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Carlo Maccia - The CTO dose registry: a tool for optimizing patient radiation protection
1. The CTO dose registry: a
tool for optimizing patient radiation
protection
Carlo Maccia (PhD)
Centre d’Assurance de qualité des Applications Technologiques dans le
domaine de la Santé (CAATS)
Bourg-La-Reine - France
2. GENERAL FRAMEWORK
• The increasing number and complexity of CTO
procedures has led to a higher number of
patients at risk for tissue reactions and skin
injuries.
• Monitoring of their dose indicators is essential
in recognizing these patients, optimizing their
radiation protection and organizing their follow
up.
3. Angular distribution of x-ray beams and
overlaps CTO - LAD and Right Coronary
artery
1st attempt
(280 impacts)
2nd attempt
(241 impacts)
5. Objectives of the CTO dose registry
• Assess patient radiation protection practices
and implement optimization strategies
• Provide a tool for educational purposes in
radiation protection
• Better define high dose procedures
• Define trigger levels for different procedures
(antegrade, retrograde)
• Give guidelines about thresholds
6. Objectives of the CTO dose registry
• Set up a core team of 4-5 experts (medical
physicist, interventional cardiologist, nurse or
radiographer(?), bio-medical engineer(?)) to
review cases
• Define incidents/accidents, according to Basic
Euro CTO Club, Safety Standards, European
Basic Safety Standards, local laws…
7. RECOMMANDATIONS
• There must be a commitment of major CTO
participating centers to be able to keep the
registry up and running at all times, and to
update and adapt to new demands or
regulations continuously :
– New x-ray systems like hybrid cath-labs and new
medical interventional procedures
– More staff involved including new medical
specialists
8. RECOMMANDATIONS
• Registry should be easily accessed and the
forms should be easy to fill in
• Registry could include reporting dose levels
relevant to tissue reactions like RIHD (radiation-
induced heart diseases) or cancer
• Some trigger events should be included
whatever the procedure
– wrong patient, wrong procedure, unintended
exposure of pregnant patient
9. RECOMMANDATIONS
• Registry should offer information and benefits
to the participating center, like :
– a list of things that could go wrong and ways to
avoid them
– as well as general (cumulative dose is usually only
an indicator, less and less accurate the further from
the isocenter one is working)
– tailored advice including expert review or training
programme if needed.
10. RECOMMANDATIONS
• There should be interaction with the users
(provided they have agreed)
a) to get more information about some
cases
b) to offer optimization means
12. THE REGISTRY OUTCOMES
• Graphs and histograms per procedure (median
and 3rd quartile) because outliers are easy to
identify
• Explanation of outstanding values
• Graphs of AK (Cumulative Air Kerma at IRP) vs
number of patients, or per patient if repeated
procedures in same location, and/or for the
same lesion
13. THE REGISTRY OUTCOMES
• Estimated peak skin dose at different levels of accuracy
depending on the amount of information given by the
machine
• All information from the manufacturer from both fluoro
and cine runs
– Patient Dose Structured Report
– Dose report
– DAP and/or AK information
– Fluoro time
– Statistics on local, international or published average
for the procedure
14. PROMOTION OF THE CTO DOSE
REGISTRY
• A means of promotion of the CTO dose registry could
be a certificate underscoring that the participating
center is part of a recognized international quality
system (EuroCTO club for instance)
• CTO dose registry slides should be included in training
material in the ERCTO website
• To give talks about CTO dose registry in invited lectures
in training courses and professional meetings
15. TECHNICAL POINTS
• Organizing data collection (SDR report)
• Ensuring quality of data
• Maintaining database
• Handling data
• Data analysis
• Preparing a EuroCTO club final document.
• Publishing a paper
18. LOCAL DOSE REGISTRY RESULTS
18 months follow-up (n = 810) : mean
DAP values by cardiologist
0
50
100
150
200
250
A B C D F E G H I
DAP (Gy.cm2)
19. LOCAL DOSE REGISTRY RESULTS
18 months follow-up (n = 810) : mean
AK values by cardiologist
0
500
1000
1500
2000
2500
3000
3500
4000
4500
A B C D F E G H I
AK (mGy)
20. Conclusion
Use the best dose reduction options available
as frequently as possible
Manage radiation as well as you manage
drugs or contrast agents
Collaborate with medical physicist
(dosimetry)
Complying with it will lead to substantial dose
savings for both patient and operator.