The frequency of encountering radiodermatitis caused by X-ray fluoroscopic procedures for ischaemic heart disease is increasing. In severe cases, devastating ulcers with pain, for which conservative therapy is ineffective, emerge. Radiation-induced ulcers are notorious for being difficult to treat. Simple skin grafting often fails because of the poor state of the wound bed. A vascularized flap is a very good option. However, the non-adherence of the well-vascularized flap with the irradiated wound bed is frequently experienced.
To ameliorate the irradiated wound bed, bone marrow-derived platelet-rich plasma (bm-PRP) was delivered during the surgery.
Materials and Methods:
Four patients with severe cutaneous radiation injury accompanied by unbearable pain after multiple fluoroscopic procedures for ischaemic heart disease were treated. Wide excision of the lesion and coverage with a skin flap supplemented with bm-PRP injection was performed.
All patients obtained wound closure and were relieved from pain. No complication concerning the bone marrow aspiration and delivery of bm-PRP was observed.
Supplementation of bm-PRP can be an option without major complications, time, and cost to improve the surgical outcome for irradiated wounds.
Bone marrow; cardiac fluoroscopy; platelet-rich plasma; radiation ulcer; skin flap
This case report describes a routine diagnostic left heart catheterisation (coronary angiography, aortography and left ventriculography) procedure at Sultan Qaboos University Hospital, Oman, which was complicated by the development of new asymptomatic, but permanent, left bundle branch block that was observed incidentally towards the end of the procedure. The patient was completely asymptomatic and haemodynamically stable throughout the procedure and afterwards. Urgent investigations, immediately after the procedure, including routine blood, serial cardiac troponin I, serial electrocardiograms, chest X-ray, and urgent echocardiography were normal and failed to show any possible causation of the LBBB. The results of left heart catheterisation showed two vessel coronary artery disease and severe mitral valve regurgitation. After eight days, the patient went on to have coronary artery bypass surgery and mitral valve replacement surgery both of which were successful. To the best of our knowledge, this is the first case report to describe the occurrence of permanent LBBB after left heart catheterisation. This report describes the case and reviews the literature for the incidence and implications of such a complication.
LBBB; Left bundle branch block; Coronary angiography; aortography; Left ventriculography; Left heart catheterisation; Diagnostic heart catheterisation; Case Report; Oman
Balloon atrial septostomy was undertaken under cross sectional echocardiographic control in 63 consecutive infants: in no case was fluoroscopic imaging required. The procedure was performed in the cardiac catheterisation laboratory, ward side room, or at the bedside in the neonatal intensive care unit. Catheterisation via the umbilical vein was attempted in 37 infants aged less than 48 hours old and was successful in 27. No complication was clearly attributable to the procedure though two infants died. A nine day old child died from disseminated intravascular coagulation the day after septostomy by the iliofemoral route and another, aged nine days, died of necrotising enterocolitis which had developed when he was eight days old, after umbilical catheterisation at eight hours. Balloon atrial septostomy is a safe and easy procedure under cross sectional echocardiographic imaging control. Catheterisation via the umbilical vein was safe, easy to perform, and is appropriate in infants aged less than 48 hours.
Percutaneous vertebroplasty (PV) requires relatively lengthy fluoroscopic guidance, which might lead to substantial radiation exposure to patients or operators. The two-fluoroscopic technique (two-plane radiographs obtained using two fluoroscopes) during PV can provide simultaneous two-planar projections with reducing operative time. However, the two-fluoroscopic technique may expose the operator or patient to increased radiation dose. The aim of this study was to quantify the amount of radiation exposure to the patient or operator that occurs during PV using one- vs. two-fluoroscopic technique.
Two radiation dosimeters were placed on the right flank of each patient and on the upper sternum of each operator during 26 single-level PV procedures by one senior surgeon. The use of two-fluoroscopic technique (13 patients) and one-fluoroscopic technique (13 patients) were allocated in a consecutive and alternative manner. The operative time and mean radiation dose to each patient and operator were monitored and compared between groups.
Mean radiation dose to the patient was 1.97 ± 1.20 mSv (95% CI, 0.71 to 3.23) for the one-fluoroscopic technique group vs. 0.95 ± 0.34 mSv (95% CI, 0.85 to 1.23) for the two-fluoroscopic technique group (P =0.031). Mean radiation dose to the operator was 0.27 ± 0.12 mSv (95% CI, 0.17–0.56) for the one-fluoroscopic technique group vs. 0.25 ± 0.14 mSv (95% CI, 0.06–0.44) for the two-fluoroscopic technique group (P = 0.653). The operative time was significantly different between groups: 47.15 ± 13.48 min (range, 20–75) for the one-fluoroscopic technique group vs. 36.62 ± 8.42 min (range, 21–50) for the two-fluoroscopic technique group (P =0.019).
Compared to the one-fluoroscopic technique, the two-fluoroscopic technique used during PV provides not only shorter operative times but also reduces the radiation exposure to the patient. There was no significant difference between the two techniques with regards to radiation exposure to the operator.
Vertebral compression fracture; Osteoporosis; Vertebroplasty; Radiation dose
LABELED BACKGROUND: Radiotherapy may cause common cutaneous side effects such as acute and chronic radiodermatitis and also rare skin conditions. CASE REPORT: A 42-year-old woman who received radiotherapy for invasive breast carcinoma developed multiple, scaly, rough papules and nodules restricted to treatment fields six months after completion of the treatment. A relapse of the breast cancer and/or seborrheic keratosis was ruled out by histological confirmation of verruca vulgaris. CONCLUSION: We report the first case of verruca vulgaris associated with radiation treatment. Radiotherapists and dermatologists should be aware of this possibility and be able to differentiate it from other skin lesions associated with irradiation.
Recent improvements in x-ray technology have greatly contributed to the advancement of diagnostic imaging. Fluoroscopically guided neurointerventional procedures with digital subtraction angiography (DSΛ) are being performed with increasing frequency as the treatment of choice for a variety of neurovascular diseases. Radiation-induced skin injuries can occur after extended fluoroscopic exposure times, and the injuries have recently been reported. In this article, measured radiation doses at the surface of Rando Phantom with Skin Dose Monitor, and estimated and measured entrance skin doses in patients underwent neurointerventional procedures are reported as well as means of reducing radiation doses absorbed by patients and personnel to avoid occurrence of radiation-induced injuries.
fluoroscopically guided interventional procedure, digital subtraction angiography, radiation protection
Radiodermatitis is a known complication in patients having undergone radiotherapy. It usually appears 2 to 5 years after irradiation. We are reporting on a case of radiodermatitis that occurred within months after coronary dilatation and stenting. It started with painful swelling, followed by a typical appearance on the skin surface. Histological finding confirmed the diagnosis. However, magnetic resonance imaging showed changes in the subcutaneous tissue extending into the ribs. A radical debridement was performed including removal of a partially necrotic 4th rib. The defect was closed with a latissimus dorsi transposition flap. Our findings are compared with the literature reports.
X-ray fluoroscopy is widely used for image guidance during cardiac intervention. However, radiation dose in these procedures can be high, and this is a significant concern, particularly in pediatric applications. Pediatrics procedures are in general much more complex than those performed on adults and thus are on average four to eight times longer1. Furthermore, children can undergo up to 10 fluoroscopic procedures by the age of 10, and have been shown to have a three-fold higher risk of developing fatal cancer throughout their life than the general population2,3.
We have shown that radiation dose can be significantly reduced in adult cardiac procedures by using our scanning beam digital x-ray (SBDX) system4-- a fluoroscopic imaging system that employs an inverse imaging geometry5,6 (Figure 1, Movie 1 and Figure 2). Instead of a single focal spot and an extended detector as used in conventional systems, our approach utilizes an extended X-ray source with multiple focal spots focused on a small detector. Our X-ray source consists of a scanning electron beam sequentially illuminating up to 9,000 focal spot positions. Each focal spot projects a small portion of the imaging volume onto the detector. In contrast to a conventional system where the final image is directly projected onto the detector, the SBDX uses a dedicated algorithm to reconstruct the final image from the 9,000 detector images.
For pediatric applications, dose savings with the SBDX system are expected to be smaller than in adult procedures. However, the SBDX system allows for additional dose savings by implementing an electronic adaptive exposure technique. Key to this method is the multi-beam scanning technique of the SBDX system: rather than exposing every part of the image with the same radiation dose, we can dynamically vary the exposure depending on the opacity of the region exposed. Therefore, we can significantly reduce exposure in radiolucent areas and maintain exposure in more opaque regions. In our current implementation, the adaptive exposure requires user interaction (Figure 3). However, in the future, the adaptive exposure will be real time and fully automatic.
We have performed experiments with an anthropomorphic phantom and compared measured radiation dose with and without adaptive exposure using a dose area product (DAP) meter. In the experiment presented here, we find a dose reduction of 30%.
Radiation injury in the skin causes radiodermatitis, a condition in which the skin becomes inflamed and the epidermis can break down. This condition causes significant morbidity and if severe it can be an independent factor that contributes to radiation mortality. Radiodermatitis is seen in some settings of radiotherapy for cancer and is also of concern as a complication post-radiation exposure from accidents or weapons, such as a “dirty bomb”. The pathogenesis of this condition is incompletely understood. Here we have developed a murine model of radiodermatitis wherein the skin is selectively injured by irradiation with high-energy electrons. Using this model we showed that the interleukin-1 (IL-1) pathway plays a significant role in the development of radiodermatitis. Mice that lack either IL-1 or the IL-1 receptor developed less inflammation and less severe pathological changes in their skin, especially at later time-points. These findings suggest that IL-1 pathway may be a potential therapeutic target for reducing the severity of radiodermatitis.
OBJECTIVE: To establish the feasibility and safety of an appropriately trained clinical nurse specialist performing diagnostic cardiac catheterisation. DESIGN: Non-randomised retrospective comparison between the first 100 and second 100 consecutive investigations by a clinical nurse specialist and 200 consecutive patients investigated by two cardiology registrars over a similar period. SETTING: Regional cardiac centre performing 3200 catheterisation procedures per annum. PATIENTS: 200 patients undergoing routine (non-emergency) cardiac catheterisation for investigation of ischaemic heart disease. MAIN OUTCOME MEASURES: Procedural complications, image quality, fluoroscopy times. RESULTS: Satisfactory diagnostic images in all nurse specialist cases with no deaths and two complications (coronary artery dissection and femoral pseudoaneurysm). Procedure duration and fluoroscopy times slightly shorter for clinical nurse specialist by 3 and 1.6 minutes, respectively (P < 0.05). CONCLUSIONS: Non-medical practitioners can be trained to perform straightforward cardiac angiography in low risk patients with consultant supervision, as for cardiology registrars. With important restrictions such posts may have a limited role in supporting future consultant based services.
Minimally invasive spine surgery requires placement of the skin incision at an ideal location in the patient's back by the surgeon. However, numerous fluoroscopic x-ray images are sometimes required to find the site of entry, thereby exposing patients and Operating Room personnel to additional radiation. To minimize this exposure, a radiopaque localizer grid was devised to increase planning efficiency and reduce radiation exposure.
The radiopaque localizer grid was utilized to plan the point of entry for minimally invasive spine surgery. Use of the grid allowed the surgeon to accurately pinpoint the ideal entry point for the procedure with just one or two fluoroscopic X-ray images.
The reusable localizer grid is a simple and practical device that may be utilized to more efficiently plan an entry site on the skin, thus reducing radiation exposure. This device or a modified version may be utilized for any procedure involving the spine.
Radiation; Exposure; Minimally Invasive; Spine Surgery; Localization; Innovation; Grid
The aim of this study was to retrospectively evaluate the technical success rates and clinical effectiveness of fluoroscopically guided nose tube drainage of mediastinal abscesses and a nasojejunum feeding tube in post-operative gastro-oesophageal anastomotic leakage (GEAL).
From January 2006 to June 2011, 18 cases of post-operative GEAL with mediastinal abscesses after oesophagectomy with intrathoracic oesophagogastric anastomotic procedures for oesophageal and cardiac carcinoma were treated by insertion of a nose drainage tube and nasojejunum feeding tube under fluoroscopic guidance. We evaluated the feasibility of two-tube insertion to facilitate leakage site closure and complete resolution of the abscess, and the patients’ nutritional benefit was also evaluated by checking the serum albumin level between pre- and post-enteral feeding via the feeding tube.
The two tubes were placed successfully under fluoroscopic guidance in 18 patients (100%). The procedure time for two-tube insertion ranged from 20 to 40 min (mean 30 min). 17 patients (94%) achieved leakage site closure after two-tube insertion and had a good tolerance of two tubes in the nasal cavity. The serum albumin level was significant, increased from pre-enteral feeding (2.49±0.42 g dl−1) to the post-enteral feeding (3.58±0.47 g dl−1) via the feeding tube (p<0.001). The duration of follow-up ranged from 1 to 49 months (mean 19 months).
The insertion of nose tube drainage and a nasojejunum feeding tube under fluoroscopic guidance is safe, and it provides effective relief from mediastinal abscesses in GEAL after oesophagectomy. Moreover, our findings indicate that two-tube insertion may be used as a selective procedure to treat mediastinal abscesses in post-operative GEAL.
Advances in knowledge
Directive drainage of mediastinal abscesses in post-operative GEAL may be an effective treatment.
This is an observational study and the aim is to evaluate the effect of dietary supplements based on Resveratrol, Lycopene, Vitamin C and Anthocyanins (Ixor®) in reducing skin toxicity due to external beam radiotherapy in patients affected by breast cancer.
Materials and methods
71 patients were enrolled and they were divided in two different groups: a control group (CG) of 41 patients treated with prophylactic topical therapy based on hyaluronic acid and topical steroid therapy in case of occurrence of radiodermatitis, and a Ixor-Group (IG) of 30 patients treated also with an oral therapy based on Resveratrol, Lycopene, Vitamin C and Anthocyanin (Ixor®) at a dose of 2 tablets/day, starting from 10 days before the radiation treatment until 10 days after the end of treatment. Skin toxicity has been related to PTV, to breast volume that received a radiation dose equal or lower than 107%, included between 107% and 110%, or greater than 110% of the prescribed dose. Moreover it's been studied the relationship between skin toxicity and the chemotherapy schedule used before treatment. We calculated in both groups the percentage of patients who had a skin toxicity of grade 2 or 3 (according to RTOG scale). Absolute risk reduction (ARR), relative risk (RR) and odds ratio (OR) have been calculated for each relationship.
Control Group (CG) patients with a PTV > 500 ml presented skin toxicity G2 + G3 in 30% of cases, versus 25% of Ixor-Group (IG) [OR 0.77]. In patients with a PTV < 500 ml G2 + G3 toxicity was 0% in the IG compared to 18% in CG (OR 0.23). When Dmax was less than or equal to 107% of the prescribed dose skin toxicity was G2 + G3 in 12.5% in CG, versus 0% in IG (OR 0.73), instead when Dmax was included between 107 and 110% of the prescribed dose, G2 + G3 skin toxicity was 35% in CG and 21% in IG (OR 0.50). In patients undergoing chemotherapy with anthracyclines and taxanes, G2 + G3 toxicity was 27% in CG, against 20% in IG (OR 0.68).
The protective effect of Resveratrol, Lycopene, Vitamin C and Anthocyanin (Ixor®) is more detected in patients with PTV < 500 ml, when Dmax reaches values lower or equal to 107%, but not exceeding 110% of the prescribed dose, and in patients undergoing adjuvant chemotherapy with anthracyclines and taxanes.
Radiotherapy; Breast; Toxicity; Skin
A tracking system has been developed to provide real-time feedback of skin dose and dose rate during interventional fluoroscopic procedures. The dose tracking system (DTS) calculates the radiation dose rate to the patient’s skin using the exposure technique parameters and exposure geometry obtained from the x-ray imaging system digital network (Toshiba Infinix) and presents the cumulative results in a color mapping on a 3D graphic of the patient. We performed a number of tests to verify the accuracy of the dose representation of this system. These tests included comparison of system–calculated dose-rate values with ionization-chamber (6 cc PTW) measured values with change in kVp, beam filter, field size, source-to-skin distance and beam angulation. To simulate a cardiac catheterization procedure, the ionization chamber was also placed at various positions on an Alderson Rando torso phantom and the dose agreement compared for a range of projection angles with the heart at isocenter. To assess the accuracy of the dose distribution representation, Gafchromic film (XR-RV3, ISP) was exposed with the beam at different locations. The DTS and film distributions were compared and excellent visual agreement was obtained within the cm-sized surface elements used for the patient graphic. The dose (rate) values agreed within about 10% for the range of variables tested. Correction factors could be applied to obtain even closer agreement since the variable values are known in real-time. The DTS provides skin-dose values and dose mapping with sufficient accuracy for use in monitoring diagnostic and interventional x-ray procedures.
skin dose; dosimetry; radiation safety; cardiac fluoroscopic procedures; fluoroscopic dose; dose tracking; real-time dosimetry; fluoroscopic interventional procedures
OBJECTIVES--To evaluate the frequency and nature of complications in patients undergoing diagnostic cardiac catheterisation and to assess the feasibility of a voluntary cooperative audit system. METHODS--27 centres enrolled patients over a two year period. Each centre voluntarily reported numbers of patients catheterised every month. Complications were reported as they occurred. Feedback was provided in the form of newsletters and reports. RESULTS--39,795 procedures were registered, of which 33,776 were diagnostic catheterisations in adults or adolescents, 1265 were paediatric catheter studies in patients under the age of 12 years, and 4754 were coronary angioplasties or balloon dilatation of valves. 83.3% of diagnostic catheter studies in adults were left heart studies with coronary arteriography. The overall complication rate for diagnostic studies was 0.80%, mortality rate 0.12%, emergency surgical intervention rate 0.08%. Complication rates varied between centres, but there was no correlation with case load. Different patterns of complication were associated with different technical approaches. CONCLUSIONS--Complication rates of diagnostic catheterisation are low but neither negligible nor irreducible. Voluntary audit of this kind has limitations, but it is useful and inexpensive.
During the last 15 years, developments in X-ray technologies have substantially improved the ability of practitioners to treat patients using fluoroscopically guided interventional techniques. Many of these procedures require a greater use of fluoroscopy and more recording of images. This increases the potential for radiation-induced dermatitis and epilation, as well as severe radiation-induced burns to patients. Many fluoroscope operators are untrained in radiation management and do not realize that these procedures increase the risk of radiation injury and radiation-induced cancer in personnel as well as patients. The hands of long-time fluoroscope operators in some cases exhibit radiation damage—especially when sound radiation protection practices have not been followed. In response, the Center for Devices and Radiological Health of the United States Food and Drug Administration has issued an Advisory calling for proper training of operators. Hospitals and administrators need to support and enforce the need for this training by requiring documentation of credentials in radiation management as a prerequisite for obtaining fluoroscopy privileges. A concerted effort on the part of professional medical organizations and regulatory agencies will be required to train fluoroscopy users to prevent physicians from unwittingly imparting serious radiation injuries to their patients.
Credentialing fluoroscopist; Fluoroscopist radiation dose
Cholesterol crystal embolisation is a frequently underdiagnosed condition. While coronary catheterisation is safe and commonly performed, the reported patient developed very painful trash feet after undergoing this routine procedure. Ulceration and gangrene occurred after catheter manipulation during cardiac angiography, which caused occlusion of the small arteries in his feet. The triad of pain, livedo reticularis, and intact peripheral pulses is pathognomonic for cholesterol embolisation. The prognosis depends on the extent of the systemic disease and a high rate of mortality (75–80%) is observed. Prognosis is poor and the treatment is only supportive. It is suggested that while cardiac catheterisation is largely safe and a very commonly performed procedure, it can still lead to complications with serious side effects and can even prove fatal.
cholesterol crystal embolisation; coronary angiography; gangrene
OBJECTIVE—To assess the feasibility, safety, and clinical impact of diagnostic cardiac catheterisation in a multipurpose laboratory in a district general hospital without cardiac surgery.
METHODS—A prospective audit of the first 2000 consecutive cases between September 1992 and March 1997. Unstable patients were referred to a surgical centre for investigation, in line with subsequently published British Cardiac Society (BCS) guidelines, but all other patients requiring cardiac catheterisation were investigated locally and are included in this report. The function of the laboratory was also compatible with the BCS guidelines regarding staffing, operators, equipment, number of cases, and locally available vascular surgery.
RESULTS—Of the 2000 cases, 1988 studies were completed (99%), 1985 (99%) included coronary angiography, and 1798 (90%) were performed as day cases. Left main stem disease was present in 157 (8%), three vessel disease in 683 (34%), two vessel disease in 387 (19%), single vessel disease in 424 (21%), and normal coronary arteries in 494 (25%). Of the latter, 284 (14% of the total) had another cardiac diagnosis for which they were investigated (for example, valvar heart disease). Referral for cardiac intervention following catheterisation was made in 1172 of the 2000 cases (intervention rate 59%; catheter:intervention ratio 1.7:1). The interventions performed were coronary artery bypass grafting (CABG) in 736 of the 1172 cases (63%), other types of cardiac surgery in 122 (10%), combined CABG and other cardiac surgery in 71 (6%), and percutaneous transluminal coronary angioplasty in 243 (21%). There were two catheter related deaths (0.1%), both of which occurred within 24 hours of the procedure, and a further nine major cardiovascular complications with residual morbidity (0.45%). These were myocardial infarction in two (0.1%), cerebrovascular events in two (0.1%), and surgical vascular complications in five (0.25%). In addition, there were eight successfully treated, life threatening arrhythmias (0.4%).
CONCLUSIONS—Diagnostic cardiac catheterisation can be performed safely and successfully in a local hospital. When BCS guidelines are followed, the mortality is similar to published pooled data from regional centres (0.1% v 0.12%). The high intervention rate indicates a persistent unmet demand in the districts, which will continue to affect surgical and interventional services.
Keywords: cardiac catheterisation; audit; district general hospital; coronary artery disease
Some details of 544 episodes of infective endocarditis occurring in 541 patients during 1981 and 1982 are reported. The mean age of patients was 51.6 years and there was a greater proportion of males (2:1). Of the 544 episodes 347 (63%) were due to streptococci, 19% to staphylococci, and 14% to bowel organisms. A wide variety of other organisms were responsible for a few cases, and 10% were culture negative. In 60% the portal of entry of the infection could not be ascertained: 19% were probably of dental origin: 16% arose from the alimentary, genitourinary, or respiratory tracts or from the skin or in association with drug addiction, fractures, or pregnancy; the remaining 5% were related to cardiac or other vascular surgery, cardiac catheterisation, haemodialysis, or other procedures involving the blood stream. Seventy-four (14%) of the 541 patients (mean age 59.0 years) died; the mortality was 30% in staphylococcal cases, 14% in infections due to bowel organisms, and 6% in other streptococcal infections. One hundred and seventy-one (32%) of the patients appeared to have had normal hearts before the onset of illness and another 59 (11%) had cardiac lesions not previously recognised. The aortic valve was the most common site of infection. Ninety (17%) of the patients had prosthetic valves or had undergone other cardiac surgery while 34 (6%) had had a previous episode of infective endocarditis. Nine (1.6%) episodes were not diagnosed until necropsy or operation and 34 (6.3%) required urgent valve replacement.
Minimally invasive percutaneous pedicle screw instrumentation methods may increase the need for intraoperative fluoroscopy, resulting in excessive radiation exposure for the patient, surgeon, and support staff. Electromagnetic field (EMF)-based navigation may aid more accurate placement of percutaneous pedicle screws while reducing fluoroscopic exposure. We compared the accuracy, time of insertion, and radiation exposure of EMF with traditional fluoroscopic percutaneous pedicle screw placement.
Minimally invasive pedicle screw placement in T8 to S1 pedicles of eight fresh-frozen human cadaveric torsos was guided with EMF or standard fluoroscopy. Set-up, insertion, and fluoroscopic times and radiation exposure and accuracy (measured with post-procedural computed tomography) were analyzed in each group.
Sixty-two pedicle screws were placed under fluoroscopic guidance and 60 under EMF guidance. Ideal trajectories were achieved more frequently with EMF over all segments (62.7% vs. 40%; p = 0.01). Greatest EMF accuracy was achieved in the lumbar spine, with significant improvements in both ideal trajectory and reduction of pedicle breaches over fluoroscopically guided placement (64.9% vs. 40%, p = 0.03, and 16.2% vs. 42.5%, p = 0.01, respectively). Fluoroscopy time was reduced 77% with the use of EMF (22 s vs. 5 s per level; p < 0.0001) over all spinal segments. Radiation exposure at the hand and body was reduced 60% (p = 0.058) and 32% (p = 0.073), respectively. Time for insertion did not vary between the two techniques.
Minimally invasive pedicle screw placement with the aid of EMF image guidance reduces fluoroscopy time and increases placement accuracy when compared with traditional fluoroscopic guidance while adding no additional time to the procedure.
Minimally invasive; Electromagnetic field navigation; Pedicle screw; Fluoroscopy; Accuracy
To estimate the frequency and nature of complications in patients undergoing diagnostic cardiac catheterisation and to assess time trends in complications since the introduction of a voluntary cooperative audit.
Cardiac centres undertaking diagnostic cardiac catheterisation in England and Wales during the 10 years 1990–9 were invited to join the study. Each participating centre reported numbers of patients catheterised each month and details of complications and deaths as they occurred. Complication rates were calculated for the main diagnostic procedures and for each participating hospital and time trends in complications were examined.
41 cardiac centres contributed. 211 645 diagnostic procedures in adults and 7582 paediatric procedures were registered. The majority (87%) of diagnostic catheter studies in adults were left heart studies with coronary arteriography. The overall complication rate for adult procedures was 7.4/1000, with mortality at 0.7/1000; for paediatric procedures the complication rate was similar but mortality rather higher. Complication rates varied between centres but there was little association with caseload. Time trends across the decade showed both complication and mortality decreasing; from 9.5 to 5.8/1000 and from 1.4 to 0.4/1000, respectively.
Complication rates of diagnostic catheterisation are low but neither negligible nor irreducible. While voluntary audit of cardiac catheter complications is useful and inexpensive, there is a clear need to establish a formal reporting system in all cardiac catheter laboratories, with clear definitions of reportable complications.
complications; cardiac catheterisation; medical audit
Study of 80 consecutive patients undergoing elective diagnostic cardiac catheterisation showed that after the procedure 25 (31%) developed myoglobinaemia. This was attributed to complications of the catheterisation in two. The remaining 23 had received premedication by intramuscular injection. In patients without intramuscular injections myoglobinaemia did not occur after uncomplicated cardiac catheterisation. The study did not support the proposition that cardiac catheterisation results in myocardial damage which can be detected by abnormalities of myoglobin but not by conventional indications of myocardial necrosis.
OBJECTIVE—To assess complications of diagnostic cardiac catheterisation in a non-surgical centre by review of the first three years' experience and audit of 2804 diagnostic left heart procedures.
DESIGN—Analysis of a prospective database of cardiac catheter procedures.
SETTING—District general hospital without available on site cardiac surgery.
RESULTS—The rate of major complications of cardiac catheterisation was 0.07%. Mortality was 0.07%, and the rate of arterial complications (requiring surgical repair) was 0.24% for brachial arteries and 0.17% for femoral. These results are comparable to those reported from national and international surgical centres.
CONCLUSION—A diagnostic cardiac catheterisation service can be offered in non-surgical hospitals without an increased risk to patients. It highlights the relevance of training in angioplasty and questions the appropriateness of starting preliminary invasive cardiology training of specialist registrars in district general hospitals.
Keywords: cardiac catheterisation; complications; specialist training; district general hospital
OBJECTIVE--To assess the incidence and subsequent management of misplaced devices as a complication of therapeutic embolisation procedures. DESIGN--Retrospective review of case notes, cardiac catheterisation reports, and angiograms. SETTING--Tertiary referral centre for congenital heart disease. PATIENTS--205 consecutive children and adults undergoing therapeutic embolisation for congenital heart disease in the 10 years up to 1 April 1993. This group had 231 therapeutic embolisation procedures at 241 sites using coils, umbrella devices, or detachable balloons. MAIN OUTCOME MEASURES--Incidences of misplacement and retrieval of the device; morbidity and mortality. RESULTS--The incidence of misplacement was 3% (10/332) of devices deployed and 4.3% (10/231) of procedures performed. Retrieval from distal pulmonary arteries was not attempted in two patients, but transcatheter retrieval of coils and umbrellas from systemic and pulmonary vessels, using snares or retrieval baskets, was successful in the remaining eight. There were no deaths or serious sequelae related to the procedure, but one patient required femoral arteriotomy for removal of an umbrella device retrieved only as far as the groin. In four of the five most recent cases, the misplaced device was retrieved and the therapeutic embolisation was completed at the same procedure. CONCLUSIONS--Misplacement of a device during therapeutic embolisation is a recognised complication that can be satisfactorily dealt with by transcatheter retrieval without recourse to surgery. For retrieval to be successful it is important to have a wide selection of retrieval equipment available and to be conversant with its use.
This software tool locates and computes the intensity of radiation skin dose resulting from fluoroscopically guided interventional procedures. It is comprised of multiple modules. Using standardized body specific geometric values, a software module defines a set of male and female patients arbitarily positioned on a fluoroscopy table. Simulated X-ray angiographic (XA) equipment includes XRII and digital detectors with or without bi-plane configurations and left and right facing tables. Skin dose estimates are localized by computing the exposure to each 0.01 × 0.01 m2 on the surface of a patient irradiated by the X-ray beam. Digital Imaging and Communications in Medicine (DICOM) Structured Report Dose data sent to a modular dosimetry database automatically extracts the 11 XA tags necessary for peak skin dose computation. Skin dose calculation software uses these tags (gantry angles, air kerma at the patient entrance reference point, etc.) and applies appropriate corrections of exposure and beam location based on each irradiation event (fluoroscopy and acquistions). A physicist screen records the initial validation of the accuracy, patient and equipment geometry, DICOM compliance, exposure output calibration, backscatter factor, and table and pad attenuation once per system. A technologist screen specifies patient positioning, patient height and weight, and physician user. Peak skin dose is computed and localized; additionally, fluoroscopy duration and kerma area product values are electronically recorded and sent to the XA database. This approach fully addresses current limitations in meeting accreditation criteria, eliminates the need for paper logs at a XA console, and provides a method where automated ALARA montoring is possible including email and pager alerts.
Peak skin dose; sentinal event; DICOM structured report dose; patient entrance reference point; fluoroscopy; interventional radiology; Joint Commission (JC); radiation dose; Digital Imaging and Communications in Medicine (DICOM)