如何减少经桡动脉介入治疗的放射线损伤（cit）课件

HowtoReduceTheFluoroscopyExposureDuringTRIProcedure LiYue M D TheFirstAffiliatedHospitalofHarbinMedicalUniversity Radialarteryoffersaneffective LM truebifurcation AMIelderlypatients CTO etc andmoresafealternativesiteforperformingdiagnosticandinterventionalcoronaryprocedures Transradialintervention TRI YonseiMedJ 2005Aug31 46 4 503 10YonseiMedJ 2006Oct31 47 5 680 7ChinMedJ 2007Apr5 120 7 539 44CircJ 2007Jun 71 6 855 61ChinMedJ 2007Apr5 120 7 598 600CatheterCardiovascInterv 20071 70 5 670 5JInvasiveCardiol 2004Mar 16 3 129 32AmJCardiol 2004May15 93 10 1282 5AmHeartJ 2008Nov 156 5 864 70CatheterCardiovascInterv 2009Jun1 73 7 883 7CardiovascRevascMed 2009Apr Jun 10 2 73CatheterCardiovascInterv 2010Jun1 75 7 991 5 Conclusion TheTRIisassociatedwithlessCKDthantheTFI Heart 2010Oct 96 19 1538 42 Chronickidneyinjury 297cases Oct 2000 Mar 2002 Oneinvasivecardiologist H W L whohadvastexperienceinradialaccesscatheterization 1 500cases Germany CatheterCardiovascInterv 2006Jan 67 1 12 6 Conclusion TRIisburdenedwitha100 increaseinoperatorradiationexposureduringdiagnosticcoronarycatheterizationproceduresanda50 increaseduringcoronaryinterventions EurHeartJ 2008Jan 29 1 63 70 Conclusion TRIincreaseradiationexposureofoperatorsdespiteextensiveuseofspeci cprotectiondevicesiscurrentlyagrowingproblemfortheinterventionalcardiologisthealth Operator Patient 1 813catheterizationcasesperformedatahigh volume 1400cases year institutionbetweenJanuary2007andJuly2009by5cardiologists AmJCardiol 2010Oct1 106 7 936 40 Operatorexperience 4monthsduringwhichfemoralaccesswasthedefaultapproach femoraln 340 6monthsduringwhichoperatorstransitionedfromfemoraltoradialaccess femoraln 405 radialn 280 6monthsduringwhichradialaccesswasthedefaultapproach femoraln 103 radialn 685 Theauthorssaythat intheinitialstagesofradialexperience longer fluoroscopytimes arerequiredtonavigatetheguidewiretotheaorticroot overcominganatomicvariationsandloops Catheterengagementtothecoronaryostiamayalsorequiremoremanipulationcomparedtothefemoralapproach 曝光时间 曝光量 CircJ 2006Jan 70 1 44 8 Radiosensitiveindicatorsarearrangedonthejacket RadiationexposureduringvariouslesionsPCI CTO SuzukietalCircJ2006 70 44 48 CatheterCardiovascInterv 2008Feb1 71 2 160 4 ThemaximumESDexceeded1Gyin66procedures 3Gyin32procedures and5Gyin15procedures exceedthethresholdsforradiationskininjuriesinmanycases 72cases Thethresholdsoftransienterythema permanentepilation anddelayeddermalnecrosisare2 7 and12Gy Theemphasisshouldnotbeonwhetherthereisaslightdifferencebetweendoingradialandfemoralbutwhythereissuchbroadvariabilityamongoperatorsatthesameinstitutionwhopresumablyaredoingsimilarcases CatheterCardiovascInterv 2008Feb1 71 2 160 4 Aims Toassesstheeffectivenessofadose reductionprogrammbasedonradiationprotectiontraining accordingtotherecommendationsoftheEuratomCouncil theInternationalCommissiononRadiologicalProtectionandtheFrenchSocietyofCardiology ArchivesofCardiovascularDisease 2009 102 821 827 Theradialapproachwasusedin 80 oftheprocedures low uoroscopicandcinepulserates 6 25and12 5frames second respectively alargeintensi er eldsize 23cm withanaposteriorinumericmagni cation maximalcollimation optimalX raytube patient imageintensi erdistances maximalsource patientdistance minimalpatient imageintensi erdistance Routineleftventriculographywasdiscouraged Thenumberofruns choiceandangulationoftheprojectionsnecessarytoobtainthebestpossibleanalysisofthecoronaryarterieswerenotlimited Radiationdose reductionprogramme Conclusion Traininginradiationprotectionwereassociatedwitha50 reductioninradiationexposuretopatientsundergoinginvasivecardiacprocedures withoutanylossofdiagnosticinformation Deterministicinjury 必然性效应 Occuronceathresholdlevelofexposurehasbeenexceeded SkinandeyeinjuriesStochasticinjury 随机性效应 AnylevelofexposurecancauseinjuryCancer Typesofradiationinjury 2Gy opacityoflens 5Gy cataracta Anycellsthatareimmature undifferentiated andactivelydividing ie stomachmucosa basallayerofskin stemcells aremoreradiosensitivethanmature nondividingcells Radiationeffectsonthehumancell Directcellulardamage S phasecellsareparticularlyradioresistant Indirectcellulardamagethroughproductionofreactiveoxidativespecies Ionizingradiationcancausehydrolysisofwaterwithinthecell resultinginahydrogenmoleculeandhydroxyl freeradical moleculeproduction Two thirdsofradiation inducedDNAdamageisaconsequenceoftheindirectdamagedonebyfreelydiffusinghydroxylradicals 羟自由基 Radiation inducedskininjuries Theincidenceissmallwhencomparedwiththenumberof uoroscopicallyguidedproceduresperformed buttheconsequencescanbedevastating PatienthistoryAreaofskinexposed Sensity X rayexposureitself Dose Riskfactors Patienthistory 1 connectivetissuedisorders particularlylupus scleroderma 硬皮病 andmixedconnectivetissuedisorder 2 Ataxiatelangiectasia 运动失调性毛细血管扩张症 arare autosomalrecessivedisorder3 withothercellularDNArepairabnormalitiesorchromosomalbreakagesyndromes 染色体断裂综合征 4 Diabetesandhyperthyroidism5 Chemotherapeuticagents actinomycinD doxorubicin bleomycin 5 uorouricil andmethotrexate 6 Obesity Moreradiationisnecessarytopenetratethebodyinlargerpatients EffectiveskindoseisdeterminedbyBMI patient andfluorotime operator SuzukietalCircJ2007 71 229 233 Differentialskinsensity Careneedstobeparticularlytakeninareasofthinnerskinandextremities Theareasofthebodyrankedfrommosttoleastsensitiveare Anteriorneck antecubital 肘前的 andpoplitealspaces 腘部 exor 屈侧 surfacesofextremities chestandabdomen face back extensor 伸侧 surfaces napeofneck scalp 头皮 palmsandsoles Skinentrancedosethresholdsforskininjury EffectDose Gy OnsetEarlytransienterythema2HoursMainerythema 红斑 610daysPermanentepilation 脱发 73weeksDermalatrophy1012weeks 1yearInduration 硬结 10 1yearTelangiectasia 毛细血管扩张 10 1yearLatedermalnecrosis12 1yearDrydesquamation 脱屑 144weeksMoistdesquamation184weeksLateerythema158 10weeksIschemicdermalnecrosis18 10weeksSecondaryulceration246weeks 5Gy skinrashWeeksafterprocedure resolvedafter6months 20Gy initialdermatitis2monthsafterprocedure Image2yearsafter Radiation inducedlensinjuries Manifestasposteriorsubcapsularopacities 后囊下浑浊 Thelatentperiodbetweenexposureandonsetappearstobeinverselyrelatedtodose Theminimumdoserequiredtoproduceopacitiesinthelensisapproximately1 3Gyforacuteexposures 4Gyforfractionatedexposures LONG TERMCANCERRISK Insummary thereissomeevidencethatoccupationalexposureincreasestheincidenceofcancer particularlyfemalebreastcancerorleukemia buttheevidenceisweakatcurrentexposurelevels AmHeartJ 2009 157 118 24 HowtominimizingX rayinjurytothepatient Positionthedetectorasclosetothepatientaspracticable withthex raytubeasfarfromthepatientaspossible Carefulreviewofthepatient shistory Ifthedetectorispositionedfarfromthepatient theimagemaybeblurred the uoroscopicmachineinABC automaticbrightnesscontrol modewillautomaticallyincreasethekVpormA orboth toimprovetheimagebrightness thisresultsinincreasedradiationdosetothepatient Usetheexposurepedalassparinglyaspossible Radiationexposureduring uoroscopyisdirectlyproportionaltothelengthoftimetheunitisactivatedbythefootpedalswitch U S FDAguidelinesrequirethatthetotalelapsed uoroscopytimeberecordedinthepatientrecordforeverypatientprocedure heavyfoot ontheX raypedal Usealowpulserate uoroscopyDecreasefrom30pulsesto15or7 5pulsespersecondwheneverpossible Viewandsaveimageswithlast image hold fluoro store Thisallowsforstoringandreviewingofthelastimagewithoutre exposingthepatienttomoreradiation Alterthepositio