"Hands Off": Best Practice Radiation Safety is Rarely Achieved in Microcatheter Angiography.
TL;DR
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, suggesting that best practices in radiation safety are rarely achieved in MA.
Abstract
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.