Optimal resources for the examination and endovascular treatment of the peripheral and visceral vascular systems. AHA Intercouncil report on peripheral and visceral angiographic and interventional laboratories

Radiation management and credentialing of fluoroscopy users

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.

Complication rates of diagnostic angiography performed by vascular surgeons

The objective of this study was to compare the complication rates of diagnostic angiography performed by vascular surgeons to those previously published by interventional radiologists. From May 1999 through August 2000, 3 board-certified vascular surgeons performed 224 endovascular procedures in a modern endovascular suite. Of these 224 procedures, 144 were diagnostic angiographies. A retrospective chart review was conducted to identify periprocedural complications of these angiographies. The patients were classified into 3 groups according to the indication for angiography, and the major and overall complication rates were tabulated. The complication rates for the initial 25 and subsequent 119 arteriographies were compared to evaluate the presence of a learning curve. Thirty-eight percent of angiographies were performed to define aneurysmal anatomy (type I), 51% to define peripheral arterial stenosis or occlusion (type II), and 12% to assess symptomatic carotid artery disease or mesenteric ischemia (type III). The major complication rates for these 3 types were 0%, 2.7%, and 5.9%, respectively, and showed no statistical difference (Fischer's exact test) compared to published rates of 0.7%, 2.9%, and 9.1%. Major complications included an external iliac artery dissection, a cerebral air embolus, and a deep venous thrombosis. The overall major complication rate was 2.1%, which compares to published rates of 1.9-2.9%. The major complication rates for the initial 25 and final 119 were 8% and 0.8%, respectively. Vascular surgeons can perform diagnostic angiography with acceptable complication rates. The complication rate is reduced with angiographic experience.

Fluoroscopy: patient radiation exposure issues

Fluoroscopic procedures (particularly prolonged interventional procedures) may involve high patient radiation doses. The radiation dose depends on the type of examination, the patient size, the equipment, the technique, and many other factors. The performance of the fluoroscopy system with respect to radiation dose is best characterized by the receptor entrance exposure and skin entrance exposure rates, which should be assessed at regular intervals. Management of patient exposure involves not only measurement of these rates but also clinical monitoring of patient doses. Direct monitoring of patient skin doses during procedures is highly desirable, but current methods still have serious limitations. Skin doses may be reduced by using intermittent exposures, grid removal, last image hold, dose spreading, beam filtration, pulsed fluoroscopy, and other dose reduction techniques. Proper training of fluoroscopic operators, understanding the factors that influence radiation dose, and use of various dose reduction techniques may allow effective management of patient dose.

Protecting patients by training physicians in fluoroscopic radiation management

During the past 15 years, developments in x-ray technologies have substantially enhanced the ability of practitioners to treat patients using fluoroscopically guided interventional techniques. However, many of these procedures require a greater use of fluoroscopy and serial imaging (cine). This has increased the potential for radiation-induced dermatitis, epilation, and severe radiation-induced burns to patients. It has also increased the potential for radiation injury and radiation-induced cancer in personnel. This work will describe a number of the cases that have appeared in the literature and current recommendations and credentialing requirements of various organizations whose members use fluoroscopy. Finally, a program for implementing training of physicians in radiation management as a means of reducing the risk of injury to patients and personnel is recommended.