Abstract
Objectives
To determine opinions and perceptions of interventional cardiologists on the topic of radiation and vascular access choice.
Background
Transradial approach for cardiac catheterization has been increasing in popularity worldwide. There is evidence that transradial access (TRA) may be associated with increasing radiation doses compared to transfemoral access (TFA).
Methods
We distributed a questionnaire to collect opinions of interventional cardiologists around the world.
Results
Interventional cardiologists (n = 5332) were contacted by email to complete an on-line survey from September to October 2013. The response rate was 20% (n = 1084). TRA was used in 54% of percutaneous coronary interventions (PCIs). Most TRAs (80%) were performed with right radial access (RRA). Interventionalists perceived that TRA was associated with higher radiation exposure compared to TFA and that RRA was associated with higher radiation exposure that left radial access (LRA). Older interventionalists were more likely to use radiation protection equipment and those who underwent radiation safety training gave more importance to ALARA (as low as reasonably achievable). Nearly half the respondents stated they would perform more TRA if the radiation exposure was similar to TFA. While interventionalists in the United States placed less importance to certain radiation protective equipment, European operators were more concerned with physician and patient radiation.
Conclusions
Interventionalists worldwide reported higher perceived radiation doses with TRA compared to TFA and RRA compared to LRA. Efforts should be directed toward encouraging consistent radiation safety training. Major investment and application of novel radiation protection tools and radiation dose reduction strategies should be pursued.
Highlights
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We examined radiation safety and arterial access practices among 1000 cardiologists.
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Radial access is perceived as having higher radiation dose compared to femoral access.
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Right radial access is performed more frequently than left radial access.
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US operators use less radiation protection that non-US operators.
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Only 2/3 of interventionalists are mandated to undergo radiation safety training.
1
Introduction
The balance between optimizing patient outcomes and reducing procedural complications remains a priority in interventional cardiology. Compared to transfemoral access (TFA) for coronary angiography and intervention, numerous studies have demonstrated reduction in vascular complications with transradial access (TRA), improvements in ambulation time, decreased cost and length of post-procedure hospital stay, and simplified same-day discharge . Nonetheless, despite these advantages of TRA, a concern remains about the association between transradial catheterization and increased radiation exposure to both the operator and the patient . Minimizing radiation exposure to both the patient and cardiac catheterization laboratory personnel represents a continued challenge associated with all invasive procedures. While the adoption of TRA approach varies, it has been slow in the United States , and large differences in TRA adoption and in clinical practice exist worldwide . Perceived increased radiation exposure associated with TRA access has been proposed as a barrier to more widespread adoption in United States. Therefore, we sought to investigate the attitudes and practices of interventional cardiologists around the world in regards to radiation safety. We specifically sought to determine which factors might contribute to the differences in adoption of TRA access, such as current radiation safety practices, including differences in attitudes and procedural practices between TRA versus TFA.
2
Methods
Respondents were interventional cardiologists from various institutions throughout the world. Specifically, surveys were sent to interventional cardiologists on all major continents with a total of 81 countries. A total of 5432 interventional cardiologists and fellows were invited to participate in the survey via emails acquired through the American College of Cardiology (ACC) website, The Society for Cardiovascular Angiography and Interventions (SCAI), Sociedad Latinoamericana de Cardiología Intervencionista (SOLACI), European Society of Cardiology (ESC) and searching various email contact addresses in cardiology journals. A comprehensive 38-question survey ( Appendix A ) was designed and distributed in a bulk email which contained a cover letter using Qualtrics ( www.qualtrics.com , Provo, UT), a professional survey design and distribution website. An initial survey request was sent to all interventional cardiologists followed by a second request two weeks later to those who had not responded to the initial request. Another two weeks later, a final request to complete the survey was sent to those who had not completed or started the survey. Participants were informed that the survey was anonymous and voluntary. No incentive was offered for participation and no penalty for nonparticipation. The surveys were completed between September 8th and October 9th 2013. Approval for the study was obtained from the Institutional Review Board at the University of Illinois at Chicago.
ALARA (acronym for “as low as is reasonably achievable”) was defined as making every reasonable effort to maintain exposures to radiation as far as practically possible.
2.1
Statistical analysis
Responses were automatically entered into a database and tabulated by Qualtrics as frequencies and used for descriptive statistics. Chi-square analyses and Fisher exact tests were used to perform group comparisons of categorical outcomes. T-tests were performed to compare continuous variables between groups. Linear regressions estimated with least square methods are performed to evaluate the relationships between various measures of the adoption of TRA and potential factors. All analyses were performed using SAS 9.2 (Cary, NC). A P value of less than 0.05 was considered significant for all tests.
2
Methods
Respondents were interventional cardiologists from various institutions throughout the world. Specifically, surveys were sent to interventional cardiologists on all major continents with a total of 81 countries. A total of 5432 interventional cardiologists and fellows were invited to participate in the survey via emails acquired through the American College of Cardiology (ACC) website, The Society for Cardiovascular Angiography and Interventions (SCAI), Sociedad Latinoamericana de Cardiología Intervencionista (SOLACI), European Society of Cardiology (ESC) and searching various email contact addresses in cardiology journals. A comprehensive 38-question survey ( Appendix A ) was designed and distributed in a bulk email which contained a cover letter using Qualtrics ( www.qualtrics.com , Provo, UT), a professional survey design and distribution website. An initial survey request was sent to all interventional cardiologists followed by a second request two weeks later to those who had not responded to the initial request. Another two weeks later, a final request to complete the survey was sent to those who had not completed or started the survey. Participants were informed that the survey was anonymous and voluntary. No incentive was offered for participation and no penalty for nonparticipation. The surveys were completed between September 8th and October 9th 2013. Approval for the study was obtained from the Institutional Review Board at the University of Illinois at Chicago.
ALARA (acronym for “as low as is reasonably achievable”) was defined as making every reasonable effort to maintain exposures to radiation as far as practically possible.
2.1
Statistical analysis
Responses were automatically entered into a database and tabulated by Qualtrics as frequencies and used for descriptive statistics. Chi-square analyses and Fisher exact tests were used to perform group comparisons of categorical outcomes. T-tests were performed to compare continuous variables between groups. Linear regressions estimated with least square methods are performed to evaluate the relationships between various measures of the adoption of TRA and potential factors. All analyses were performed using SAS 9.2 (Cary, NC). A P value of less than 0.05 was considered significant for all tests.
3
Results
Of the 5332 interventional cardiologists invited to participate, 1084 (20%) filled out the survey forms. 34 respondents were excluded from the study because they were not currently practicing interventional cardiologists.
3.1
Demographics
Of the 1084 respondents, almost 50% were from North America (including 44% from the United States), 22% from Asia, 8% from South America, and 18% from Europe. Within the United States, 26% were from the Northeast, 25% from the Southeast, 24% from the Midwest, 9% from the Southwest, and 15% from the West Coast ( Fig. 1 ). Respondents’ age groups are shown in Fig. 2 . Fig. 3 shows the hospital affiliation of the respondents who were evenly distributed between university-based hospitals (39%) and private practice (42%). A minority (19%) of the respondents had less than 5 years of interventional experience ( Fig. 4 ), and most were male (94%).
3.2
Individual and institutional practices
The mean number of diagnostic angiograms performed by our respondents annually was 393 ± 230. The mean number of percutaneous coronary interventions (PCIs) annually was 180 ± 110 ( Table 1 ). Institutional volumes of the respondents were 1227 diagnostic angiograms annually. Importantly, the mean percentage of PCIs performed using the radial approach was 54%, with right radial access being used approximately 80% of the time. 65% of the respondents were mandated to undergo radiation safety training, while 64% reported availability of radiation training at their institution.
| Variable | |
|---|---|
| Age, mean ± SD (years) | 48 ± 10.2 |
| Women (%) | 6 |
| Interventional Experience (years) | 14.52 ± 8.64 |
| Diagnostic cardiac catheterizations per year | 393.7 ± 230.84 |
| PCI per year | 180 ± 109.5 |
| Urban hospital location (vs. rural) (%) | 88% |
| PCI per institution | 1229 ± 1013.98 |
| Radial PCI Operator (%) | 53.8 ± 34.746 |
| Radial PCI Institution (%) | 45.1 % ± 31.72 |
| Right Radial (%) | 79.5 ± 28.3 |
| Cardiac Catheterization Laboratory Age (years) | 6 ± 3.95 |
3.3
Attitudes of all respondents
Respondents stated that compared to femoral access, radial access has substantially increased radiation exposure (6 on a scale of 1–10, with 10 being “significantly increased radiation dose”) and the distribution of responses appeared bimodal ( Fig. 5 ). When asked to quantify the increase associated with radial access, respondents stated that radial access had about a 31% increase in radiation exposure to the clinician and the patient compared with femoral access. Respondents also cared more about the increased radiation exposure to themselves (5.5 out of a 10 point scale with 10 being “utmost concern”) versus the patient (4.5 out of 10 on the same scale). Respondents who were overall less concerned about radiation exposure appeared to care more about the patient exposure while the respondents who were overall more concerned about increased radiation exposure were more concerned about the impact on themselves ( Fig. 6 ). Respondents believed that fluoroscopic time increases on average 23% during radial access compared to femoral during PCIs. Finally, when asked if they would perform more radial access procedures if the radiation exposure was similar or identical to that of femoral access, 47% of interventional cardiologists report that they would do more radial, 37% state that they would not do more radial, and 16% state that they did not know ( Tables 2 and 3 ).
| Variable | |
|---|---|
| Importance of ALARA (scale 1–10) | 4.1 ± 1.15 |
| Goggles Importance (scale 1–10) | 7.1 ± 3.2 |
| Thyroid Collar Importance (scale 1–10) | 9.13 ± 1.8 |
| Table Lead Apron Importance (scale 1–10) | 8.8 ± 2.1 |
| Moveable Lead Shield Importance (scale 1–10) | 8.5 ± 2.3 |
| Radiation Protection Drape Importance (scale 1–10) | 6 ± 3.3 |
| Radiation Protection Armboard Importance (scale 1–10) | 5.4 ± 3.3 |
| Dosimeter Importance (scale 1–10) | 8.2 ± 2.6 |
| Increasing Distance Importance (scale 1–10) | 8 ± 2.6 |
| Fluoroscopy-save Importance (scale 1–10) | 7.8 ± 2.59 |
| Radial Impact on Operator Exposure (scale 1–10) | 5.6 ± 2.6 |
| Radial Exposure Compared to Femoral Increase (%) | 30.9 ± 23.8 |
| Radial Exposure concern to self (scale 1–10) | 5.2 ± 3.3 |
| Radiation Exposure concern to the patient (scale 1–10) | 4.73 ± 3.1 |
| Fluoroscopy Rate (frames/s) | 12.9 ± 5.25 |
| Cine Rate (frames/s) | 15.62 ± 5.86 |
| Fluoroscopy Increase Radiation Diagnostic (%) | 22.6 ± 22.17 |
| Fluoroscopy Increase in PCI (%) | 22.9 ± 22.23 |
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