Minimizing radiation exposure during Interventional Cardiology - - PowerPoint PPT Presentation
Minimizing radiation exposure during Interventional Cardiology procedures Multicenter experience from Innova* IGS 520 users 1 1 Pr. Gilard, University Hospital in Brest, France and Dr. Karsenty, Clinic St Martin in Pessac, France Imagination at
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Multicenter experience from Innova* IGS 520 users1
1 Pr. Gilard, University Hospital in Brest, France and Dr. Karsenty, Clinic St
Martin in Pessac, France * Trademark of General Electric Company
Improving dose management takes a strategy – what we call the GE Blueprint. It includes low-dose imaging technologies for minimally invasive procedures but also considers people and the culture and processes around them. Our dose management solutions provide healthcare organizations with insightful and comprehensive dose information and enable a proactive approach to radiation management.
– Dose reduction features to optimize and personalize dose settings from the tableside, while maintaining clinical details you need. – Dose awareness solutions providing insightful and comprehensive dose information to enable a proactive approach to radiation management for your healthcare organization. – Dose-efficient technologies with systems designed from the ground up to provide the image clarity you need while helping you keeping dose as low as possible.
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GE BLUEPRINT INTRODUCTION
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Dose personalization provides options to help you lower dose during imaging. InnovaSense* system optimizes imaging geometry and helps reduce radiation exposure. Dose Map displays an estimated peak skin dose1 all along the exam.
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1 Estimated skin dose at the modelized patient envelope
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4 100% 50% 24% 9% 5% 2% IQ+ Normal 30fps IQ+ Normal 15fps RDL+ Normal 15fps RDL+ Low 15fps RDL+ Low 7.5fps RDL Low 3.75fps
CURRENT CAPABILITIES TO MINIMIZE RADIATION EXPOSURE
1 Based on Innova IGS520 Operator Manual, FOV20cm, measured in IEC
60601-2-43 conditions
“It is important to have a wide range of fluoro dose available on your system. The modification of the dose setting is very easy, as it can be done with the touch of a button directly from tableside.”
InnovaSense* is an advanced patient contouring technology that uses an intelligent detector to assess movement of the gantry and select the best position for the image receptor relative to the patient. By reducing the distance from the receptor to the patient, the system optimizes imaging geometry and helps reduce radiation exposure.
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CURRENT CAPABILITIES TO MINIMIZE RADIATION EXPOSURE
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CURRENT CAPABILITIES TO MINIMIZE RADIATION EXPOSURE
1 Estimated skin dose at the modeled patient envelope
Procedure type
956 598 130 228
200 400 600 800 1000 1200 Total CA PTCA CA+PTCA
Number of patients Procedure type
Access route
8
Operators
214 73 38 17 225 142 121 27
100 200 300 400 500 OP#1 OP#2 OP#3 OP#4
Number of procedures Operators CA PTCA
STEMI
98 260
50 100 150 200 250 300 350 400
Number of procedures NON-STEMI STEMI
PATIENT DEMOGRAPHICS
373 162 115 96 520 391 15 114
100 200 300 400 500 600 Total CA PTCA CA+PTCA
Number of patients Procedure type Femoral Radial
CA: diagnostic Coronaries Angiogram procedures PTCA: Therapeutic procedure of Percutaneous Transluminal Coronary Angioplasty STEMI: ST segment Elevation Myocardial Infarctus
Fluoro dose rate Cine dose rate
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DOSE RATE
At an average fluoro dose rate, approximately 6 hours of fluoro would be required to reach 5Gy of cumulated AK. Even on an obese patient, approximately 3 hours, 20 minutes of fluoro would be required to reach 5Gy of CAK
Each bar represents the median value of the AK measured at IRP, 15cm below isocenter, as per IEC 60601-2-43.The Error bar shows the 1st and 3rd Quartile; N is the number of procedures; ALL stands for all BMI (average BMI=26.8).
5 10 15 20 25 30 35 40 ALL N=955 BMI<25 N=344 25<BMI<30 N=399 BMI>30 N=210
dose rate (mGy/min)
100 200 300 400 500 600 ALL N=955 BMI<25 N=344 25<BMI<30 N=399 BMI>30 N=210
dose rate (mGy/min)
Source to image distance (SID) Fluoro dose rate
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SYSTEM GEOMETRY OPTIMIZATION
InnovaSense enables users to maintain an average SID of 105 cm1. Decreasing SID from 120 cm to 105 cm reduces the dose rate by 25%
1 Retrospective analysis from one-year usage (2013) of Innova IGS520 at CHU Brest
² Simulated case is simulated with the user working at max SID (120cm) instead of optimized SID obtained with InnovaSense * Trademark of General Electric Company
0.90 0.95 1.00 1.05 1.10 1.15 1.20 ALL N=955 BMI<25 N=344 25<BMI<30 N=399 BMI>30 N=210
SID (m)
5 10 15 20 25 30 35 ALL N=955 BMI<25 N=344 25<BMI<30 N=399 BMI>30 N=210 actual data with InnovaSense simulated case without InnovaSense²
20 40 60 80 100 120 140 160 180 200 CA PTCA CA+PTCA
DAP (Gy.cm²)
US, NEXT survey, Miller et Al, 2012 France, RAY'ACT Survey, Georges et Al, 2014 CHU Brest, IGS520, 2013
Cumulated DAP Fluoro time
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CUMULATED DOSE
USA: Miller et Al, 2012, based on «NEXT» national US survey; multicenter national study, data collected in 2008-2009 on 171 hospitals from 30 states, 1625 CA, 160 PTCA and 622 CA+PTCA. France: Georges et Al, 2014, based on “RAY’ACT” national French survey: multicenter national study, data collected in 2010 over 48 systems (79% equipped with Flat panel) from 44 non-academic hospital, 33937 CA, 3976 PTCA and 23847 CA+PTCA Each bar represents the median value, error bar shows interquartiles.
2 4 6 8 10 12 14 16 18 20 CA PTCA CA+PTCA
fluoro time (minutes)
US, NEXT survey, Miller et Al, 2012 France, RAY'ACT Survey, Georges et Al, 2014 CHU Brest, IGS520, 2013
22% 44% 44% 77% 62%
“When the case become challenging, we are too focused on the procedure and we may deliver a high dose by not changing angulation. Now that we have Dose Map we can visualize the skin dose distribution all along the procedure and get warnings when the peak skin dose becomes significant and when it may be time to think about changing the angulation. It really changed the way we work.”
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DOSE MAP
Working at low dose, less than 1% of cases exceeded 3Gy. On some of the patients above 3Gy, most of the dose was delivered on the same skin area and reached high peak skin dose1. Dose Map provides additional dose awareness that may have prevented to reach high peak skin dose1.
1 Estimated peak skin dose at the modeled patient envelope
Number of patients > 3Gy Cumulated dose compared to estimated peak skin dose
956 7 200 400 600 800 1000 1200
Number of patients
CAK<3Gy CAK>3Gy 3.0 3.2 3.3 3.4 3.7 4.5 6.8 2.4 0.8 2.9 2.2 1.3 2.4 5.0 1 2 3 4 5 6 7 8 Pt#1 Pt#2 Pt#3 Pt#4 Pt#5 Pt#6 Pt#7
Cumulated dose (Gy) Patients
AK (Gy) estimated peak skin dose
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Before (Feb – Apr 2012) After (Nov – Jan 2014) 181 PCI procedures 299 PCI procedures 29 CTO procedures 31 CTO procedures Average BMI 27.2 Average BMI 27.4 15 fps 7.5 fps Details « Normal » Details « Low » FOV 17 cm and 15 cm FOV 20 cm with collimation
DOSE REDUCTION
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PATIENT AND OPERATOR DOSE REDUCTION
Each bar represents the mean value, N is the number of procedures
1 Measurement with an electronic dosimeter on the first operator under the lead apron on the left side of the chest.
Patient dose reduction for PCI procedures Operator dose1 reduction for PCI procedures
150.3 34.7
20 40 60 80 100 120 140 160 180 Without low dose protocol (N=181) With low dose protocol (N=299)
DAP (Gy.cm²)
77%
5.3 0.54 1 2 3 4 5 6
Without low dose protocol (N=181) With low dose protocol (N=299)
90%
20 40 60 80 100 120 140 160 180 200
PTCA CTO DAP (Gy.cm²)
US, NEXT survey, Miller et Al, 2012 France, RAY'ACT Survey, Georges et Al, 2014 Clinic St Martin, IGS520, 2013
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PATIENT DOSE IN CTO
For PTCA, each bar represents the median value, error bars show
Cumulated DAP Fluoro time
79% 50% 42%
“The use of the low-dose protocol is critical for our CTO procedures, for which fluoro time can be very long. We now feel more comfortable when starting a CTO case, since we know that using these low dose rates we really have some margin before reaching dose values that could be of a concern for the patient and for us.” Dr. B. Karsenty
5 10 15 20 25 30 35 40 45
PTCA CTO Fluoro time (minutes)
US, NEXT survey, Miller et Al, 2012 France, RAY'ACT Survey, Georges et Al, 2014 Clinic St Martin, IGS520, 2013
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CLINICAL CASE EXAMPLE
1 Estimated peak skin dose at the modeled patient envelope
CTO of the RCA Retrograde approach, septal surfing in RAO 20°, CRA30° Dose Map first alert: 1Gy threshold exceeded in RAO 20°, CRA30° Change working angulation from RAO to LAO Successful RCA revascularization Final Dose Map. Dose distributed on three different “hot spots”, with estimated peak skin dose at only 1.1Gy for a total cumulated dose of 4.1Gy Use collimation to minimize
exposed area
“Dose Map was really key in this procedure. The Dose Map information when we reached the dose threshold made us think about trying to change the angulation. Otherwise we may have been too intently focused on the procedure and may have forgotten about dose optimization.”
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QUOTE
Cath labs at CHU Brest and Clinic St Martin Pessac manage to keep patient dose levels substantially lower than current reference values even during their most challenging cases.
– Dose personalization provides options to help lower dose during imaging. – InnovaSense* system optimizes imaging geometry and helps reduce radiation exposure. – Dose Map displays an estimated peak skin dose1 all along the exam.
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1 Estimated peak skin dose at the modeled patient envelope
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