Evaluation of novel X-ray protective eyewear in reducing the eye dose to interventional radiology physicians.

The new recommendation of the International Commission on Radiological Protection for occupational eye dose is an equivalent dose limit to the eye of 20 mSv year-1, averaged over a 5-year period. This recommendation is a drastic reduction from the previous limit of 150 mSv year-1. Hence, it is important to protect physicians' eyes from X-ray radiation. Particularly in interventional radiology (IVR) procedures, many physicians use protective lead (Pb) glasses to reduce their occupational exposure. This study assessed the shielding effects of novel 0.07 mm Pb glasses. The novel glasses (XR-700) have Pb-acrylic lens molded in three dimensions. We studied the novel type of 0.07 mm Pb glasses over a period of seven consecutive months. The eye dose occupational radiation exposure of seven IVR physicians was evaluated during various procedures. All IVR physicians wore eye dosimeters (DOSIRIS™) close to the left side of the left eye. To calculate the shielding effects of the glasses, this same type of eye dosimeter was worn both inside and outside of the Pb lenses. The average shielding effect of the novel glasses across the seven physicians was 61.4%. Our results suggest an improved shielding effect for IVR physicians that use these glasses. No physician complained that the new glasses were uncomfortable; therefore comfort is not a problem. The lightweight glasses were acceptable to IVR physicians, who often must perform long procedures. Thus, the novel glasses are comfortable and reasonably protective. Based on the results of this study, we recommend that IVR physicians use these novel 0.07 mm Pb glasses to reduce their exposure.

Hybrid Operating Room System for the Treatment of Thoracic and Abdominal Aortic Aneurysms: Evaluation of the Radiation Dose Received by Patients.

In recent years, endovascular treatment of aortic aneurysms has attracted considerable attention as a promising alternative to traditional surgery. Hybrid operating room systems (HORSs) are increasingly being used to perform endovascular procedures. The clinical benefits of endovascular treatments using HORSs are very clear, and these procedures are increasing in number. In procedures such as thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR), wires and catheters are used to deliver and deploy the stent graft in the thoracic/abdominal aorta under fluoroscopic control, including DSA. Thus, the radiation dose to the patient is an important issue. We determined radiation dose indicators (the dose-area product (DAP) and air karma (AK) parameters) associated with endovascular treatments (EVAR and TEVAR) using a HORS. As a result, the mean ± standard deviation (SD) DAPs of TEVAR and EVAR were 323.7 ± 161.0 and 371.3 ± 186.0 Gy x cm2, respectively. The mean ± SD AKs of TEVAR and EVAR were 0.92 ± 0.44 and 1.11 ± 0.54 Gy, respectively. The mean ± SD fluoroscopy times of TEVAR and EVAR were 13.4 ± 7.1 and 23.2 ± 11.7 min, respectively. Patient radiation dose results in this study of endovascular treatments using HORSs showed no deterministic radiation effects, such as skin injuries. However, radiation exposure during TEVAR and EVAR cannot be ignored. The radiation dose should be evaluated in HORSs during endovascular treatments. Reducing/optimizing the radiation dose to the patient in HORSs is important.

Radiation eye dose to medical staff during respiratory endoscopy under X-ray fluoroscopy.

Although the clinical value of fluoroscopically guided respiratory endoscopy (bronchoscopy) is clear, there have been very few studies on the radiation dose received by staff during fluoroscopically guided bronchoscopy. The International Commission on Radiological Protection (ICRP) is suggesting reducing the occupational lens dose limit markedly from 150 to 20 mSv/year, averaged over defined periods of five years. The purpose of this study was to clarify the current occupational eye dose of bronchoscopy staff conducting fluoroscopically guided procedures. We measured the occupational eye doses (3-mm-dose equivalent, Hp(3)) of bronchoscopy staff (physicians and nurses) over a 6-month period. The eye doses of eight physicians and three nurses were recorded using a direct eye dosimeter, the DOSIRIS. We also estimated eye doses using personal dosimeters worn at the neck. The mean ± SD radiation eye doses (DOSIRIS) to physicians and nurses were 7.68 ± 5.27 and 2.41 ± 1.94 mSv/6 months, respectively. The new lens dose limit, 20 mSv/year, may be exceeded among bronchoscopy staff, especially physicians. The eye dose of bronchoscopy staff (both physicians and nurses) was underestimated when measured using a neck dosimeter. Hence, the occupational eye dose of bronchoscopy staff should be monitored. To reduce the occupational eye dose, we recommend that staff performing fluoroscopically guided bronchoscopy wear Pb glasses. correct evaluation of the lens dose [Hp(3)] using an eye dosimeter such as the DOSIRIS is necessary for bronchoscopy staff.

Impact of Diabetes Mellitus on Critical Limb Ischemia With Below the Knee Disease: Japan Below-the-Knee Artery Treatment Subanalysis.

BACKGROUND: A strong association exists between diabetes mellitus and critical limb ischemia. METHODS AND RESULTS: We performed endovascular therapy on 1060 limbs in 884 patients with below knee lesions only. The patients were divided into diabetes (DG) and nondiabetes groups (NDG). Limb salvage was poorer in the DG (79% vs 89%, P = .0061). No significant difference was observed in mortality, amputation-free survival (AFS), and target vessel revascularization (TVR). Multivariate analysis revealed diabetes status, infection, poor activity of daily living (ADL), younger age, and procedure failure as independent predictors of major amputation in DG. In the NDG, procedure failure was the predictor, and younger age and poor ADL showed tendency of major amputation. CONCLUSIONS: Mortality, AFS, and TVR showed no significant difference between the 2 groups, but major amputation was more frequent in DG. Not only revascularization but also infection and diabetes control were very important for limb salvage in DG.

Occupational eye dose in interventional cardiology procedures.

It is important to measure the radiation dose [3-mm dose equivalent, Hp(3)] in the eye. This study was to determine the current occupational radiation eye dose of staff conducting interventional cardiology procedures, using a novel direct eye dosimeter. We measured the occupational eye dose [Hp(3)] in physicians and nurses in a catheterization laboratory for 6-months. The eye doses [Hp(3)] of 12 physicians (9 with Pb glasses, 3 without), and 11 nurses were recorded using a novel direct eye dosimeter, the DOSIRISTM. We placed dosimeters above and under the glasses. We also estimated the eye dose [0.07-mm dose equivalent] using a neck personal dosimeter. The eye doses among interventional staff ranked in the following order: physicians without Pb glasses > physicians with Pb glasses > nurses. The shielding effect of the glasses (0.07-mm Pb) in a clinical setting was approximately 60%. In physicians who do not wear Pb glasses, the eye dose may exceed the new regulatory limit for IR staff. We found good correlations between the neck dosimeter dose and eye dosimeter dose (inside or outside glasses, R2 = 0.93 and R2 = 0.86, respectively) in physicians. We recommend that interventional physicians use an eye dosimeter for correct evaluation of the lens dose.

A Rotatable Quality Control Phantom for Evaluating the Performance of Flat Panel Detectors in Imaging Moving Objects.

As the use of diagnostic X-ray equipment with flat panel detectors (FPDs) has increased, so has the importance of proper management of FPD systems. To ensure quality control (QC) of FPD system, an easy method for evaluating FPD imaging performance for both stationary and moving objects is required. Until now, simple rotatable QC phantoms have not been available for the easy evaluation of the performance (spatial resolution and dynamic range) of FPD in imaging moving objects. We developed a QC phantom for this purpose. It consists of three thicknesses of copper and a rotatable test pattern of piano wires of various diameters. Initial tests confirmed its stable performance. Our moving phantom is very useful for QC of FPD images of moving objects because it enables visual evaluation of image performance (spatial resolution and dynamic range) easily.

Uncommon presentation of drug-refractory pacemaker-mediated common atrioventricular nodal reentrant tachycardia and a simple solution by reprogramming.

An 81-year-old woman who had undergone dual chamber pacemaker implantation for sick sinus syndrome was referred to our hospital with drug-refractory common atrioventricular (AV) nodal reentrant tachycardia. Ventricular pacing (Vp) following premature atrial contraction (PAC) with a long AV interval induced ventriculoatrial (VA) conduction, which allowed the tachycardia to be initiated. The sensed AV interval was shortened to 80 ms, allowing Vp during the refractory period of VA conduction. Postventricular atrial refractory period was shortened to 180 ms to sense PACs with short coupling interval. After reprogramming, the suppression of the tachycardia by blocking VA conduction following Vp was confirmed.

Complex renal artery aneurysm: successful exclusion with balloon-expandable covered stent.

We report an incidentally noted aneurysm in the left renal artery in a 60-year-old woman. Repair was recommended due to the size of the aneurysm and the patient's history of hypertension. The aneurysm was located in a bifurcation lesion, and angulation at the site was approximately 90 degrees. We were able to successfully exclude the aneurysm, however, with a balloon-expandable covered stent. This suggests that balloon-expandable covered stents offer excellent delivery and precise deployment, even in cases where complex anatomical issues are involved.

Renal dysfunction on admission as a predictor for in-hospital mortality of patients with stanford type B acute aortic dissection.

Stanford type A and open false lumen are accepted predictors for in-hospital mortality in patients with acute aortic dissection (AAD). However, the association of renal dysfunction on admission with in-hospital mortality is not well known. The aim of this study was to investigate the prognostic value of renal dysfunction in patients with AAD. A total of 250 patients with type B AAD admitted to our institution between January 2003 and August 2011 were enrolled in this study. In multivariate logistic regression analysis, the significant predictors of in-hospital mortality were age (odds ratio [OR] 1.575, 95% confidence interval [CI] 1.078-2.864, p = 0.024), maximum aortic diameter measured by an initial computed tomography (CT) (OR 1.740, 95% CI 1.029-2.940, p = 0.039), decreased enhancement of kidney (OR 7.716, 95% CI 2.335-25.501, p = 0.001) and estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m(2) on admission (OR 2.782, 95% CI 1.062-7.283, p = 0.037). In conclusions the results identified a renal dysfunction on admission as the independent predictor of in-hospital mortality in type B AAD. Further investigations are needed to evaluate therapies and strategies for decreasing the deterioration of renal function to improve in-hospital mortality in patients with AAD.

Percutaneous closure of post-infarction ventricular septal defect using an Amplatzer septal occluder.

A 77-year-old woman underwent percutaneous closure of post-infarction ventricular septal defect. The defect was successfully closed with a 20-mm Amplatzer septal occluder with a small residual shunt and Qp/Qs improved from 3.38 to 1.48. She was discharged 30 days after procedure. To our knowledge, this is the first case reported in Japan.

Occupational dose in interventional radiology procedures.

OBJECTIVE: Interventional radiology tends to involve long procedures (i.e., long fluoroscopic times). Therefore, radiation protection for interventional radiology staff is an important issue. This study describes the occupational radiation dose for interventional radiology staff, especially nurses, to clarify the present annual dose level for interventional radiology nurses. MATERIALS AND METHODS: We compared the annual occupational dose (effective dose and dose equivalent) among interventional radiology staff in a hospital where 6606 catheterization procedures are performed annually. The annual occupational doses of 18 physicians, seven nurses, and eight radiologic technologists were recorded using two monitoring badges, one worn over and one under their lead aprons. RESULTS: The annual mean ± SD effective dose (range) to the physicians, nurses, and radiologic technologists using two badges was 3.00 ± 1.50 (0.84-6.17), 1.34 ± 0.55 (0.70-2.20), and 0.60 ± 0.48 (0.02-1.43) mSv/y, respectively. Similarly, the annual mean ± SD dose equivalent range was 19.84 ± 12.45 (7.0-48.5), 4.73 ± 0.72 (3.9-6.2), and 1.30 ± 1.00 (0.2-2.7) mSv/y, respectively. The mean ± SD effective dose for the physicians was 1.02 ± 0.74 and 3.00 ± 1.50 mSv/y for the one- and two-badge methods, respectively (p < 0.001). Similarly, the mean ± SD effective dose for the nurses (p = 0.186) and radiologic technologists (p = 0.726) tended to be lower using the one-badge method. CONCLUSION: The annual occupational dose for interventional radiology staff was in the order physicians > nurses > radiologic technologists. The occupational dose determined using one badge under the apron was far lower than the dose obtained with two badges in both physicians and nonphysicians. To evaluate the occupational dose correctly, we recommend use of two monitoring badges to evaluate interventional radiology nurses as well as physicians.

Percutaneous focused force aortic valvuloplasty using the buddy-catheter technique.

Percutaneous transcatheter aortic valvuloplasty is seriously limited by high restenosis rates. We report a case where the use of a buddy-catheter technique during balloon inflation allowed increased focused force onto calcified stiff commissures with an increase in resultant valve area. This technique may result in further valve area enlargement and decrease the restenosis rate.

Interatrial mechanical dyssynchrony shown by tissue doppler imaging during atrial flutter.

Although regular supraventricular tachycardia is traditionally classified on the basis of P-wave morphology, diagnostic accuracy is limited to information obtained from surface electrocardiography. Intracardiac electrophysiology is a conclusive although invasive diagnostic method. We report a case of regular supraventricular tachycardia with a heart rate of 162 bpm. M-mode echocardiography of the interatrial septum clarified both the atrial rate and the ventricular response ratio. Tissue Doppler M-mode imaging demonstrated the delay between the posterior wall motion of the left and right atrium. Although it deserves further study, transthoracic echocardiography may provide useful information in addition to electrocardiography.

Long-term results of the S.M.A.R.T. Control(TM) stent for superficial femoral artery lesions, J-SMART registry.

BACKGROUND: The use of a stent in the treatment of lesions of the superficial femoral artery (SFA) remains controversial. Although some reports have suggested that use of a nitinol stent in conjunction with aggressive medical management is effective for long SFA lesions, few long-term, large-scale studies have been done. METHODS AND RESULTS: A retrospective analysis was conducted of data from a multicenter study in which the S.M.A.R.T. Control(TM) stent was used for treatment of de novo SFA lesions. A total of 528 lesions in 432 patients were included. Mean patient age was 72.5±9.1 years; mean stent length was 15.7±8.1cm; 259 lesions (49%) were classified as C/D according to the TransAtlantic Inter-Society Consensus (TASC) II classification. Primary and secondary patency at 4 years was 66% and 87%, respectively. No cilostazol administration (41% re-stenosis group vs. 29% no-restenosis group, P<0.01), female gender (42% vs. 26%, P<0.01), younger age (70.7±9.3 years vs. 72.9±9.0 years, P<0.05), and chronic total occlusion (CTO; 72% vs. 52%, P<0.01) were independent predictors of re-stenosis. CONCLUSIONS: The S.M.A.R.T. Control(TM) stent provided good long-term durability in the treatment of SFA lesions, and no cilostazol administration, female gender, younger age and CTO were associated with re-stenosis.

Incidence and outcome of surgical procedures after sirolimus-eluting stent implantation: a report from the j-Cypher registry.

The incidence of surgical procedures after sirolimus-eluting stent (SES) implantation and, more importantly, the rate of perioperative stent thrombosis (ST) and/or other adverse events have not yet been adequately addressed. The incidence and outcome of the surgical procedures after SES implantation were prospectively evaluated in a large-scale multicenter registry of patients undergoing SES implantation. Among 12,824 patients enrolled in the registry, cumulative incidences of surgical procedures were 0.7% at 60 days, 5.1% at 1 year and 14.7% at 3 years. Surgical procedures were performed in 1,430 patients including non-coronary artery bypass graft (CABG) surgery in 1,275 patients and CABG in 189 patients. The incidences of death/myocardial infarction/ST (definite or probable) and ST (definite or probable) at 30 days after surgical procedures were 2.7 and 0.35%, respectively. Surgery performed within 60 days after SES implantation as compared with that performed beyond 60 days was associated with significantly higher incidences of death/myocardial infarction/ST (definite or probable) and ST (definite or probable) at 30 days after surgical procedures (6.4 vs. 2.5%: P = 0.02 and 2.2 vs. 0.23%: P = 0.002, respectively). Surgery within 60 days as well as hemodialysis and small body mass index were independent risk factors of death/myocardial infarction/ST (definite or probable) identified by multivariable analysis. Surgical procedures were required fairly often after SES implantation. The incidences of adverse cardiac events including ST after surgical procedures were acceptably low. Surgery within 60 days after SES implantation carried significantly higher risks as compared with those beyond 60 days.