Vascular access route (radial vs femoral) and radiation exposure in percutaneous coronary interventions and diagnostic angiography

1. Vascular access route (radial vs femoral)
and radiation exposure in percutaneous
coronary interventions and diagnostic
angiography
S. Rigattieri, A. Sciahbasi, E. Mussino, S. Drefahl, F.R. Pugliese
«Sandro Pertini» Hospital
Rome, Italy

2. Disclosures:
• None of the authors has any relevant financial
interests to disclose

3. Background
• X-ray dose during interventional cardiology procedures should
be kept as low as reasonably acceptable (ALARA) in order to
prevent direct and stochastic damage for both the patient and
the operator.
Deterministic effect
Stochastic effect

4. The issue of dose in Interventional
Cardiology
• Patient dose is usually measured as Dose-Area
product or Air Kerma
Picano et al. EuroIntervention 2012;8:649-653

5. Determinants of radiation dose in PCI
Mayo PCI Registry
91% femoral
9% radial;
vascular access not
considered
Fetterly et al. JACC Intv 2011; 4: 336-43

6. Radial access update - NCDR
Feldman DN et al. Circulation 2013; 127: 2295-2306

7. Radial approach can be challenging..

8. Brueck et al.
Philippe et al.
Geijer et al.
Nell et al. Diag
Nell et al. PCI
Brasselet et al. OP-1
Brasselet et al. OP-2
Brasselet et al. OP-3
Brasselet et al. OP-4
Larrazet et al.
Lo et al.
Lehmann et al.
Lange et al.
Sandborg et al.
Mercuri et al.
Delewi et al. diag.
Delewi et al. PCI
Achenbach et al. PCI
Hetherington et al.
Transradial catheterization
was not associated with
higher patient radiation
exposure than
transfemoral access

9. Learning curve
Hildick-Smith, CCI 2004;61:60-68

10. RIVAL radiation substudy
Fluoroscopy time
Jolly et al. JACC Intv 2013;6:258-66

11. RIVAL radiation substudy
AIR KERMA
mGy
Jolly et al. JACC Intv 2013;6:258-66

12. Methods
• Study design: single-center, retrospective study aimed to
compare radiation exposure of patients during
percutaneous coronary interventions (PCI) and diagnostic
coronary angiography (CA) according to the vascular access
route (radial vs femoral).
• Population:
– Inclusion criteria: all patients undergoing PCI or CA in our
laboratory from May 2009 to May 2013 for whom radiation
exposure data (Dose Area Product) were available.
– Exclusion criteria: PCI of chronic total occlusion.
• Measurement: the DAP meter was integrated in the X-ray
system; all the procedures were carried out in a single
catheterization room.

13. Statistical analysis
• Stepwise multiple linear regression analysis
was performed in order to compare radiation
exposure between RA and FA adjusting for
clinical and procedural confounders.
• Dose Area Product values (DAP, cGy.cm2) were
logarithmically transformed because the
distribution was positively skewed.
• Beta coefficients are routinely interpreted in
terms of percent change.

14. Results
• DAP values were available for 1396 out of
4110 procedures.
• RA was used in 1153 procedures (82.6%) and
was right-sided in 82.3% of cases.
• The overall rate of RA in the Cath Lab was
68%, 69%, 75% and 87% for each of the 4
years considered, respectively.

15. Clinical and procedural characteristics
Radial
Femoral
p
N
1153
243
Age (years)
65.4 ± 11.9
68.0 ± 12.1
0.002
BMI (kg/m2)
27.4 ± 4.4
26.4 ± 3.9
0.001
Female gender (%)
25.8
32.9
0.015
Bypass study (%)
2.8
11.9
0.000
PCI (%)
47.4
60.4
0.000
Multivessel PCI (%)
4.6
8.6
0.011
Ad hoc PCI (%)
39.2
53.5
0.000
Pressure wire (%)
1.5
0.4
0.125
IVUS (%)
1.8
1.2
0.377
Primary PCI (%)
13.0
37.4
0.000
IABP (%)
0.3
1.2
0.106
Thrombus asp. (%)
6.2
17.3
0.000

16. Patient radiation exposure
P<0.01

17. Fluoroscopy time
P<0.05

18. Correlation
Spearman’s rho 0.761
p<0.001

19. Linear regression analysis
Beta
95% C.I.
Lower bound
Upper bound
p
Access (FA vs RA)
0.054
-0.024
0.133
0.175
Female gender
-0.039
-0.404
-0.275
<0.001
Age
0.003
0.001
0.006
0.008
BMI
0.054
0.048
0.061
<0.001
Diagnostic only
-0.582
-0.768
-0.396
<0.001
Primary PCI
0.257
0.028
0.486
0.028
Ad hoc PCI
0.293
0.132
0.455
<0.001
N° stents (2 vs 1)
0.263
0.154
0.371
<0.001
N° stents (≥3 vs 1)
0.441
0.255
0.626
<0.001
Bypass study
0.298
0.156
0.440
<0.001
FFR/IVUS
0.419
0.258
0.581
<0.001
Multivessel PCI
0.012
-0.138
0.163
0.868
Thrombus aspiration
0.025
-0.099
0.150
0.690

20. Study limitations
• Retrospective design, DAP values were only
available for a minority of patients.
• Variables affecting the radiation exposure
(position of the X-ray tube, distance between
patient and image intensifier, height of the
table) were not measured.
• The radiation exposure of the interventional
cardiologists was not considered.

21. Conclusions
After adjusting for clinical and procedural
confounders, radial approach was not found
to be associated with increased radiation
exposure of patients as compared to femoral
approach in an experienced radial center.

22. In the Future…
Is TRI superior to TFI ?
Should Bivalirudin be prolonged
Is Bivalirudin superior to UFH ? after PCI ?

23. In the Future…
RAD MATRIX