"Hands Off": Best Practice Radiation Safety is Rarely Achieved in Microcatheter Angiography.
OBJECTIVE Microcatheter angiography (MA) is often performed immediately following access of the common femoral artery using a 4 French micropuncture sheath directly attached to a 10 cubic centimeter (cc) syringe to evaluate the suitability of iliofemoral access. It can also be performed at the end of an operation to assess for access-related complications in procedures requiring large bore (≥12 French) percutaneous access. The operator's hands are particularly vulnerable in MA and we hypothesize that best practices in radiation safety are rarely achieved in MA. METHODS A retrospective review was performed of all patients who underwent elective percutaneous endovascular aneurysm repair (pEVAR) at a single institution from 2020-2023. Operative reports and digital subtraction angiography (DSA) were reviewed to determine the prevalence of "pre-large bore" and "post-large bore" MA. The primary end-point was the rate of direct operator exposure in MA. Secondary end-points included the rate of intra-operative access complications and radiation dose area product (DAP). RESULTS 144 patients underwent pEVAR with 282 percutaneous femoral access sites. Of the 282 percutaneous common femoral artery access sites, 9% (N = 25) underwent pre-large bore MA only, 24% (N = 67) underwent post-large bore MA only, and 56% (N = 159) underwent both pre-large bore and post-large bore MA for a total of 410 microcatheter angiograms. The overall rate of direct operator exposure was 56% (N = 231/410) for MA. Individual rates of operator exposure ranged from 51-71% and the three most prevalent performers accumulated cumulative DAP values of 342, 386 and 479 Gy ∙cm2 from MA alone during the study period. Operator exposure was not associated with laterality, C-arm angulation, sheath size, or BMI. There were only 10 intra-operative or peri-operative access complications (6.9% overall; 3.5% per access site) of which only four were specifically recognized by MA. CONCLUSION MA was routinely performed in elective pEVAR and best practices in radiation safety were rarely achieved with a high rate of direct operator exposure to the beam of radiation. The overall rate of access-related complications in elective pEVAR is low and the window for detecting access-related complications with MA is narrow. Because of the high rate of operator exposure, selective MA and the development of guidelines for best practice technique MA should be considered.