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Procedural determinants of fluoroscopy time in patients undergoing cardiac catheterization.

Byline: Syed Fayaz Mujtaba, Tahir Saghir, Jawaid Akbar Sial and Nadeem Hassan Rizvi

KEYWORDS: Angiography, Fluro time, PCI, Radiation.

INTRODUCTION

In modern era cardiac catheterization has established its role as a diagnostic and interventional modality in cardiovascular disease.1-3 Increase in number of procedures is due to advancement in both operator expertise and improvement in hardware, hence fewer complications are associated with cardiac catheterization procedures.

Due to increased number of cardiac catheterization procedures, concerns regarding radiation safety have arisen.4-6 Increased radiation exposure has been associated with periprocedural complications including early mortality, emergent CABG, and contrast-induced nephropathy.7

Fluoroscopic time (FT) is most easily assessed tool for radiation exposure. Cath labs can assess their FT to make changes in their procedural techniques to minimize radiations to operator and helping staff.This is worth mentioning that cine images are not included in FT, therefore FT may not be a sole useful value for radiation dose to patient.8,9

This study aim was to find the mean fluoroscopy time of diagnostic invasive coronary angiography (ICA) and percutaneous coronary artery intervention (PCI) performed in cardiac catheterization lab of a tertiary cardiac setup. Results of this study may emphasize on reducing the fluoroscopy time to avoid excessive radiation exposure.

METHODS

This descriptive cross sectional study was conducted at catheterization Laboratory National institute of cardiovascular diseases, Karachi from June 2014 to June 2015. It was approved by hospital ethical review committee and informed consent was taken from all patients included. Patients of both gender and age between 18 to 90 years undergoing cardiac catheterization procedures due to different indications were included. Radiation exposure time was measured in terms of fluoroscopy time (FT), minutes from time of onset of fluoroscopy till the end of procedure.

All the procedures were performed by different operators with different level of expertise and were grouped into two (consultants, senior registrar's and post fellow trainees). Procedures were categorized into three groups depending on the nature of procedure (coronary angiography, percutaneous coronary intervention (PCI)), and two groups on basis of accesses sites (femoral and radial). Data was entered and analyzed using SPSS-21. Mean +- standard deviation (SD) and median [interquartile range (IQR)] were calculated for continuous variables such as age (years) and fluoroscopy time (FT) (minutes). Mann-Whitney U/Kruskal-Wallis test was applied to examine the differences in fluoroscopy time (FT) by baseline and procedural characteristics of the patient. Two sided p-value of a$?0.05 was be taken as criteria of statistical significance.

Table-I: Assessment of fluoroscopy time of invasive coronary angiographic procedures by baseline characteristics.

###Frequency(%)###Fluoroscopy Time(FT)

###N=731###Mean +- SD###Median(IQR)###P-value

Gender

Male###75.2%(550)###4.19 +- 4.33 minutes###3(3.4) minutes###0.905

Female###24.8%(181)###4.14 +- 3.45 minutes###3(3.8) minutes

Age

Up to 50 years###41.5%(303)###4.38 +- 4.87 minutes###3(3.6) minutes###0.395

More than 50 years###58.5%(428)###4.03 +- 3.52 minutes###3(3.4) minutes

Accesses site

Femoral###91.8%(671)###4.04 +- 4.03 minutes###2.9(3.3) minutes###<0.001*

Radial###8.2%(60)###5.7 +- 4.95 minutes###5.25(4.05) minutes

Operator

Consultant###19.3%(141)###4.24 +- 4.52 minutes###2.5(3.5) minutes

Senior registrar###12.7%(93)###3.23 +- 3.26 minutes###2.3(2.2) minutes###<0.001*

Post fellow###68%(497)###4.33 +- 4.15 minutes###3.4(3.5) minutes

LV angiogram

Yes###60.7%(444)###4.31 +- 3.87 minutes###3.3(3.4) minutes###0.003*

No###39.3%(287)###3.97 +- 4.5 minutes###2.5(3.1) minutes

Normal coronary anatomy

Yes###19%(139)###3.76 +- 3.25 minutes###2.7(2.9) minutes###0.115

No###81%(592)###4.27 +- 4.31 minutes###3.1(3.4) minutes

LM disease

Yes###7.4%(54)###3.27 +- 2.64 minutes###2.4(2.8) minutes###0.020*

No###92.6%(677)###4.25 +- 4.22 minutes###3.1(3.4) minutes

Table-II: Assessment of fluoroscopy time of percutaneous coronary intervention by baseline characteristics of the study sample

###Frequency(%)###Fluoroscopy Time(FT)

###N=226###Mean +- SD###Median(IQR)###P-value

Gender

Male###1.4%(184)###9.6 +- 6.03 minutes###7.8(7.35) minutes###0.999

Female###18.6%(42)###9.65 +- 6.34 minutes###8.85(6.8) minutes

Age

Up to 50 years###37.9%(50)###9.64 +- 6.28 minutes###8(7.4) minutes###0.859

More than 50 years###62.1%(82)###9.49 +- 5.53 minutes###8.35(7.5) minutes

Accesses site

Femoral###72.1%(163)###9.23 +- 5.85 minutes###7.9(6.2) minutes###0.17

Radial###27.9%(63)###10.6 +- 6.56 minutes###8.4(9) minutes

Type of procedure

Elective PCI###80.5%(182)###10.03 +- 6.42 minutes###8.3(7.5) minutes###0.089

Primary PCI###19.5%(44)###7.91 +- 4.01 minutes###6.55(4.9) minutes

LAD stented

Yes###60.2%(136)###9.97 +- 6.35 minutes###8.35(6.7) minutes###0.273

No###39.8%(90)###9.08 +- 5.62 minutes###7.2(7.6) minutes

RCA stented

Yes###32.7%(74)###9.97 +- 6.87 minutes###8.15(7.9) minutes###0.958

No###67.3%(152)###9.44 +- 5.66 minutes###7.9(6.6) minutes

LCX stented

Yes###16.4%(37)###11.53 +- 7.15 minutes###10.6(9.4) minutes###0.043

No###83.6%(189)###9.24 +- 5.79 minutes###7.5(6.2) minutes

OM stented

Yes###5.8%(13)###13.2 +- 7.95 minutes###13(9.8) minutes###0.07

No###94.2%(213)###9.39 +- 5.89 minutes###7.9(6.6) minutes

Number of stents placed

One###83.2%(188)###8.77 +- 5.2 minutes###7.4(5.8) minutes

Two###13.7%(31)###12.98 +- 8.37 minutes###10.6(11) minutes###<0.001*

Three###2.7%(6)###17.9 +- 6.78 minutes###14.6(4.5) minutes

RESULTS

Study sample consist of 731 patients who underwent invasive coronary angiography (ICA) and 226 patients who underwent percutaneous coronary intervention (PCI). Mean age of 731 coronary angiography patients was 53.97 +- 10.75 years, majority, 75.2% (550), were male, and access for the procedure was femoral for majority, 91.8% (671), of the patients. Mean age of 266 percutaneous coronary intervention (PCI) patients was 54.92 +- 11.67 years, 81.4% (184) were male, and procedural access was femoral in 72.1% (163) of the patients. Mean fluoroscopy time (FT) was 4.18 +- 4.13 minutes for coronary angiographic procedures and 9.61 +- 6.07 minutes for percutaneous coronary intervention (PCI) procedures.

Assessment of fluoroscopy time (FT) for coronary angiographic procedures by patient characteristics are presented in Table-I. FT was observed significantly higher in procedures with radial access, 5.25 (4.05) vs. 2.9 (3.3) minutes, p-value = <0.001, as compare to femoral access. Operator's experience had negative association with fluoroscopy time (FT) of the procedure with p-value of <0.001. FT was higher for the procedures where LV angiogram was done, 3.3 (3.4) vs. 2.5 (3.1) minutes, p-value = 0.003. And patients with left main (LM) disease were found to have lower FT, 2.4 (2.8) vs. 3.1 (3.4) minutes, p-value = 0.020.

Assessment of fluoroscopy time (FT) for percutaneous coronary intervention procedures by patient characteristics are presented in Table-II. No statistically significant difference in fluoroscopy time (FT) of percutaneous coronary intervention was observed by gender, age, procedural access, type of procedure, and disease anatomy. Fluoroscopy time (FT) of percutaneous coronary intervention procedure was found to be positively associated with the number of stents deployed during procedure (p-value 20 years. Most junior ones, who performed majority of procedures, were post-fellowship trainees having experience of less than two years. Senior registrar was the middle group. We found that FT of the first two groups is almost comparable. While the FT of senior registrar's was much lesser. This was surprising as consultants being most experienced group were thought to have less FT. This may be because consults are rarely performing only LHC. Most of the time these are performed either by post fellowship trainees or senior registrar, therefore their reflexes in performing LHC are not good as these assumed.

Fluoroscopy time for PCI was 9.61 +- 6.07 minutes. This is much lower than previous studies done by Federman J et al. (24 minutes) and Patee PL et al. (19 minutes) during 90's.21,22 Unlike other local studies, we did not find any significant difference between radial and femoral route PCI.15,16

Unlike other study during the intervention two vessel stenting significantly increased fluoroscopy time.23 Another study involving 20,669 procedures has shown that the treatment of two or more lesions correlated with an increase in radiation exposure.24 Intervention requires a clear idea about size, diameter and type of stenting. Therefore each time a lesion is stented time is doubled. Therefore second stenting has more than an additive effect on fluoroscopy time.

In modern era stenting time has also reduced dramatically, in our study one stent and two stent PCI had FT 8.77 +- 5.2 minutes and 12.98 +- 8.37 minutes respectively. In 80's for one stent and two stent fluoroscopy time was 17.1 min for single-vessel PTCA and 19.8 min for double-vessel PCI.25,26

Lesion complexity and artery involved also determines fluoroscopy time.18 In our study stenting of LCX and OM had longer fluoroscopy time than interventions involving other arteries. Other studies too have shown that LCX intervention took longer radiation dosage. A study with 1,827 patients undergoing angioplasty has shown that the complexity of the lesion treated, angioplasty of the CX and number of lesions treated correlated with an increase in the radiation dose.27 LCX is often difficult to engage and require multiple images to get a clear idea regarding size and proper position of stent.

Primary PCI required lesser fluoroscopy time. This is because only single culprit artery is involved most of the times. Due to urgency of condition decision is promptly made and multiple views are not taken. As a policy we did only culprit lesion PCI when the patients were hemodynamicaly stable.

Study Limitations: This historical prospective study was conducted at one single center with data collection from medical records. In future more studies are needed after controlling the co-morbidities that were present in this study in the both groups.

CONCLUSION

For invasive coronary angiographic procedures radial route increased fluoroscopy time. For percutaneous coronary intervention femoral and radial route fluoroscopy time were not significantly different.

Acknowledgement: Mr. Musa Karim for statistical analysis and tabulation of data.

Grant Support and Financial Disclosures: None.

REFERENCES

1. Goodman S, Huang W, Yan A, Budaj A, Kennelly B, Gore J, et al. The expanded global registry of acute coronary events: baseline characteristics, management practices, and hospital outcomes of patients with acute coronary syndromes. Am Heart J. 2009;158:193-201. doi: 10.1016/j. ahj.2009.06.003.

2. Eagle K, Nallamothu B, Mehta R, Granger C, Steg P, Van de Werf F, et al. Trends in acute reperfusion therapy for ST-segment elevation myocardial infarction from 1999 to 2006: we are getting better but we have got a long way to go. Eur Heart J. 2008;29:609-617. doi: 10.1093/eurheartj/ehn069

3. Gogo PJ, Dauerman H, Mulgund J, Ohman E, Patel M, Cohen D, et al. Changes in patterns of coronary revascularization strategies for patients with acute coronary syndromes (from the CRUSADE quality improvement initiative). Am J Cardiol. 2007;99:1222-1226. doi: 10.1016/j. amjcard.2006.12.037.

4. Lewis WJ, Moore RJ, Balter S. Review of radiation safety in the cardiac catheterization laboratory. Cath Cardiovasc Diag. 1992;25:186-194. doi: 10.1002/ccd.1810250304

5. Smith SC Jr, Feldman TE, Hirshfeld JW Jr. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol. 2006;47:1-121. doi: 10.1161/CIRCULATIONAHA.106.173220

6. Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines. J Am Coll Cardiol. 2006;48:247-346. doi: 10.1016/j.jacc.2006.07.010.

7. Nikolsky E, Pucelikova T, Mehran R, Balter S, Kaufman L, Fahy M. An evaluation of fluoroscopy time and correlation with outcomes after percutaneous coronary intervention. J Invasive Cardiol. 2007;19(5):208-213.

8. Chida K, Saito H, Otani H, Kohzuki M, Takahashi S, Yamada S, et al. Relationship between fluoroscopic time, dose-area product, body weight, and maximum radiation skin dose in cardiac interventional procedures. Am J Roentgenol. 2006;186:774-778. doi: 10.2214/AJR.04.1653.

9. Fransson SG, Persliden J. Patient radiation exposure during coronary angiography and intervention. Acta Radiol Stockh Swed. 2000;41(2):142-144.

10. Fazel R, Curtis J, Wang Y, Einstein AJ, Smith-Bindman R, Tsai TT, et al. Determinants of fluoroscopy time for invasive coronary angiography and percutaneous coronary intervention: Insights from the NCDR(A(r)). Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 2013;82(7):1091-1105. doi: 10.1002/ccd.24996.

11. Pattee PL, Johns PC, Chambers RJ. Radiation risk to patients from percutaneous transluminal coronary angioplasty. J Am Coll Cardiol. 1993;22(4):1044-1051.

12. Dash H, Leaman DM. Operator radiation exposure during percutaneous Transluminal coronary angioplasty. J Am Coll Cardiol. 1984;4:725-728.

13. Finci L, Meier B, Stefenino G, Roy P, Rutishauser W. Radiation exposure during diagnostic catheterization and single-and double-vessel percutaneous transluminal coronary angioplasty. Am J Cardiol. 1987;60:1401-1403.

14. Cascade PN, Peterson LE, WejszczukWJ, Mantel J. Radiation exposure to patients undergoing percutaneous transluminal coronary angioplasty. Am J Cardiol. 1987:59:996-997.

15. Farman MT, Khan NU, Sial JA, Saghir T, Rizvi SNH, Zaman KS. Comparison of fluoroscopy time during coronary angiography and interventions by radial and femoral routes-can we decrease the fluoroscopy time with increased experience? An observational study. Anadolu Kardiyol Derg. 2011;11(7):607-612. doi: 10.5152/akd.2011.163.

16. Usman A, Hussain F, Iqbal T, Tuyyab F. Fluoroscopy time during cardiac catheterization procedures using the radial and femoral routes. J Ayub Med Coll Abbottabad. 2015;27(3):569-572.

17. Khan M, Qadir F, Hanif B, Villani A, Ahmedins B. To determine the safety and success of transradial coronary angiography and angioplasty-a local experience. J Pak Med Assoc. 2010;60(10):809-813.

18. Bashore TM. Radiation safety in the cardiac catheterization laboratory. Am Heart J. 2004;147(3):375-378. doi: 10.1016/j.ahj.2003.10.015.

19. Abbott JD. The pace of transradial procedural learning. Circulation. 2014;129(22):2250-2252. doi: 10.1161/CIRCULATIONAHA.114.010061.

20. Di Mario C, Sutaria N. Coronary angiography in the angioplasty era: Projections with a meaning. Heart Br Card Soc. 2005;91(7):968-976. doi: 10.1136/hrt.2005.063107.

21. Federman J, Bell MR, Wondrow MA, Grill DE, Holmes DR. Does the use of new intracoronary interventional devices prolong radiation exposure in the cardiac catheterization laboratory? J Am Coll Cardiol. 1994;23(2):347-351.

22. Pattee PL, Johns PC, Chambers RJ. Radiation risk to patients from percutaneous transluminal coronary angioplasty. J Am Coll Cardiol. 1993;22(4):1044-1051.

23. Bernardi G, Padovani R, Morocutti G, Vano E, Malisan MR, Rinuncini M, et al. Clinical and technical determinants of the complexity of percutaneous transluminal coronary angioplasty procedures: Analysis in relation to radiation exposure parameters. Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 2000;51(1):1-9; discussion 10.

24. Delewi R, Hoebers LP, Ramunddal T, Henriques JP, Angeras O, Stewart J, et al. Clinical and procedural characteristics associated with higher radiation exposure during percutaneous coronary interventions and coronary angiography. Circ Cardiovasc Interv. 2013;6(5):501-506. doi: 10.1161/CIRCINTERVENTIONS.113.000220.

25. Cascade PN, Peterson LE, Wajszczuk WJ, Mantel J. Radiation exposure to patients undergoing percutaneous transluminal coronary angioplasty. Am J Cardiol. 1987;59(9):996-997.

26. Finci L, Meier B, Steffenino G, Roy P, Rutishauser W. Radiation exposure during diagnostic catheterization and single-and double-vessel percutaneous transluminal coronary angioplasty. Am J Cardiol. 1987;60(16):1401-1403.

27. Fetterly KA, Lennon RJ, Bell MR, Holmes DR, Rihal CS. Clinical determinants of radiation dose in percutaneous coronary interventional procedures: Influence of patient size, procedure complexity, and performing physician. JACC Cardiovasc Interv. 2011;4(3):336-343. doi: 10.1016/j.jcin.2010.10.014.
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Publication:Pakistan Journal of Medical Sciences
Date:Feb 28, 2019
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