European Heart Journal Advance Access published online on September 4, 2008
European Heart Journal, doi:10.1093/eurheartj/ehn394
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Operator vs. patient radiation exposure in transradial and transfemoral coronary interventions
Interventional Cardiologist
Faculty of Medicine
Laval Hospital, Quebec Heart-Lung Institute
Laval University
Quebec, QC
Canada G1V 4G5
Tel: +1 418 656 8711
Fax: +1 418 656 4544
Medical Physicist
Laval Hospital
Quebec Heart-Lung Institute
Quebec, QC
Canada G1V 4G5
Department of Mechanical Engineering
McGill University
Montreal
Canada
Email: olivier.bertrand{at}crhl.ulaval.ca
We were interested by the recent report from Brasselet et al.1 measuring radiation exposure to patients and operators after transradial and transfemoral coronary diagnostic and interventions. In brief, they showed that using standard leaded glass and flaps, transradial procedures were associated with higher patient and operator radiation exposures. In the light of these findings, they concluded that ‘radial route indication should be promptly reconsidered...’. Before such conclusion can be drawn, we would like to make the following comments:
- (1) Transradial approach has been initially described more than 15 years ago and it has become popular mainly outside US.2 Today, it is the best method to minimize the risks of access site complications and bleeding after percutaneous coronary interventions (PCIs).3
- (2) Bleeding post-PCI is a dreadful consequence, which increases acute morbidity and mortality, prolongs hospitalization, and costs millions to health systems. Major bleeding post-PCI is now recognized as a strong independent predictive factor of mortality.4 Patients at higher risk of bleeding are also those who benefit the most from transradial approach.
- (3) Clinical scenarios associated with increased risk of bleeding such as primary and rescue PCI were excluded from Brasselet's study.
- (4) Transradial approach has also permitted the development of outpatient PCI practice even when maximized anticoagulation and high-risk patients are involved.5,6
- (5) Basically, similar to other previously published reports, this report shows that longer fluoroscopy time is associated with increased patient and physician exposure. Since patients are not exposed several times, the remote stochastic and non-stochastic risks associated with transradial approach remain negligible and certainly should not be weighted against the immediate risks of bleeding and/or access site complications.
- (6) We fully agree with the authors that radiation exposure is an important issue most of the time under-evaluated by most operators. Although the authors claim optimized radiation protection, we notice that there is no mention of operators wearing leaded glasses nor are they visible on their pictures. Cataract is a non-stochastic risk, which means that the incidence would presumably be close to 100% if the operator reaches a certain threshold. In our institution, where transradial approach has been the default technique for the last 14 years, operators perform about 1000 diagnostic catheterizations and 200–300 PCI cases/year and have been strongly advised to wear leaded glasses (still not all operators wear them!). By keeping annual eye exposure below the recommended 150 mSv, a cardiologist could therefore works for more than 35 years before reaching the cataract threshold.7
- (7) From Figure 2, it appears that most of the difference in radiation exposure results from the diagnostic part. Indeed, difficulties in catheter progression through the arm and/or subclavian part can lead to additional fluoroscopy and is, however, recommended to avoid potential arterial damages. Thus, the practice of ad hoc procedures compared with diagnostic and PCI in separate procedures has an important role in limiting patient and staff exposure.
- (8) Once the transradial approach becomes a common practice, there are several tricks that can help to reduce radiation exposure like exchanging catheters over wire placed in the ascending aorta without using fluoroscopy.
- (9) Finally, from the report of Brasselet et al., those promoting transradial approach should take a step back and carefully revisit the radiation protection devices they currently use and look for further optimization. For example, instead of using 0.5 mm leaded glass, why not use thicker protection that would further reduce operator exposure!
- (2) Bleeding post-PCI is a dreadful consequence, which increases acute morbidity and mortality, prolongs hospitalization, and costs millions to health systems. Major bleeding post-PCI is now recognized as a strong independent predictive factor of mortality.4 Patients at higher risk of bleeding are also those who benefit the most from transradial approach.
References
- Brasselet C, Blanpain T, Tassan-Mangina S, Deschildre A, Duval S, Vitry F, Gaillot-Petit N, Clément JP, Metz D. Comparison of operator radiation exposure with optimized radiation protection devices during coronary angiograms and ad hoc percutaneous coronary interventions by radial and femoral routes. Eur Heart J (2008) 29:63–70.
[Abstract/Free Full Text] - Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn (1989) 16:3–7.[Web of Science][Medline]
- Agostoni P, Biondi-Zoccai GG, de Benedictis ML, Rigattieri S, Turri M, Anselmi M, Vassanelli C, Zardini P, Louvard Y, Hamon M. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol (2004) 44:349–356.
[Abstract/Free Full Text] - Manoukian SV, Feit F, Mehran R, Voeltz MD, Ebrahimi R, Hamon M, Dangas G, Lincoff AM, White HD, Moses JW, King SB, Ohman EM, Stone GW. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY Trial. J Am Coll Cardiol (2007) 49:1362–1368.
[Abstract/Free Full Text] - Bertrand OF, De Larochelliere R, Rodes-Cabau J, Proulx G, Gleeton O, Nguyen CM, Déry JP, Barbeau G, Noel B, Larose E, Poirier P, Roy L. A randomized study comparing same-day home discharge and abciximab bolus only to overnight hospitalization and abciximab bolus and infusion after transradial coronary stent implantation. Circulation (2006) 114:2636–2643.
[Abstract/Free Full Text] - Bertrand OF, Larose E, De Larochelliere R, Proulx G, Nguyen CM, Déry JP, Gleeton O, Barbeau G, Noel B, Rouleau J, Boudreault JR, Roy L, Rodés-Cabau J. Outpatient percutaneous coronary intervention: Ready for prime time? Can J Cardiol (2007) 23(Suppl B):58B–66B.[Web of Science]
- International Commission on Radiation Protection. (2000) Oxford: Pergamon Press. ICRP 85.
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