Radiation Dose During Contemporary Percutaneous Coronary Interventions for Chronic Total Occlusion: Insights From the PROGRESS-CTO Registry

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Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with high radiation doses. In this manuscript, we examined the contemporary trends and determinants of radiation dose in the PROGRESS CTO registry. The radiation dose during CTO PCI has not changed significantly since 2020, highlighting the need for innovation and operator education to further improve radiation safety.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with high radiation doses.^1,2 Radiation can cause deterministic (skin injury) and stochastic (cancer, cataracts) effects.^3,4 We recently showed a decrease in radiation dose during CTO PCI between 2012 and 2020, but it is not known whether this trend has continued.²

We examined the contemporary trends and determinants of radiation dose in 5410 CTO PCIs performed between 2020 and 2023 at 28 centers participating in the PROGRESS CTO (Prospective Global Registry for the Study of CTO Intervention; Clinicaltrials.gov identifier: NCT02061436) registry. The study was approved by the institutional review board of each center.

The median air kerma radiation dose was 2.1 (interquartile range [IQR] 1.1-3.6) Gray (Gy). There was no change in radiation dose since 2020 (Figure, A) and lesion complexity did not change (Figure, B). Intravascular imaging was more frequently used in the lowest air kerma tertile group (80.6% vs 50%, P < .001). Novel X-ray systems (Siemens Q.zen and Philips Allura Clarity) were associated with a lower radiation dose and their use has been increasing (Figure, C & D).

The mean age was 64.4 ± 27.8 years. Most patients were men (80%), 43% had diabetes mellitus, and 26% had prior coronary artery bypass graft surgery. The median body mass index (BMI) was 30.4 ± 6.3 kg/m². Patients in the highest air kerma radiation dose tertile (> 2.8Gy) were more likely to be men (86% vs 71%, P < .001), have higher BMI (31.4% vs 28.5%, P < .001) and diabetes mellitus, (49.1% vs 41.6%, P < .001), and more frequently had complex CTO lesions (Japanese [J]-CTO score: 2.61 ± 1.23 vs 2.10 ± 1.20, P < .001; PROGRESS CTO score: 2.3 ± 1.0 vs 2.0 ± 0.92, P < .001).

The most common CTO target vessel was the right coronary artery (RCA) (52.2%), and RCA CTO PCI was more likely to be in the highest air kerma radiation dose tertile (54.4% vs 47%, P < .001). The left anterior descending artery (LAD) was the second-most common target vessel (27.3%) and LAD CTO PCI was more likely to be in the lowest air kerma radiation dose tertile (31.2% vs 25.8%, P = .002). Antegrade wiring was used in 83.4% of the procedures and retrograde crossing in 29.3% of the procedures. The retrograde approach was associated with a higher air kerma radiation dose (2.8, IQR 1.69-4.68 Gy) and more likely to be performed with high (> 5 Gy) radiation dose (odds ratio [OR] 2.05; 95% CI, 1.71-2.45; P < .001) (Figure, E), followed by antegrade dissection and reentry (2.5, IQR 1.4-4.0 Gy) and antegrade wiring (2, IQR 1.08-3.45 Gy). Technical success was 87.3%, and procedural success was 85.9%. In-hospital major adverse cardiovascular events were 1.9%. No radiation skin injury was reported.

Despite a reduction in radiation dose during CTO-PCI between 2012 and 2020,² no further decrement was observed since then. Werner et al showed air kerma radiation dose reduction between 2012 and 2017 in a European Registry of CTO PCI;⁵ however, recent data is lacking. Lack of further radiation dose reduction may be related to lack of further improvements in X-ray equipment and limited adoption of radiation-reducing strategies. Lesion complexity did not change. Additional efforts, such as implementing ultra-low dose fluoroscopic protocols,⁶ could help further reduce radiation dose.

Limitations. PROGRESS-CTO is an observational study with all inherent limitations. There was no independent core laboratory and event adjudication for the complications. Cases were performed at experienced CTO PCI centers, limiting generalizability to less experienced centers.

In summary, radiation dose during CTO PCI has not significantly changed since 2020, highlighting the need for innovation and operator education to further improve radiation safety.

From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.

Acknowledgments: The study data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools hosted at the Minneapolis Heart Institute Foundation (MHIF), Minneapolis, Minnesota. The authors are grateful for the philanthropic support of our generous anonymous donors, and the philanthropic support of Drs. Mary Ann and Donald A Sens; Mrs. Diane and Dr. Cline Hickok; Mrs. Wilma and Mr. Dale Johnson; Mrs. Charlotte and Mr. Jerry Golinvaux Family Fund; the Roehl Family Foundation; the Joseph Durda Foundation; Ms. Marilyn and Mr. William Ryerse; Mr. Greg and Mrs. Rhoda Olsen. The generous gifts of these donors to the Minneapolis Heart Institute Foundation’s Science Center for Coronary Artery Disease (CCAD) helped support this research project.

Disclosures: Dr. Sandoval receives consulting/speaker honoraria from Abbott Diagnostics, Roche Diagnostics, Zoll, and Philips; is an associate editor for JACC Advances; and holds Patent 20210401347. Dr. Burke receives consulting and speaker honoraria from Abbott Vascular and Boston Scientific. Dr. Brilakis receives consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, and Teleflex; research support from Boston Scientific, GE Healthcare; is the owner of Hippocrates LLC; and is a shareholder in MHI Ventures, Cleerly Health, and Stallion Medical. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN 55407, USA. Email: esbrilakis@gmail.com; X: @dnzmtlu; @m1chaella_alex; @RempakosT, @AhmedAlOgaili; @yadersandoval; @esbrilakis; @CCAD_MHIF

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