Operator radiation exposure and physical discomfort during a right versus left radial approach for coronary interventions

1. Operator Radiation Exposure and Physical Discomfort during
a Right versus Left Radial Approach for Coronary
Interventions
Herman KadoM.D., AmbarM Patel M.D., Siva Suryadevara M.D., Dominick
Angiolillo M.D., Martin Zenni M.D., Lyndon Box M.D., Theodore A Bass M.D.,
Luis A Guzman M.D.

2. Background
• Most data has been collected using right radial
• Initial data argue against left radial access
• Increase operator discomfort
• More challenge cases
• Increase radiation
• Increase procedural time
• Increase room time

3. N = 1225
Total number of patients screened
N = 100
Total number of patients randomized
Excluded N = 2
Excluded N = 1125
Prior CABG
Patient refusal
Competitive study
Radial artery occlusion
Radial artery spasm
ST-ACS
AV graft
Absent radial pulse
Femoral approach
Physician preference
Other
N = 28
Right Radial
N = 27
Left Radial
N = 98
Total number of patients undergoing procedure
N = 55
High BMI (>=30)
N = 43
Low BMI (<30)
N = 21
Right Radial
N = 22
Left Radial
N = 49
Left Radial
N = 49
Right Radial
Study Design

4. Study Design
• Stratified according to BMI <> 30
• Each operator had its own randomization block
• Primary end point
Operator radiation exposure at the head and
thyroid level
• Secondary end point
Operator discomfort
• Sample size was calculated after an interim analysis
of the first 25 patients. It was advise to have a total
of 80 patients to demonstrate superiority (power of
80% and alpha 0.05)

5. Study Design (Dosimeters)
Dosimeters placement
• External at head level (at lead glass in the I.I. side)
• External at Thyroid level
• Internal at sternum level
Each operator had its own dosimeter for left vs right as
well as > vs < 30 BMI
Therefore each operator had 4 sets of 3 dosimeters
All procedures were performed from the pt’s right side
All operators have to start with Judkins Dx catheters

7. Results

8. LRA(n=50) RRA(n=50) p-value
Age 57.97 ± 10.66 60.66 ± 8.89 0.29
BMI 31.90 ± 8.4 30.80 ± 6.6 0.49
Male 30 (61 %) 29 (59 %) 0.71
Caucasian 29 (59 %) 30 (61 %) 0.71
History of CAD 24 (49 %) 29 (59 %) 0.34
History prior PCI 18 (37 %) 24 (49 %) 0.33
History of PVD 2 (4 %) 2 (4 %) 0.98
History of CHF 3 (6 %) 6 (12 %) 0.54
Hypertension 40 (81 %) 43 (88 %) 0.52
Diabetes 25 (51 %) 27 (55 %) 0.53
Dyslipidemia 35 (71 %) 39 (79 %) 0.51
Tobacco use 27 (55 %) 31 (63 %) 0.53
Indication: ACS 25 (51 %) 30 (61 %) 0.32

9. LRA (n = 50) RRA (n = 50) p-value
Procedural Success 48 (96%) 48 (96%) 1.00
FT (min) 10.5 ± 7.9 10.9 ± 8.0 0.82
Patient Radiation (mGy) 1484.3 ± 974.4 1,727.8 ± 1,381.4 0.32
Scenes 13.7 ± 8.5 14.4 ± 9.4 0.71
Contrast (ml) 110.1 ± 58.8 104.55 ± 60.0 0.65
Catheters 3.02 ± 1.8 2.78 ± 1.4 0.45
Diagnostic Only 23 (46%) 27 (54%) 0.55
PCI only 25 (50%) 21 (42%) 0.54

10. Direct Radiation to Patient
1484+974
1727+1380
3000
2500
2000
1500
1000
500
0
Radiation (mGy)
LRA
RRA
p=0.59

11. Primary end point: Radiation at head level

12. Primary end point: Radiation at thyroid level

13. Internal Radiation

14. N = 1225
Total number of patients screened
N = 100
Total number of patients randomized
N =98
Total number of patients analyzed
Excluded N = 2
Excluded N = 1125
Prior CABG
Patient refusal
Competitive study
Radial artery occlusion
Radial artery spasm
ST-ACS
AV graft
Absent radial pulse
Femoral approach
Physician preference
Other
N = 28
Right Radial
N = 27
Left Radial
N = 98
Total number of patients undergoing procedure
N = 55
High BMI (>=30)
N = 43
Low BMI (<30)
N = 21
Right Radial
N = 22
Left Radial
Radiation and BMI

15. Procedural Results
BMI < 30 (n=43) BMI > =30 (n=55) p-value
Contrast (ml) 114.95 ± 67.30 101.36 ± 51.88 0.26
FT (min) 11.19 ± 8.78 10.38 ± 7.28 0.62
Total Patient Radiation
(mGy/min)
167.92 ± 194.53 177.41 ± 64.74 0.74
Number of Scenes 14.95 ± 9.55 13.34 ± 8.56 0.38

16. 30
25
20
15
10
5
0
External Head
(mRems/min)
External Thyroid
(mRems/min)
BMI <30
BMI >=30
Internal Sternum
(mRems/min)
P = 0.72
P = 0.78
P = 0.43

17. 45
40
35
30
25
20
15
10
5
0
Radiation and BMI according to RRA vs LRA
External Head
(mRems/min)
External Thyroid
(mRems/min)
Internal Sternum
(mRems/min)
BMI < 30
P=0.04 P=0.01
P=0.27
External Head
(mRems/mins)
External Thyroid
(mRems/mins)
Internal Sternum
(mRems/mins)
BMI>=30
LRA
RRA
P=0.21
P=0.36
P=0.05

18. Operator Discomfort
It was determined at two different time points of the
procedure
• At the time of obtaining arterial access.
• At the end of the procedure
It was graded from 0-10
Significant discomfort was considered when the
operator graded it at > 4

19. p=0.017
22
Operator Discomfort
10
LRA
RRA
p=0.38
4 4
30
25
20
15
10
5
0
Vascular Access Procedure
Discomfort During Access and BMI
30
p=0.58
10
p=0.005
3.7
LRA
RRA
5
35
30
25
20
15
10
5
0
BMI >30 BMI < 30

20. Left Radial Procedure

21. Right Radial Procedure

22. Summary and Conclusions
• Left and right radial access appear to have similar
success as well as procedural related efficacy
• The left radial approach was associated with
significant decrease in radiation exposure to the
operator
• The BMI does not appear to influence the
performance of either right or left radial approach
• Irrespective of BMI, similar reduction in operator
radiation was seen using the left radial approach

23. Summary and Conclusions
• Even though the left radial approach was associated
with increase operator discomfort, this was only
noted at the time to obtain vascular access and only
present in patients with increase BMI.
• No increased operator discomfort was noted during
the performance of the procedure.

24. Thank you