Catheterization and Cardiovascular Interventions 85:400 (2015)
Editorial Comment Fluoroscopic Time: Necessary but Not Sufficient Stephen Balter,* PhD Departments of Radiology and Medicine, Columbia University, New York City, New York
Key Points
Contrast utilization and fluoroscopic time decreased over time due to increased operator proficiency. There is no estimate of radiation hazard because radiation utilization was not recorded. Fluoroscopic time is an increasingly imprecise measure of radiation risk because of improving equipment configurations. The article “Temporal trends of fluoroscopy time and contrast utilization in coronary chronic total occlusion revascularization: insight from a multicenter United States registry” published in this issue of CCI [1] evaluates temporal trends in fluoroscopy time and contrast utilization performed at three USA institutions between January 2006 and November 2011. The reported higher success rates over time achieved while using less fluoro and contrast is impressive. Michael’s paper [1] uses fluoro time as a surrogate for radiation use. Although this is the only “radiation” metric collected in most cardiac registries [2], is an increasingly imprecise indicator of radiation risk. The decoupling between fluoro time and radiation hazards is discussed by Michel [1].
Fluoroscopy time is a reasonable indicator of operator work intensity. As such, it should still be tracked along with contrast use and all available dose metrics [3]. The reduction of fluoro time over the study reflects increased operator competence in the performance of Complex Total Occlusion (CTO) procedures. The reduction of contrast use is probably a combination of replacing cine with stored fluoroscopy for documentation (no need for extra contrast for the cine) and the simple collection of fewer stored runs. Newer fluoroscopic hardware and configurations continue to reduce fluoroscopic dose rates. Total fluoroscopic times are now drifting upward due to a variable combination of image quality effects and a trend toward performing increasingly complex CTOs. The authors of this article hint at this effect in their discussions of methods to reduce dose rates. However, in my opinion, the conclusion should have included a recommendation to include direct dose measurement data in future registries.
REFERENCES 1. Michael TT, Karmpaliotis D, Brilakis ES, Alomar M, Abdullah SM, Kirkland BL, Mishoe KL, Lembo N, Kalynych A, Carlson H, Banerjee S, Luna M, Lombardi W, Kandzari DE. Temporal trends of fluoroscopy time and contrast utilization in coronary chronic total occlusion revascularization: Insight from a multicenter United States Registry. Catheter Cardiovasc Interv 2014;85: 393–399. 2. Fazel R, et al. Determinants of fluoroscopy time for invasive coronary angiography and percutaneous coronary intervention: Insights from the NCDR((R)). Catheter Cardiovasc Interv 2013; 82:1091–1105. 3. Chambers CE. Radiation monitoring in the cath lab. Catheter Cardiovasc Interv 2013;82:1106–1107.
Conflict of interest: Nothing to report. *Correspondence to: Stephen Balter, Ph.D. Columbia University, 163 Ft. Washington Ave Heart Center, 2nd Floor, New York NY 10032. E-mail: [email protected] Received 15 December 2014; Revision accepted 21 December 2014 DOI: 10.1002/ccd.25814 Published online 9 February 2015 in Wiley Online Library (wileyonlinelibrary.com) C 2015 Wiley Periodicals, Inc. V
Editorial Comment Fluoroscopic Time: Necessary but Not Sufficient Stephen Balter,* PhD Departments of Radiology and Medicine, Columbia University, New York City, New York
Key Points
Contrast utilization and fluoroscopic time decreased over time due to increased operator proficiency. There is no estimate of radiation hazard because radiation utilization was not recorded. Fluoroscopic time is an increasingly imprecise measure of radiation risk because of improving equipment configurations. The article “Temporal trends of fluoroscopy time and contrast utilization in coronary chronic total occlusion revascularization: insight from a multicenter United States registry” published in this issue of CCI [1] evaluates temporal trends in fluoroscopy time and contrast utilization performed at three USA institutions between January 2006 and November 2011. The reported higher success rates over time achieved while using less fluoro and contrast is impressive. Michael’s paper [1] uses fluoro time as a surrogate for radiation use. Although this is the only “radiation” metric collected in most cardiac registries [2], is an increasingly imprecise indicator of radiation risk. The decoupling between fluoro time and radiation hazards is discussed by Michel [1].
Fluoroscopy time is a reasonable indicator of operator work intensity. As such, it should still be tracked along with contrast use and all available dose metrics [3]. The reduction of fluoro time over the study reflects increased operator competence in the performance of Complex Total Occlusion (CTO) procedures. The reduction of contrast use is probably a combination of replacing cine with stored fluoroscopy for documentation (no need for extra contrast for the cine) and the simple collection of fewer stored runs. Newer fluoroscopic hardware and configurations continue to reduce fluoroscopic dose rates. Total fluoroscopic times are now drifting upward due to a variable combination of image quality effects and a trend toward performing increasingly complex CTOs. The authors of this article hint at this effect in their discussions of methods to reduce dose rates. However, in my opinion, the conclusion should have included a recommendation to include direct dose measurement data in future registries.
REFERENCES 1. Michael TT, Karmpaliotis D, Brilakis ES, Alomar M, Abdullah SM, Kirkland BL, Mishoe KL, Lembo N, Kalynych A, Carlson H, Banerjee S, Luna M, Lombardi W, Kandzari DE. Temporal trends of fluoroscopy time and contrast utilization in coronary chronic total occlusion revascularization: Insight from a multicenter United States Registry. Catheter Cardiovasc Interv 2014;85: 393–399. 2. Fazel R, et al. Determinants of fluoroscopy time for invasive coronary angiography and percutaneous coronary intervention: Insights from the NCDR((R)). Catheter Cardiovasc Interv 2013; 82:1091–1105. 3. Chambers CE. Radiation monitoring in the cath lab. Catheter Cardiovasc Interv 2013;82:1106–1107.
Conflict of interest: Nothing to report. *Correspondence to: Stephen Balter, Ph.D. Columbia University, 163 Ft. Washington Ave Heart Center, 2nd Floor, New York NY 10032. E-mail: [email protected] Received 15 December 2014; Revision accepted 21 December 2014 DOI: 10.1002/ccd.25814 Published online 9 February 2015 in Wiley Online Library (wileyonlinelibrary.com) C 2015 Wiley Periodicals, Inc. V
