The growth in fluoroscopy-guided procedures has put operators between a rock and a hard place, or should I say, between exposure to radiation and the opportunity to obtain clinically useful information. According to the American Heart Association, the rate of patients who underwent PCI increased 58 percent between 1992 and 2004, making the potential for cumulative exposure to operators as they treat more of these patients greater.
A number of strategies have been identified to minimize exposure, from protective garments and shielding to effective dose management and staff training. Still, any advancement is welcome news. Putting practicalities aside, two reports this month offered opportunities for reducing radiation exposure for physicians.
The first was reported in Journal of the American College of Cardiology: Cardiovascular Interventions. Lange and colleagues in Germany noted that their research and studies by others have demonstrated that using the radial approach to PCI increases operator exposure to radiation compared with the femoral approach. They speculated that this added risk of exposure was one reason that some interventionalists shied away from embracing transradial PCI.
They took a safety strategy used in femoral PCI, pelvic lead shielding, and applied it to the radial setting with a randomized study that allowed them to compare operator radiation dose in both approaches. Operator radiation dose with radial access dropped from 20.9 uSv with no pelvic lead shielding to 9 uSv with pelvic lead shielding. Operators fared better with femoral access, though, at 15.3 uSv to 2.9 uSv.
A step forward, but Lange et al conceded pelvic lead shielding didn’t close the “radiation gap” and additional approaches are still needed.
How about shelving the lead clothing line completely?
In a clinical trial at the 35th annual meeting of the Society for Cardiovascular Angiography and Interventions (SCAI), Giora Weisz, MD, offered a possible solution that put robotic system in the limelight with the operator remotely orchestrating the procedure behind radiation-shielded panels. Weisz, director of clinical cardiovascular research at the Center for Interventional Vascular Therapy at NewYork-Presbyterian Hospital/Columbia University Medical Center in New York City, reported that investigators treated 164 patients at nine sites using the system.
Median reduction in radiation exposure to the operator was 94.8 percent lower than the levels found at the standard table position, according to Weisz, and overall procedure success rate was 97.6 percent.
The robotic system, the CorPath 200 System (Corindus Vascular Robotics) has yet to receive FDA approval. Nor is it clear that if approved, hospitals could afford it. As yet, that rock and hard place hasn't shifted much, but the possibility that operators may be extracted from the middle is looking more promising.
Cardiovascular Business, editor