CTO proctor).

Orlando Marrero, RCIS, MBA, can be contacted at orlm8597@icloud.com

Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com.

14740 W 101st Terrace
Lenexa, KS 66215

Phone: 913-648-3730
or 1-877-7RADPAD (1-877-772-3723)

Fax: 913-648-0131

Email: info@radpad.com