Impact of Operators' Height on Individual Radiation Exposure Measurements During Catheter-Based Cardiovascular Interventions.

AIM: This study is aimed to evaluate the impact of an operators' height on personal radiation exposure measurements during cardiovascular interventional procedures. Based upon both clinical data and phantom simulation, a new approach for monitoring an individual's exposure is proposed. METHODS: The clinical component of this study was composed of the operators and staff in a single center full service cardiovascular laboratory being divided into 2 groups based upon their height: group A included all individuals whose height was <165 cm; group B included the individuals >165 cm. All operators wore a standard TLD dosimeter at all times with doses recorded for 12 months. To support these clinical findings, a second investigation was performed utilizing a phantom. Measurements were obtained at 100 and 135 cm from the radiation source during simulation of different cardiovascular interventional procedures. RESULTS: The radiation dose measured from the personal dosimeters identified that Group A, operators <165 cm, had significantly higher doses than those recorded in Group B, operators >165 cm, when compared among individuals performing similar tasks (physicians, technicians, and nurses): 4.55 ± 4.0 (Group A) versus 1.95 ± 1.0 (Group B) mSv (P < 0.01). During procedure simulation with the phantom, the doses measured were similarly significantly higher if measured at 100 cm than at 135 cm from the radiation source. CONCLUSION: This study suggests that the height from radiation source does impact the measured dose from an operator worn personal TLD. This was operator specific, consistent thought-out multiple procedures, and confined with phantom measurements.

A clinical-angiographic risk scoring system for coronary artery anomalies.

Congenital coronary anomalies remain a debated issue. On the basis of a critical review of the literature and our historical series, we propose a simple clinical profile scoring system for congenital coronary anomalies. A review of literature over the past 30 years was performed, searching for a relationship between the worst coronary anomaly presentation and manifestations and the anatomical and functional features. A risk scoring system was created based on these features, and retrospectively applied to our historical series of 140 consecutive patients (52 females; mean age, 60.1±19.3 years; mean follow-up, 60±23 months). Origin from the pulmonary artery, intramural course, intramyocardial course, coronary fistula with a significant pulmonary-to-systemic flow ratio, superimposed coronary artery disease, and associated congenital heart disease were associated with the worst clinical presentation. The risk scoring system gave 2 points to anatomical features and 1 point to the association with clinical and functional characteristics: 3 risk classes were identified: >3, 2-3, and <2 points. The system showed good correlation with presentation and manifestations on follow-up. Although not exhaustive, the proposed scoring system may simplify the clinical evaluation of patients with such abnormalities, being a model for decision making.

New subclavian artery angioplasty technique for treating subclavian coronary steal syndrome.

Left subclavian artery stenting is usually performed through the standard femoral route using a guiding catheter technique. This technique has obvious drawbacks in the case of coronary subclavian steal due to the poor opacification of the left internal mammary artery (LIMA) ostium, and difficult access to the LIMA in the case of plaque shifting, especially when the vertebral artery and the LIMA ostia are very close to the left subclavian artery stenosis. We have developed an "ad hoc" technique to minimize catheter manipulation and contrast injection, and to optimize LIMA and vertebral artery visibility during stent implantation, which includes access through the brachial artery and a long sheath guiding catheter. This technique should be preferred to the standard femoral route because of its intrinsic advantages.

Impact of intracardiac echocardiography on radiation exposure during adult congenital heart disease catheter-based interventions.

BACKGROUND: Intracardiac echocardiography (ICE) is a widespread approach in many cardiovascular procedures in which it has the potential to reduce the fluoroscopy time and patients radiation exposure. We sought to assess the patient radiation exposure during transcatheter closure of interatrial communications with and without ICE-guidance. METHODS: In a prospective consecutive series of 25 consecutive patients who underwent transcatheter closure of interatrial communications between May and October 2005 with (15 patients) and without (10 patients) ICE-guidance in a single secondary care referral centre, we measured the dose-area product (DAP), the fluoroscopy dose-area product (FDAP), the total dose-area product (TDAP), and the mean procedural time. RESULTS: In patients underwent ICE-guided transcatheter closure procedure the mean fluoroscopy time, the mean DAP, mean FDAP, and mean TDAP resulted significantly lower than in control patients: 2.0 +/- 0.21 (range 1.6-2.2) versus 5.05 +/- 0.54 (range 4.2-5.8) minutes (P < 0.001) , 13.72 +/- 9.03 (range 11.36-14.63) versus 21.95 +/- 6.93 (range 20.90-23.93) Gycm2 (P < 0.001), 8.25 +/- 1.22 (range 6.60-9.50) versus 20.15 +/- 8.83 (range 18.90-20.93) Gycm2 (P < 0.001), and 29.33 +/- 1.51(range 27.16-31.00) versus 32.61 +/- 2.53 (range 29.20-35.55) Gycm2 (P < 0.01). On the contrary, the mean procedural time, was significantly higher in ICE-guided transcatheter closure patients: 30.2 +/- 2.45 (range 23-40) versus 24.5 +/- 2.45 (range 24-31) minutes (P = 0.03). CONCLUSION: The radiation exposure during ICE-guided transcatheter closure of interatrial communications in this group of patients was quite lower than that reported in literature for such procedures and compared favourably with radiation exposure of patients in whom the intervention was performed without ICE guidance.

Subclavian artery angioplasty in elderly patients with coronary-subclavian steal syndrome: preliminary comparison between a modified brachial technique and the standard femoral approach / 老年心脏病学杂志（英文版）

Background and Objective Elderly patients who have been submitted to coronary bypass grafting with the left internal mammary artery (LIMA) may develop a coronary-subclavian steal syndrome because of a left subclavian artery (LSA) stenosis. Usually stenting of LSA is performed by the standard femoral route with guiding catheter technique, but this technique can be particularly difficult in elderly patients who often have iliac-femoral kinking and aortic tortuosity. We compared a new ad hoc brachial artery approach technique with the standard guiding catheter technique through the femoral access. Methods Between January 2005 and September 2006, four patients underwent LSA stenting using the left brachial artery access obtained with a 6F or 7F 45-cm-long valved anti-kinking sheath as the Super Arrow Flex sheath (Arrow International, PA, USA). The sheath was positioned just before the LIMA graft ostium and a 0.035 inch 260-cm-long Storq guidewire (Cordis Inc., Johnson & Johnson, Warren, NJ) was advanced across the lesion to the descending aorta. A balloon-expandable Genesis (Cordis Inc., Johnson & Johnson, Warren, NJ) endovascular stent was easily deployed, and the correct position was checked by direct contrast injection through the long sheath. This small group of patients has been compared to a group of 5 age-matched patients with coronary steal syndrome in whom the procedure has been performed with standard technique including femoral approach and guide catheter. Results The procedure was successful in all patients; vertebral and LIMA ostia remained patent in all cases. In the control group, cannulation of the subclavian artery was difficult in two cases, while one patient developed a groin hematoma. Mean pretreatment gradient was 32 mm Hg with a range of 25 to 40 mm Hg (34 mmHg, range 26-43, in the control group, P=0.87) and fell to 2 mm Hg with a range of 0 to 4 mm Hg (3.1 mmHg, range 0 to 5, P=0.89) posttreatment. Mean contrast dose was 60±16 ml (138±26 ml in the control group, P＞0.01), whereas mean fluoroscopy and procedural time were 5.7±1.6 minutes (10.8±1.0 minutes in the control group, P＞0.01) and 15.7±6.3 minutes (28±7.1 minutes in the control group, P＞0.01). At a mean follow-up of 10±3.2 months all patients are alive and free from angina and residual induced ischemia. Conclusions Our brief study suggested that brachial artery access be considered the optimal route to treat coronary-subclavian steal syndrome in elderly patients because of clear advantages; these included no manipulation of catheter to cannulate the artery, perfect coaxial position of the catheter at the site of LSA stenosis, clear visualization of the LIMA and vertebral ostia, and easy access to these vessels in case of plaque shifting or embolic protection device deployment.

An improved technique for gaining radial artery access in endovascular interventions.

We present a simple technique to avoid time loss and potential dangerous maneuvers for catheterization of the radial artery in endovascular interventions. If any difficulties are encountered when advancing the guide wire after the arterial puncture using standard transradial kits, we found it useful to routinely use a 60-mm polyethylene radial pressure line catheter like the Leader Cath (Vygon, Ecquen, France), which is more flexible and less traumatic than short catheters and are usually available in the standard hydrophilic transradial kit. With the 20-gauge needle within the arterial lumen, it is sufficient to advance the guide wire 3 or 4 cm, followed by the insertion of the radial pressure line catheter for administering a vasodilator cocktail. The contrast injection through the catheter is safer than through the needle, and visualization of the underling problems may avoid any time loss and complications. The standard sheath insertion is facilitated by the pressure line catheter that acts as a dilator. This technique, especially when performing coronary or peripheral interventions in which large introducers are needed, may avoid potentially dangerous vascular complications and improve the success rate.

Evidence against the widespread use of angiography of noncoronary arteries during coronary artery angiography and cardiac catheterization.

PURPOSE: Although the most widely used screening techniques for extracardiac atherosclerotic distributions are noninvasive, in patients undergoing coronary arteriography, the question as to whether angiography of extracardiac arteries at the time of cardiac catheterization is really effective or if it should be considered malpractice is still open. We sought to determine the safety and real usefulness of angiography of extracardiac arteries performed by trained invasive cardiologists during cardiac catheterization. METHODS: Medical records of all patients undergoing combined coronary and noncoronary angiography between May 1998 and December 2002 were retrospectively reviewed. Moderate to severe arterial stenosis (>50% stenosis), vessel occlusion, aneurysmal, or severe ectasia were noted as significant angiographic findings. RESULTS: Two hundred and seventy patients (165 males, mean age = 67.7+/-9.2 years, mean serum creatinine = 1.1+/-0.8 mg/dl) underwent combined cardiac catheterization and angiography of extracardiac arteries following specific indications. Significant findings were reported in 66 (24.4%) patients. Logistic regression analyses revealed three-vessel coronary artery disease [CAD; odds ratio (OR)=9.917; 95% confidence interval (CI) = 2.2 to 43.8; P = .002) and hypercholesterolemia (OR = 2.851; 95% CI=1.03 to 7.9; P = .044) to be independent predictors of extracardiac atherosclerotic involvement. Complications rate was negligible. The detection of significant angiographic findings led to endovascular treatment in 37.8% and surgical vascular repair in 33.3% of cases. CONCLUSIONS: Angiography of extracardiac arteries at the time of coronary angiography appears justified only in patients with specific indications, multivessel CAD, and hypercholesterolemia.

Concomitant peripheral vascular and coronary artery disease: a new dimension for the global endovascular specialist?

BACKGROUND: Early and accurate diagnosis of peripheral atherosclerosis is of paramount importance for global ma agement of patients with known coronary artery disease (CAD). HYPOTHESIS: We sought to evaluate retrospectively the prevalence and clinical relevance of significant abdominal vessel stenosis or aneurysm (AVA) in patients undergoing coronary angiography. METHODS: Medical records of consecutive patients who underwent coronary angiography at two public institutions over a 12-month period were evaluated. Angiographic results of patients who underwent diagnostic abdominal aorta angiography, based on clinical criteria, to evaluate abdominal vessels the same time as coronary angiography were analyzed. RESULTS: During the study period, AVA was reported in 180 (35.7%) of 504 consecutive patients (335 men, mean age 68 +/- 13.8 years): renal artery stenosis was found in 13.1% of cases (66 patients), aortoiliac artery disease in 13.7% (69 patients and aortic aneurysmal disease in 8.9% (45 patients). Logistic regression analyses revealed > or = 3-vessel CAD (odds ratio [OR] 9.917, p = 0.002), age >65 years (OR 3.817, p = 0.036), > or =3 risk factors (OR 2.8, p = 0.048) as independent predictors of AVA. CONCLUSION: Multiple vascular atherosclerotic distributions are frequent in elderly patients who have multivessel CAD and a high-risk profile, suggesting the usefulness of a more global and comprehensive cardiovascular approach.

Angiographic characteristics of renal arterial disease over the spectrum of coronary artery disease.

BACKGROUND/AIM: The angiographic characteristics of renal artery stenoses (RAS) in patients with coronary artery disease (CAD) have not been yet fully investigated. We sought to evaluate the angiographic characteristics of RAS in patients with CAD. METHODS: The medical records of consecutive patients who underwent coronary angiography in a single public institution over a 12-month period were evaluated. The patients who underwent coincident diagnostic renal angiography to evaluate renal vessels on the basis of clinical criteria and who had at least one-vessel CAD were analyzed. Moderate (50-70%) to severe (70-100%) arterial stenoses were noted as significant angiographic findings. The types of stenosis (ostial, true renal, mixed) and presence and location of calcium were recorded. RESULTS: Angiographically significant RAS were reported in 40 (19.5%) of 205 consecutive patients (mean age 67.1 +/- 12.8 years, mean serum creatinine concentration 2.1 +/- 0.5 mg/dl, mean glomerular filtration rate 52 +/- 13 ml/min) for a total of 55 lesions. The RAS severity was moderate in 30.9% (17/55), severe in 69.1% (38/55), ostial in 27.2% (15/55), true renal in 10.9% (6/55), and mixed in 61.8% (34/55) of the patients. The mean lesion length was 16 +/- 1.8 mm. Patients with > or = 3-vessel CAD had a statistically significantly higher prevalence of mixed calcified RAS (18/24, 75%). Logistic regression analyses revealed > or = 3-vessel CAD (odds ratio 9.917, p = 0.002), age > 65 years (odds ratio 3.817, p = 0.036), and > or = 3 risk factors (odds ratio 2.8, p = 0.048) as independent predictors of RAS. CONCLUSION: RAS in multivessel CAD patients seems to have a peculiar angiographic pattern, such as a higher prevalence of mixed calcified lesions and poststenotic enlargement, that should be taken in account when dealing with RAS.