international atomic energy agency can cardiac procedures be graded in complexity and related with...

International Atomic Energy Agency

Can cardiac procedures be Can cardiac procedures be graded in complexity and graded in complexity and

related with dose?related with dose?

L 8.3

Lecture 8.3: Complexity 2Radiation Protection in Cardiology

Educational ObjectivesEducational Objectives

1. Complexity related factors in cardiac interventions

2. Relationship of patient dose with technical and clinical factors

3. Development of complexity index and its utility


factors determining patient’s exposure

adequacy of equipment

fluoroscopy time

cine-angiography time

operator’s experienceprocedure complexity


fluoro time: 1 m’ 20 sec

total DAP: 102 dGy

simple case straightforward right


difficult caseextreme vessel tortuosity

fluoro time: 20 m’

total DAP: 1074 dGy


complexity related factors

• age

• number of vessels treated

• occluded vessels

• previous CABG

• poor Ejection Fraction

quantification never proposed


Clinical and technical determinants of the Clinical and technical determinants of the complexity of PTCA procedures. Analysis in complexity of PTCA procedures. Analysis in

relation to fluoroscopy time relation to fluoroscopy time (Cathet Cardiovasc Intervent 2000; 51:1-9)(Cathet Cardiovasc Intervent 2000; 51:1-9)


PTCA characteristicsn 402, 21/06/96-08/05/98 (50% of tot)

0

50

100

150

200

250

300

350one-lesion

multi-lesion

multivessel

76.3%

15.4%8.2%

Stenting 49% (x procedure)

mean fluoro time 11,5’ ± 8,6’

success 96.5 %


patients’ characteristicsn 402, M 72 % age 62±11

one vessel

two vessels

three vessels

34.1%34.9%

31%

6% previous CABG mean EF 58% ± 10


clinical factors testedclinical factors tested

• age

• sex

• single or multivessel disease

• EF

• previous CABG

no significant correlation with fluoro time or exposure parameters


Weight (seconds) score Constant 159 -

lesion B2 (AHA) 151 - lesion > B2 (AHA) 400 1

IVUS 315 - simple stenting 157 -

bifurcation stenting 331 1,5 ostial stenting 346 0,8

occlusion 3 months 943 2,8 moderate tortuosity 234° -

severe tortuosity 1471 4,9 double balloon technique 350* -

double wire technique 140* -

p< 0.001, p<0.01*, p<0.005°


0

1

2

3

4

5

6

7

0 1000 2000 3000 4000 5000

r = 0.576P < 0.0001

complexity index/fluoro time correlationmost significant & less operator-dependent variables

Com

ple

xit

y In

dex

Fluoro time (sec)


0

200

400

600

800

1000

1200

1400

1600

1800

2000

simple medium complex CI = 0 CI 1.5 CI > 1.5

215 119 68

Flu

oro

tim

e (s

ec)

complexity index-based stratification fluoro time

P < 0.0001


0

500

1000

1500

2000

2500


215 119 68

Cin

e fr

ames

(n

)complexity index-based stratification cine frames

P = 0.0377

P = ns

P = 0.001


0

50

100

150

200

250

DAP

Gy

* cm

2 complexity index-based stratification total DAP

P < 0.0001

P = 0.0015

215 119 68



procedural success rate procedural success rate (402 cases, 50% of total activity)(402 cases, 50% of total activity)

97,6

93,3

89,7

84

86

88

90

92

94

96

98

simple medium complex

%

P = 0.00787


fluoro time in different diagnostic fluoro time in different diagnostic procedures (844) procedures (844)

0

1

2

3

4

5

6

7

Coro only Coro + LV Right cath. Graft Aortogr

min

ute

s

2.6±3.4 2.7±2.3

6.1±6.0 6.1±4.9

6.8±7.1

65%


• In our experience, fluoroscopy time and total DAP were directly related to technical and not to clinical factors

• The weight of these factors can be quantified in order to anticipate the radiation dose needed to treat patients undergoing complex procedures

conclusions (I)conclusions (I)


• Comparison of different centers and operators for quality control assessment, as well as the definition of appropriate fluoroscopy time and DAP doses, should take into account complexity indexes

• Further studies in different institutions are warranted to corroborate this data

conclusions (II)conclusions (II)

international atomic energy agency can cardiac procedures be graded in complexity and related with...

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