Transition from TF to TR Access in IO: Effect on Patient Radiation Exposure and Fluoroscopy Time

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1 Transition from TF to TR Access in IO: Effect on Patient Radiation Exposure and Fluoroscopy Time Mircea Cristescu, Amanda Smolock, George Carberry, Prasad Dalvie, John Fallucca, Paul Laeseke, Orhan Ozkan, Michael Woods

2 No conflicts of interest Disclosures

3 Background Cardiology and IR literature describe the benefits of TR access with regards to: Patient preference Cost Complication profile 1-7?Patient dose?fluoroscopy time 8-10,16 IR: Limited Cardiology: Mixed

4 Background Large cardiology series: No overall difference in procedural parameters during TF to TR transitions over several months But do also describe a learning curve Potential transient incr. dose & procedure length early on TR-PCI success depends on operator experience, and a case volume of 50 cases is required to achieve outcomes comparable to experienced operators [FT, contrast used, failure rate] The improvement in fluoroscopy time and other procedure-related parameters was seen after approximately 25 cases with further improvement after 75 cases.

5 Background Kasasbeh ES, Parvez B, Huang RL, Hasselblad MM, Glazer MD, Salloum JG, Cleator JH, Zhao DX. Learning curve in transradial cardiac catheterization: procedure-related parameters stratified by operators' transradial volume. J Invasive Cardiol Nov;24(11):

6 Purpose We sought to evaluate whether this phenomenon applied to interventional oncology (IO) procedures, in particular with regards to the metrics of patient radiation exposure and fluoroscopy times, in intra-arterial IO procedures during our institution's initial adoption of TR access

7 Materials and Methods PACS/EPIC queried under IRB exemption IO procedures included: Bland embolization TACE Radioembolization Mapping All IO cases performed during the radial adoption period from 7/2014 and 9/ interventional radiologists (experience: 1-8 years) who performed both TR & TF procedures All operators began learning and utilizing TR access within this study period

8 Materials and Methods Assessed: Procedure type Access type Access success/failure Fluoroscopy time Radiation dose (DAP i.e. mgy*cm2)* *IR CT and CBCT spins are not included in the dose calculation

9 Results A total of 178 procedures were included: 79 TR 99 TF 3 cases of access failure/conversion with TR (one TR to TF and two TR to contralateral TR) Operator TF TR D 38 2 F 21 7 W L 23 8

10 Results A total of 178 procedures were included: 79 TR 99 TF 3 cases of access failure/conversion with TR (one TR to TF and two TR to contralateral TR) TACE/Bland Radioembolization Mapping TF TR 38 38% 30 38% 36 36% 27 34% 25 25% 22 28%

11 Results TF TR p DAP FT All FT in minutes All DAP in mgy*cm 2

12 Results by Procedure TACE/Bland TF TR p DAP FT Y90 TF TR p DAP FT Mapping TF TR p DAP FT All FT in minutes All DAP in mgy*cm 2

13 Results by Operator FT Dose TF TR p TF TR p D F W L All FT in minutes All DAP in mgy*cm 2

14 Summary No significant difference in overall patient radiation dose (p=0.7) Procedures performed using transradial access trended toward shorter fluoroscopy times (p=0.05) Findings generally persisted when procedures were divided into subgroups of Y90, mapping, and TACE/particle embolization.

15 Study Limitations One operator dominated TR access arm No account for trainee involvement No account for patient size/weight Heterogeneity between expected length and dose of IO procedures (dose between treatment subgroups was not adjusted for number of vessels treated, lobar versus superselective therapy, etc.) Arms not randomized No stratified evaluation between arms (Patients 1-50 vs , etc.)

16 Conclusions Early institutional experience with starting a TR program for IO suggests this may be done without increase in patient radiation dose and fluoroscopy times. Concerns over procedure dose and length should not be barriers to learning TR access.

17 References 1. Valgimigli M, Gagnor A, Calabro P, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015;385: Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004;44: Joyal D, Bertrand OF, Rinfret S, Shimony A, Eisenberg MJ. Meta-analysis of ten trials on the effectiveness of the radial versus the femoral approach in primary percutaneous coronary intervention. Am J Cardiol. 2012;109: Caputo, Ronald P., et al. Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI. Catheterization and Cardiovascular Interventions 78.6 (2011): Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012;60: Benamer H, Louvard Y, Sanmartin M, et al. A multicentre comparison of transradial and transfemoral approaches for coronary angiography and PTCA in obese patients: the TROP registry. Euro Intervention. 2007;3: Posham R, Biederman DM, Patel RS, Kim E, Tabori NE, Nowakowski FS, Lookstein RA, Fischman AM. Transradial Approach for Noncoronary Interventions: A Single-Center Review of Safety and Feasibility in the First 1,500 Cases. J Vasc Interv Radiol Feb;27(2): doi: /j.jvir Neill J, Douglas H, Richardson G, Chew EW, Walsh S, Hanratty C, Herity N. Comparison of radiation dose and the effect of operator experience in femoral and radial arterial access for coronary procedures. Am J Cardiol 2010; 106: Park EY, Shroff AR, Crisco LV, Vidovich MI. A review of radiation exposures associated with radial cardiac catheterisation. EuroIntervention. 2013;9: Simard, Trevor, et al. "Impact of Center Experience on Patient Radiation Exposure During Transradial Coronary Angiography and Percutaneous Intervention: A Patient Level, International, Collaborative, Multi Center Analysis." Journal of the American Heart Association 5.6 (2016): e Rubartelli, Paolo, et al. "Switching from Femoral to Routine Radial Access Site for ST Elevation Myocardial Infarction: A Single Center Experience." Journal of interventional cardiology 27.6 (2014): APA 12. Kedev, Sasko, et al. "Complete transitioning to the radial approach for primary percutaneous coronary intervention: a real-world single-center registry of 1808 consecutive patients with acute ST-elevation myocardial infarction." The Journal of invasive cardiology 26.9 (2014): Sciahbasi, Alessandro, et al. Evaluation of the learning curve for left and right radial approach during percutaneous coronary procedures. ; The American journal of cardiology (2011): Ball WT, Sharieff W, Jolly SS, Hong T, Kutryk MJ, Graham JJ, Fam NP, Chisholm RJ, Cheema AN. Characterization of operator learning curve for transradial coronary interventions. Circ Cardiovasc Interv Aug;4(4): Kasasbeh ES, Parvez B, Huang RL, Hasselblad MM, Glazer MD, Salloum JG, Cleator JH, Zhao DX. Learning curve in transradial cardiac catheterization: procedure-related parameters stratified by operators' transradial volume. J Invasive Cardiol Nov;24(11): Kis, Bela, Matthew Mills, and Sarah E. Hoffe. "Hepatic radioembolization from transradial access: initial experience and comparison to transfemoral access." Diagnostic and Interventional Radiology 22.5 (2016): 444.

18 Thank You