1. Comparison of Operator Radiation exposure during Coronary Angiograms and Interventions by Radial and Femoral routes – -Can we decrease the risk with increased experience? Dr. Muhammad Tariq Farman MBBS; FCPS (Cardiology) Senior Registrar KIHD (Former Fellow of Interventional Cardiology NICVD, Karachi) Co Authors: Naveed Ullah Khan, Abdul Ghaffar Khan, Tahir Saghir, Syed Nadeem Hasan Rizvi, Jawaid A. Sial, Khan Shah Zaman

2. Background Radial route of access is being increasingly used for coronary angiography and intervention Radial route of access is being increasingly used for coronary angiography and intervention Radiation exposure of operators was significantly high with radial access Radiation exposure of operators was significantly high with radial access Radiation exposure of our operators was not known either with femoral or radial route Radiation exposure of our operators was not known either with femoral or radial route Can we decrease the radiation exposure with increased experience? Can we decrease the radiation exposure with increased experience?

3. Aims and object Compare the femoral arterial route radiation exposure with radial arterial route radiation exposure Compare the femoral arterial route radiation exposure with radial arterial route radiation exposure Determine the relationship of operators experience with radiation exposure Determine the relationship of operators experience with radiation exposure

4. Materials and Methods Conducted at Cath Lab NICVD, from July 1 st 2009 to September 30, 2009 Conducted at Cath Lab NICVD, from July 1 st 2009 to September 30, 2009 1,016 patients enrolled, who came for angiography and/or intervention 1,016 patients enrolled, who came for angiography and/or intervention Patients came for RHC and valvuloplasty were excluded Patients came for RHC and valvuloplasty were excluded Written informed consent was taken and questionnaire was filled regarding demographic features and risk factors Written informed consent was taken and questionnaire was filled regarding demographic features and risk factors

5. Materials and Methods Fluoroscopy time was taken as a surrogate of radiation exposure & Fluoro time was recorded after each procedure Fluoroscopy time was taken as a surrogate of radiation exposure & Fluoro time was recorded after each procedure Majority of operators were unaware about the study (14 out of 20) Majority of operators were unaware about the study (14 out of 20) Route of access, switch over, no. of catheters, volume of contrast, anatomical variations and LMCA involvement were also noted Route of access, switch over, no. of catheters, volume of contrast, anatomical variations and LMCA involvement were also noted

6. Materials and Methods Fluoro time of f-CA was separately analyzed in consultants (well experienced), Fellows (less experience), & PG trainees. Fluoro time of f-CA was separately analyzed in consultants (well experienced), Fellows (less experience), & PG trainees. Fluoro time of r-CA was analyzed separately in well experienced (> 500 r-CA), less experienced (300-500 r-CA), trainee ( 500 r-CA), less experienced (300-500 r-CA), trainee (<200 r- CA).

7. Results 1,016 consecutive adult patients were enrolled 1,016 consecutive adult patients were enrolled 928 were diagnostic coronary angiograms 928 were diagnostic coronary angiograms f – CA ---- 734 (79%) f – CA ---- 734 (79%) r – CA ---- 194 (21%) r – CA ---- 194 (21%) 88 were Percutaneous Coronary Interventions 88 were Percutaneous Coronary Interventions f – PCI ---- 64 (72.7 %) f – PCI ---- 64 (72.7 %) r – PCI ---- 24 (27.2 %) r – PCI ---- 24 (27.2 %)

8. Femoral vs Radial Angiography Baseline characteristics Baseline characteristics P-valueRadial N=194 (%) Femoral N=734 (%) 0.580.32<0.0010.230.510.520.35 52.2 (10.2) 163.0 (13.2) 74.5 (16.0) 147 (75.8) 131 (67.5) 44 (22.7) 58 (29.9) 52.6 (10.1) 162 (10.1) 70.1 (12.9) 52.5 (72) 477 (65) 183 (24.9) 195 (26.6) Age (± SD) Height (± SD) Weight (± SD) Male sex HTNDMSmoker

9. Femoral vs Radial Angiography Procedural Characteristics P-valueRadial N=194 (%) Femoral N=734 (%) <0.0010.001<0.0010.55--??<0.001 147 (75.8) 82.9 (28.7) 6.3 (± 3.8) 14 (7.2) 01 (0.5) 14 (7.2) 1.8 (0.5) 319 (43.5) 75.6 (27.2) 4.0 (± 2.9) 63 (8.6) 15 (2.0) 41 (5.5) 2.3 (0.5) Non ionic contrast Contrast given (± SD) Fluoro time (mins) Sig. LMCA disease Graft studies Atypical Anatomy No of Catheter used

10. Femoral vs Radial Angiography P-valueRadial N=194 (%) Femoral N=734 (%) ------<0.001<0.001 81 (41.8) 111 (57.2) 02 (1.0) 07 (3.6) 6.3 (3.8) 221 (30.1) 427 (58.2) 86 (11.7) 16 (2.1) 4.0 (2.9) Procedure done by Consultant Interven. Fellow PG Fellow Switch over Fluoro Time

11. Femoral vs Radial PCI Baseline Characteristics Baseline Characteristics P-valueRadial N=24 (%) Femoral N=64 (%) 0.680.620.480.380.900.900.83 54.2 (± 2.8) 165.7 (± 9.8) 75.0 (± 11.9) 21 (87.5) 19 (79.2) 05 (20.8) 07 (29.2) 50.5 (± 10.8) 165.0 (± 10.5) 73.6 (± 12.4) 49 (76.6) 39 (60.9) 18 (28.1) 19 (29.6) Age (yrs) Height (cm) Weight (cm) Male sex HTNDMSmoking

12. Femoral vs Radial PCI Procedural Characteristics P-valueRadial N=24 (%) Femoral N=64 (%) NSNSNSNSNSNSNS 23 (95.8) 01 (4.2) 19 (79.2) 05 (20.8) 02 (8.3) 03 (12.5) 55 (85.9) 09 (14.1) 52 (81.3) 12 (18.8) 03 (4.7) 07 (10.9) 06 (19.4) ElectiveEmergency No. of vessels intervened SVD SVD 2VD 2VDCTOOstialBifurcation

13. Femoral vs Radial PCI Procedural Characteristics P-valueRadialFemoral 0.090.02 171.6 (±58.8) 15.1 (±11.8) 145.3 (±69.0) 10.3 (±7.4) Contrast given (ml) Fluoro time (mins)

14. Radiation Exposure! Can we decrease the risk with increased Experience? Can we decrease the risk with increased Experience? P-valueTrainee Less exp Well exp Access 0.042 4.4 (±2.6) 3.9 (±2.7) 4.2 (±3.5) 4.2 (±3.5)f-CA flouro time (mins ) 0.001 7.8 (±4.6) 5.7 (±3.1) 5.4 (±2.9) r-CA Flouro time (mins)

15. f-CA-- factors affecting fluoro time f-CA-- factors affecting fluoro time Univariate Analysis Univariate Analysis P-value 95 % Confidence interval (Odds Ratio).000.185.029 1.54 – 2.28 (1.918) - -.251 – 1.29 (.522) -.050 -.917 - (.484) No of catheters used Significant LMCA disease Level of Experience

16. f-CA-- factors affecting fluoro time Multivariate Analysis P-value 95 % Confidence interval (Odds Ratio) (Odds Ratio).000.027.558 – 1.206 (.882) -1.290 - -.079 (-.685) No of catheters used Significant LMCA disease

17. r-CA-- factors affecting fluoro time Univariate Analysis P-value 95 % Confidence interval (Odds Ratio) (Odds Ratio) 0.040.040.070.0000.100.00.025 – 2.56 (.071) -2.32 - -.00 (-.142) -2.483 -.114 (-1.184) 2.372 – 4.029 (3.201) -.346 – 3.87 (1.762) 1.170 – 3.353 (2.261) SexHypertensionDiabetes No of catheters used Significant LMCA disease Level of Experience

18. r-CA-- factors affecting fluoro time Multivariate Analysis P-value 95 % Confidence interval (Odds Ratio) (Odds Ratio).000.032.000.031 -.064 (.047) -2.132 - -.097 (-1.115) 1.200 – 2.967 (2.083) No of catheters used Diabetes Mellitus Level of experience

19. Review of Literature Meta analysis of 23 randomized trials (n=7020) revealed ----radial access was associated with a longer fluoroscopy time with a weighted mean difference (WMD) 0.4 minutes (95 % CI 0.3-0.5 minutes, P <0.001). Meta analysis of 23 randomized trials (n=7020) revealed ----radial access was associated with a longer fluoroscopy time with a weighted mean difference (WMD) 0.4 minutes (95 % CI 0.3-0.5 minutes, P <0.001). Jolly et al. Am Heart J 2009 ;157:132-40 Jolly et al. Am Heart J 2009 ;157:132-40

20. Review of Literature P-value Fluoro time Radial/Femora l (mins) TitleyearAuthor <0.001<0.00010.360.02 2.8 (±2.1)/ 1.7 (±1.4) 5.5 /2.4 24.4 / 24.0 12.5 /15.2 Comparison of TRA vs TFA (CCI) (EHJ) TRA & TFA in CTO (CCI) TR-PCI in STEMI (CCI) 20062008 2008 2010 Lange et al (n=297) Brasselet et al (n=420) Rathore et al (n=468) Weaver et al (n=240)

21. Conclusion Increased radiation exposure of operators is a serious health problem for the interventional cardiologist. Increased radiation exposure of operators is a serious health problem for the interventional cardiologist. Radiation exposure can be minimized with increased experience. Radiation exposure can be minimized with increased experience. Pure Radialists are more exposed to radiation, even well experienced operators can not minimize their exposure as low as femoral operators. Pure Radialists are more exposed to radiation, even well experienced operators can not minimize their exposure as low as femoral operators. Extensive use of specific protection devices should be used by pure Radialists Extensive use of specific protection devices should be used by pure Radialists Use of radial route for every patient should be reconsidered in the light of present findings. Use of radial route for every patient should be reconsidered in the light of present findings.