Proper Use of CineangiProper Use of Cineangiographic Equipment anographic Equipment an

d Contrast Agentsd Contrast AgentsGrossman’s cardiac Grossman’s cardiac

catheterization, angiography, catheterization, angiography, and interventionand intervention

CV CV R5 R5 陳儒逸陳儒逸醫師醫師Supervisor: Supervisor: 劉秉彥醫師劉秉彥醫師

The Angiography RoomThe Angiography Room

Rotation

left or right

anterior oblique

Skew

cranial or caudal

Biplane system

Single plane system

Classic Image Classic Image ChainChain

A A generatorgenerator A A cine pulse systemcine pulse system An An x-ray tubex-ray tube An An image intensifier (I.I.)image intensifier (I.I.) An optical distributorAn optical distributor A 35-mm cine cameraA 35-mm cine camera A A television cameratelevision camera and and

monitormonitor

Live fluoroscopy

Cineangiography

47 m2 and 3 m

1 mm of lead

Lead-treated glass

Filmless system

DICOM

The X-Ray TubeThe X-Ray Tube

Image Intensifier (I.I.)

Radiation SafetyRadiation Safety

Radiation exposureRadiation exposure The biologic effects of radiationThe biologic effects of radiation Proper use of monitoringProper use of monitoring The shielding equipmentThe shielding equipment

Units of Measurement• Primary unit of radiation exposure:

R: roentgen (侖琴 ) = 2.58x10-4 coulombs ( C )

• Quantitating tissue effects:

rad (radiation absorbed dose)

gray (1 Gy = 100 rad); soft tissue (1R = 0.9rad); bone (1R = 4rad)

• Different types of radiation may produce different degrees of damage

rem (radiation equivalent in man)

Sievert (1 Sv = 100 rem)

• NCRP (1987) : EDE ( effective dose equivalent) ( rem or Sv)

Biologic Effects of Radiation• The maximal annual occupational dose at 5 rem or 50 mSv.

Normal (5 mSv)• Stochastic problems

1. genetic damage (birth defect); (5%) (1 Sv == doubling baseline risk of mutation)

2. neoplasm; 0.04% / rem exposure (10 mSv)• Deterministic problems

1. Eye (cataract): 250 ~ 500 rem

2. Skin: redness (200 rem) ; temporary hair loss (300 rem)

Reducing Exposure Dose

• Minimizing the patient dose• Keep the I.I. in near contact with the patient’s

chest• Reducing the amount of fluoroscopy time (FT)

to the minimum required to position catheters• The total FT should be well under 10 minutes

for a diagnostic procedure• Avoid “lead foot” syndrome• Increasing distance or using shielding

Intravascular Contrast Agents

HOCM

6 X BLOOD

1950s

LOCM mid-1980s 2 X BLOOD

late-1980s 2~3 X BLOOD

1 X BLOOD

ˇ LOCM

Fewer episodes of bradycardia and hypoFewer episodes of bradycardia and hypotensiontension

Less anginaLess angina Less nauseaLess nausea Less heat sensation than traditional HOCLess heat sensation than traditional HOC

MM Fewer allergic effectFewer allergic effect Less nephrotoxicityLess nephrotoxicity

•Predisposing patients to thrombotic events??

＄＄ 150~200 / 200 ml (non-ionic) == 150~200 / 200 ml (non-ionic) == ＄ ＄ 3636 ＄＄ 20 / 200 ml (ionic)20 / 200 ml (ionic)

• Two or more characteristics

• Age > 65 y/o

• LVEDP > 15 mmHg

• NYHA class IV symptoms

• A history of previous reaction to contrast material

• Baseline Cr > 2.5 mg/dl