1. Influence of Access-site on
Radiation Exposure in Cardiac
Catheterization
Systematic Review and Meta-Analysis of Observational and Randomized Trials
Samir Pancholy, MD, Guillaume Plourde, Imdad Ahmed
Sunil Rao, Sanjit Jolly, Sripal Bangalore,
Tejas Patel, Olivier Bertrand
AimRADIAL2013

2. Disclosures
Research grants: Cordis, Eli-Lilly, Bristol-MyersSquibb, GE Healthcare, Sanofi-Aventis, Eurocor
Consultant: Cordis, Astra-Zeneca, Opsens
Research-Scholar from Quebec Fund for Health
Research

3. Background
Large pool of data comparing TRA vs. TFA radiation
exposure
However, it remains unclear whether TRA is
associated with clinically significant increase in
radiation exposure

4. Background
Radiation burden a function of many variables
Patient substrate
Operator experience
Operator awareness
Equipment
Angiographic routine

5. Objectives
To perform a systematic review and meta-analysis of
ALL studies (observational & randomized) comparing
radiation exposure between TRA and TFA for:
 Diagnostic coronary angiograms (DCA)
 Percutaneous coronary intervention (PCI)

6. Methods
Standard PRISMA, QUOROM (randomized) and MOOSE
(observational) protocols
PubMed, Embase, Cochrane databases using “radial”,
“femoral”, “cardiac catheterization”, “radiation
exposure”, “fluoroscopy time”,
“dose-area-product”
Cross-referencing with The Radialist.org
Last update: June 26 2013

7. Outcomes
Patient’s radiation exposure
 Fluoroscopy time (FT) (minutes)
 Dose-area-product (DAP) (Gy ・ cm2)
Operator’s radiation exposure
 Radiation dose (µSv)

8. Meta-Analysis
Data summarised as the mean difference of
continuous variables with 95% confidence intervals
Combined using the DerSimonian and Laird random
effects model with inverse variance weighting
When SD were missing, or data expressed as
medians with IQR, authors were contacted
Subgroups were based on intervention type (DCA vs.
PCI)
Separate analyses for randomized and observational
studies, and a third combining both

9. Studies selection
Total of
666,765 patients

10. Studies Characteristics
68 studies (666,765 patients), conducted between
1995-2013
18 randomized trials (n=12,051);
50 observational studies (n=654,714)
60 single-center and 8 multi-center studies
In randomized trials, 6,193 TRA and 5,858 TFA

11. Impact on FT
in diagnostic coronary angiograms
Randomized
Observational

12. Impact on FT
in percutaneous coronary interventions
Randomized
Observational

13. Impact on DAP
in diagnostic coronary angiograms
Randomized
Observational

14. Impact on DAP
in percutaneous coronary interventions
Randomized
Observational

15. TF vs TR Fluoro time
(Diagnostic)

16. LRA vs RRA Fluoro time
(PCI)

17. Effect of Training

18. Effect of Training

19. Effect of Training

20. Operator Exposure
Sciahbasi A

21. Impact on Operator Dose

22. Relationship Between Years Since 1992 and Fluoroscopy Time
PCI Cohort (Non-randomized)
TRA
TFA

23. Non-randomized trials
80
70
60
Dose-Area Product
TR
TF
50
Linear (TR)
Linear (TF)
40
30
20
18 years later
10
0
10
12
14
16
18
20
Years since first descrip on of TRI
22
24

24. Meta-regression of Fluoroscopy time and Year of
Publication since First Description of TRI (1992)
(Randomized)
6.00
Difference in means
5.20
P = 0.0001
4.40
3.60
2.80
2.00
1.20
0.40
-0.40
-1.20
-2.00
2.30
4.34
6.38
8.42
10.46
12.50
Years
14.54
16.58
18.62
20.66
22.70

25. Non-randomized Studies Reporting Fluoroscopy Time (PCI)
10.00
P = 0.0001
Difference in means
Fluoroscopy Time
8.60
7.20
5.80
4.40
3.00
1.60
0.20
-1.20
-2.60
-4.00
6.70
8.26
9.82
11.38
12.94
14.50
16.06
17.62
Years since TRI Publication
19.18
20.74
22.30

26. Conclusion
FT and DAP in TRA continues to decrease over the
last years
TRA, when compared to TFA in the last 5 years, was
associated with <1 minute higher FT for DCA and PCI
Radiation exposure is moderately increased when
initially adopting TRA (like many other skills), with
high likelihood of progressive decrease with
increasing experience.