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International Atomic Energy Agency
Can cardiac procedures be Can cardiac procedures be graded in complexity and graded in complexity and
related with dose?related with dose?
L 8.3
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Lecture 8.3: Complexity 2Radiation Protection in Cardiology
Educational ObjectivesEducational Objectives
1. Complexity related factors in cardiac interventions
2. Relationship of patient dose with technical and clinical factors
3. Development of complexity index and its utility
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Lecture 8.3: Complexity 3Radiation Protection in Cardiology
factors determining patient’s exposure
adequacy of equipment
fluoroscopy time
cine-angiography time
operator’s experienceprocedure complexity
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Lecture 8.3: Complexity 4Radiation Protection in Cardiology
fluoro time: 1 m’ 20 sec
total DAP: 102 dGy
simple case straightforward right
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Lecture 8.3: Complexity 5Radiation Protection in Cardiology
difficult caseextreme vessel tortuosity
fluoro time: 20 m’
total DAP: 1074 dGy
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Lecture 8.3: Complexity 6Radiation Protection in Cardiology
complexity related factors
• age
• number of vessels treated
• occluded vessels
• previous CABG
• poor Ejection Fraction
quantification never proposed
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Lecture 8.3: Complexity 7Radiation Protection in Cardiology
Clinical and technical determinants of the Clinical and technical determinants of the complexity of PTCA procedures. Analysis in complexity of PTCA procedures. Analysis in
relation to fluoroscopy time relation to fluoroscopy time (Cathet Cardiovasc Intervent 2000; 51:1-9)(Cathet Cardiovasc Intervent 2000; 51:1-9)
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Lecture 8.3: Complexity 8Radiation Protection in Cardiology
PTCA characteristicsn 402, 21/06/96-08/05/98 (50% of tot)
0
50
100
150
200
250
300
350one-lesion
multi-lesion
multivessel
76.3%
15.4%8.2%
Stenting 49% (x procedure)
mean fluoro time 11,5’ ± 8,6’
success 96.5 %
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Lecture 8.3: Complexity 9Radiation Protection in Cardiology
patients’ characteristicsn 402, M 72 % age 62±11
one vessel
two vessels
three vessels
34.1%34.9%
31%
6% previous CABG mean EF 58% ± 10
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Lecture 8.3: Complexity 10Radiation Protection in Cardiology
clinical factors testedclinical factors tested
• age
• sex
• single or multivessel disease
• EF
• previous CABG
no significant correlation with fluoro time or exposure parameters
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Lecture 8.3: Complexity 11Radiation Protection in Cardiology
Weight (seconds) score Constant 159 -
lesion B2 (AHA) 151 - lesion > B2 (AHA) 400 1
IVUS 315 - simple stenting 157 -
bifurcation stenting 331 1,5 ostial stenting 346 0,8
occlusion 3 months 943 2,8 moderate tortuosity 234° -
severe tortuosity 1471 4,9 double balloon technique 350* -
double wire technique 140* -
p< 0.001, p<0.01*, p<0.005°
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Lecture 8.3: Complexity 12Radiation Protection in Cardiology
0
1
2
3
4
5
6
7
0 1000 2000 3000 4000 5000
r = 0.576P < 0.0001
complexity index/fluoro time correlationmost significant & less operator-dependent variables
Com
ple
xit
y In
dex
Fluoro time (sec)
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Lecture 8.3: Complexity 13Radiation Protection in Cardiology
0
200
400
600
800
1000
1200
1400
1600
1800
2000
simple medium complex CI = 0 CI 1.5 CI > 1.5
215 119 68
Flu
oro
tim
e (s
ec)
complexity index-based stratification fluoro time
P < 0.0001
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Lecture 8.3: Complexity 14Radiation Protection in Cardiology
0
500
1000
1500
2000
2500
simple medium complex CI = 0 CI 1.5 CI > 1.5
215 119 68
Cin
e fr
ames
(n
)complexity index-based stratification cine frames
P = 0.0377
P = ns
P = 0.001
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Lecture 8.3: Complexity 15Radiation Protection in Cardiology
0
50
100
150
200
250
DAP
Gy
* cm
2 complexity index-based stratification total DAP
P < 0.0001
P = 0.0015
215 119 68
simple medium complex CI = 0 CI 1.5 CI > 1.5
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Lecture 8.3: Complexity 16Radiation Protection in Cardiology
procedural success rate procedural success rate (402 cases, 50% of total activity)(402 cases, 50% of total activity)
97,6
93,3
89,7
84
86
88
90
92
94
96
98
simple medium complex
%
P = 0.00787
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Lecture 8.3: Complexity 17Radiation Protection in Cardiology
fluoro time in different diagnostic fluoro time in different diagnostic procedures (844) procedures (844)
0
1
2
3
4
5
6
7
Coro only Coro + LV Right cath. Graft Aortogr
min
ute
s
2.6±3.4 2.7±2.3
6.1±6.0 6.1±4.9
6.8±7.1
65%
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Lecture 8.3: Complexity 18Radiation Protection in Cardiology
• In our experience, fluoroscopy time and total DAP were directly related to technical and not to clinical factors
• The weight of these factors can be quantified in order to anticipate the radiation dose needed to treat patients undergoing complex procedures
conclusions (I)conclusions (I)
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Lecture 8.3: Complexity 19Radiation Protection in Cardiology
• Comparison of different centers and operators for quality control assessment, as well as the definition of appropriate fluoroscopy time and DAP doses, should take into account complexity indexes
• Further studies in different institutions are warranted to corroborate this data
conclusions (II)conclusions (II)