1. DOES TRANSRADIAL INTERVENTION IMPACT RADIATION EXPOSURE Dr Jim Nolan University Hospital of North Staffordshire

2. 27/11/20151 Mihran Kassabian (1870-1910)

3. RADIATION EXPOSURE IS IMPORTANT Skin injury due to cardiac intervention

4. RADIATION EXPOSURE IS IMPORTANT Accessory pathway ablation 3 weeks 5 months 6.5 months

5. OPERATORS ALSO GET RADIATION INDUCED SKIN INJURY

6. RADIATION EXPOSURE AND CANCER RISK

7. RADIATION IS IMPORTANT If radial access is associated with a significant increase in radiation exposure this will offset some of its other proven benefits and could limit its applicability

8. Review of recent literature comparing radiation exposure in transfemoral and transradial cardiac catheterisation ReferenceFARA NoDAP (Gycm 2 ) FT (min)Rad Exp (uSv) NoDAP (Gycm 2 ) FT (min)Rad Exp (uSv) Mann et al 1996 - PCI 1268.813813.5 Sandborg et al 2003 -CA 4038±224.6±43651±257.5±4 Sandborg et al 2003 –CA+PCI 4247±3412.5±92475±4718.4±9 Sandborg et al 2003 -All 8243±298.6±86061±3711.9±9 Larrazet et al 2003 –ad hoc PCI 1841381221817517 Geijer et al 2004 - PCI 11469.816.45570.518.1 Lange et al 2006 –CA 10313.1±8.51.7±1.432±399215.1±8.42.8±2.164±55 Lange et al 2006 -PCI 4851±29.410.4±6.8110±1155446.3±28.711.4±8.4166±188

9. RADIAL ACCESS INCREASES RADIATION EXPOSURE FOR PATIENTS AND OPERATORS

10. Review of recent literature comparing radiation exposure in transfemoral and transradial cardiac catheterisation ReferenceFARA NoDAP (Gycm 2 ) FT (min)Rad Exp (uSv) NoDAP (Gycm 2 ) FT (min)Rad Exp (uSv) Mann et al 1996 - PCI 1268.813813.5 Sandborg et al 2003 -CA 4038±224.6±43651±257.5±4 Sandborg et al 2003 –CA+PCI 4247±3412.5±92475±4718.4±9 Sandborg et al 2003 -All 8243±298.6±86061±3711.9±9 Larrazet et al 2003 –ad hoc PCI 1841381221817517 Geijer et al 2004 - PCI 11469.816.45570.518.1 Lange et al 2006 –CA 10313.1±8.51.7±1.432±399215.1±8.42.8±2.164±55 Lange et al 2006 -PCI 4851±29.410.4±6.8110±1155446.3±28.711.4±8.4166±188

11. TRANSRADIAL APPROACH THE LEARNING CURVE Puncture failure, spasm, different guide manipulation

12. Is it valid to compare experienced femoral operators with less experienced radial operators DAP 28% reduction in radiation exposure related to learning curve

13. Influence of learning curve on radiation exposure DAP Gycm2

14. PATIENT CHARACTERISTICS ARE IMPORTANT

15. FLUOROSCOPY MODE AND PATIENT MORPHOLOGY ARE IMPORTANT

16. PERIPHERAL VASCULAR DISEEASE ALSO IMPACTS ON RADIAL OPERATORS

17. MISMATCH OF PATIENT AND OPERATOR VARIABLES INVALIDATE THE EXISTING OBSERVATIONAL STUDIES

18. RANDOMISED COMPARISON OF OPERATOR RADIATION EXPOSURE AND ACCESS SITE (Lange et al, CCI 2006, n = 297) RADIAL FEMORAL P DIAGNOSTIC STUDIES FT (mins) 2.8 1.7 <0.001 DAP (Gy.cm 2 ) 15.1 13.1<0.05 ORE (µSv.cm 2 ) 64 32<0.001 PERCUTANEOUS FT (mins) 11.4 10.4 NS DAP (Gy.cm 2 ) 46.3 51.0 NS ORE (µSv.cm 2 ) 166 110<0.05

19. USE OF ADDITIONAL RADIATION SCREENING (Tift Mann et al, JIC 1996, n = 264) FEMORAL RAD-1 RAD-2 FLUORO TIME161918 (mins) OPERATOR DOSE8.813.53.3 PER CASE (mrem/min)

20. The inadeqate radiation protection protocol imposed on the radial operators invalidates the randomised trial

21. WHAT CAN AN EXPERIENCED RADIAL OPERATOR ACHIEVE?

22. TRANSRADIAL PROCEDURES AT UHNS – RADIATION PROTECTION PROTOCOL Minimise screening and acquisition times, and use of oblique views Aduct arm after puncture Under and over table shields Extension tubing from catheter to manifold to optimise benefits of inverse square law Increased operator shielding (shin pads, glasses, hat)

23. FLUOROSCOPY TIMES OF PATIENTS UNDERGOING CA & PCI BY THE RADIAL AND FEMORAL ROUTES (UHNS PILOT DATA, N=300)

24. RADIATION DOSES OF PATIENTS UNDERGOING RADIAL AND FEMORAL PCI (UHNS PILOT DATA, N=200)

25. Operator radiation exposure and access site – UHNS controlled study μSv EXPERT OPERATOR TRAINEE OPERATOR P=NS

26. PCI OPERATIVE RADIATION EXPOSURE 2003 – 2004 TLD BADGE READINGS - UHNS

27. CONCLUSION The existing literature is unreliable and invalid For an experienced operator employing good radiation protection practice…… There is no radiation hazard to operators or patients