This article is part of the Master’s degree dissertation of Luciana Aparecida Salgado Rodrigues from the Graduate Program in Health Sciences of the
CONFLICT OF INTEREST
The authors declare no conflicts of interest.
Ad hoc percutaneous coronary intervention via radial access has become frequent in interventional cardiology services, with reduced bleeding rates, vascular complications and costs. There are few reports in the medical literature on radiological exposure rates (kerma area product − Kap, and incident air kerma − Iak) in these procedures, when they are performed via radial access. The objective of the study was to compare radiological variables in staged percutaneous coronary interventions with ad hoc interventions via radial access.
A total of 120 patients were studied, divided into two groups of 60: Group A, patients undergoing diagnostic coronary angiography and staged percutaneous coronary intervention, versus Group B, patients undergoing ad hoc percutaneous coronary intervention via radial access, from August 2014 to September 2015. The values of radiological exposure rates were measured.
When comparing Groups A and B, we observed body mass index of 27.83±4.20kg/m2 vs. 26.88±4.14kg/m2 (p=0.3); total Kap of 16,222.5±10,613.5µGym2 vs. 12,029.2±7,360.6µGym2 (p=0.01); total Iak of 3,886.8±2,946.7mGy vs. 2,940.3±1,841.0mGy (p=0.04); total fluoroscopy time of 23.2±13.17 minutes vs. 17.1±9.68 minutes (p=0.0009); SYNTAX score 14.7±8.3 vs. 13.7±8.9 (p=0.54).
Radiological exposure rates in ad hoc percutaneous coronary interventions were lower than in staged percutaneous coronary interventions, when the procedures are performed via radial access.
Technological evolution and the advent of new tools have made ad hoc percutaneous coronary intervention (PCI) a safe procedure with low rates of early complications. In ad hoc PCI, patients are subjected to higher radiation exposure in the same procedure, greater contrast volume, and, consequently, greater chance of developing contrast-induced nephropathy, longer procedure duration, difficulty in obtaining informed consent for the procedure, and a faster decision-making process, compromising the heart team concept.
Almost all data available in the literature on ad hoc PCI are from real-world registries, showing a reduction in puncture site-related vascular complications, no increase in the incidence of procedure-related complications, including mortality, and no significant changes in the immediate success rate of the procedure.
The use of radial access for coronary angiography and PCI has increased significantly in recent years. The advantages of this approach include lower bleeding and vascular complication rates, and greater patient comfort, with a significant reduction in hospital costs and length of stay.
The potential harmful effects of ionizing radiation are classified as deterministic effects, which occur when the exposure threshold is exceeded, increasing the probability of cell damage, and stochastic effects, which are threshold-independent, linked to the cell sensitivity of the exposed individual, and may cause somatic DNA damage, even in chronic low doses. The risk is cumulative for patients and professionals, and the greater the number of procedures performed, the greater the doses and the potential risks.
There are few reports in the medical literature on radiation doses for patients and health professionals in ad hoc PCI using the radial technique.
This is an observational, sequential, prospective, comparative study of radiological variables related to radiation exposure obtained in an AXIOM Artis (Siemens Healthcare GmbH, Erlangen, DE, Germany) equipment. The study was conducted from August 2014 to September 2015, in 120 patients divided into two equal groups of patients undergoing coronary angiography and staged (Group A) or ad hoc (Group B) PCI, at the
The study was approved by the Research Ethics Committee of the IAMSPE, under CAAE number 868,337. The use of an Informed Consent Form was not required, because this was an equipment protocol and data collection, and the procedures occurred regardless of the research.
The inclusion criteria included patients undergoing coronary angiography and staged or ad hoc PCI via radial access, and excluded patients who underwent other procedures (intracoronary ultrasound or fractional flow reserve) and procedures performed using the femoral technique.
The cases were sequentially selected based on the variables radial access approach and type of procedure (staged or ad hoc). They were all performed at the IAMSPE/HSPE, and included radiological exposure data. For all patients selected for the study, the SYNTAX score was calculated by the operators. As to staged PCI, we included patients referred to only one procedure after diagnostic coronary angiography. We used two forms for the staged procedures, since they were performed on different days, and the radiological doses and the other parameters were added for purposes of comparison with the ad hoc procedures.
The procedures were performed according to the local practice of the hospital and operators, who were experienced in the radial technique and blind as to the inclusion of patients in the protocol. The ad hoc PCI followed the usual protocol at the hospital, based on the agreement of the patient and the attending physician, on previous renal function, on radiological exposure, and on the amount of contrast used in the diagnostic procedure. Renal function was analyzed by comparing serum creatinine at 24 hours before elective and ad hoc PCI, and at 48 hours after the procedures.
The term dose in our study refers to the amount of radiation delivered to the patient (primary radiation) and to the environment, as well as the scattered radiation (secondary radiation), during the procedures. Doses were measured using an ionization chamber, Diamentor© PTW DALI (Freiburg), attached to the primary collimator output end (
Clinical and procedural data were compiled in a specific form, and a comparative analysis of the variables in the two groups was performed. In the radiological rate form, we compiled data regarding the images in cine mode and the total sum of doses. The variables that we compiled and analyzed were: number of cine projections (projections); amount of 15f/s and 30f/s cine frames; total fluoroscopy time (FT); cine scoping time (CST); kilovolt (kV) – ampoule tension; milliampere (mA) – ampoule current; millisecond (ms) – pulse width; frame rate (F) – frame rate μGym2 – Kap; mGy – Iak (dose in patient’s skin), presented, respectively, in total dose, fluoro, total cine, 15 f/s cine, and 30 f/s cine.
The software Sample Size Calculations Online (SISA) was used to calculate the sample size, considering the FT for ad hoc interventions as 16±10 minutes, and for staged interventions, 22±14 minutes. Epi Info™ (version 7.2 software for Windows), and an Excel (Microsoft Office 2010) database were used for statistical analysis. Categorical variables were described as frequencies and percentages, and compared with the Chi-square test or Fisher’s exact test, when appropriate. Continuous variables were described as mean and standard deviation, and compared with the Kruskal-Wallis test and paired Student’s t test for both groups. Data were expressed as median and interquartile range in nonhomogeneous groups. The level of significance was set at p<0.05.
From August 2014 to September 2015, a total of 1,936 procedures were performed in 1,460 patients, of whom 368 underwent coronary angiography and PCI, of which 203 were elective procedures, and 165 were emergency procedures. Of the 368 patients, 248 were excluded for not meeting inclusion criteria. The remaining 120 patients who underwent both procedures via radial access were divided into two equal groups: staged (Group A), and ad hoc (Group B).
When comparing the clinical characteristics of Groups A and B, there was no statistically significant difference between the variables (
Results expressed as mean ± standard deviation, or n. MI: myocardial infarction; ACS: acute coronary syndrome.
Variables
Group A (n=60)
Group B (n=60)
p-value
Age, years
70±8
66±11
0.99
Male sex
36
35
0.85
Body mass index
27.8±4.2
26.8±4.1
0.28
Current smoking
14
12
0.66
Hypercholesterolemia
39
30
0.09
Hypertension
47
51
0.34
Insulin-dependent diabetes mellitus
6
4
0.50
Non-insulin-dependent diabetes mellitus
18
16
0.68
Prior acute MI
17
14
0.53
Coronary artery bypass graft
9
1
0.008
Stable angina
28
6
0.0001
Silent ischemia
13
7
0.24
Non ST-segment elevation ACS
17
38
0.0001
ST-segment elevation MI
3
9
0.06
Results expressed as n or mean ± standard deviation. NS: non-significant.
Variables
Group A (n=60)
Group B (n=60)
p-value
Treated artery
Left main coronary artery
0
1
NS
Left anterior descending artery
29
29
NS
Left circumflex artery
15
15
NS
Right coronary artery
16
15
NS
Stent implantation
97
80
0,02
Classification of lesions
B1
13
17
NS
B2
18
21
NS
C
29
22
NS
SYNTAX score
14,7±8,3
13,7±8,9
NS
A comparative analysis of the procedures’ impact on renal function in the two groups showed that, although Group B received a higher volume of iodinated contrast (p=0.03), there was no statistically significant difference in creatinine dosages at 48 hours after the procedure (
SD: standard deviation; Q1: lower quartile; Q3: upper quartile.
Variables per group
Median (minimum – maximum)
Mean ± SD
Interquartil range
p-value
Q1
Q3
Duration of the procedure, minutes
0.03
Group A
60 (7-135)
61.23±26.20
45
75
Group B
50 (10-130)
53.35±29.54
30
65
Contrast media volume, mL
0.32
Group A
170 (60-420)
178±78
135
230
Group B
160 (20-340)
165±75
110
220
Baseline creatinine, mg/dL
0.28
Group A
1.0 (0.5-2.4)
1.04±0.38
0.8
1.2
Group B
1.1 (0.7-4.7)
1.10±0.43
0.9
1.2
Creatinine 48 hours, mg/dL
0.28
Group A
1.0 (0.6-2.5)
1.07±0.40
0.8
1.3
Group B
1.05 (0.6-5.6)
1.16±0.67
0.8
1.3
When we analyzed the radiological exposure rates and the technical parameters of the groups, we observed statistically higher values in Group A when compared with Group B in Kap total dose, Kap fluoro, Kap cine, Iak total dose, Iak fluoro, Iak cine, total scoping time, CST, and number of projections (
SD: standard deviation; Q1: lower quartile; Q3: upper quartile; Kap: kerma area product; Iak: incident air kerma.
Variables per group
Median (minimum – maximum)
Mean ± SD
Interquartile range
p value
Q1
Q3
Kap total dose, µGym2
0.01
Group A
13,751.1 (3,054.8-63,522.2)
16,222.5±10,613.5
9,374.8
20,245.4
Group B
12,009.9 (2,002.4-35,663.5)
12,029.2±7,360.6
6,375.9
35,663.5
Kap fluoro, µGym2
0.04
Group A
7,338.4 (117.1-53,589.6)
9,936.4±8,381.6
3,744.6
13,262.3
Group B
5,976.2 (788.4-24,434.1)
7,169.0±5,303.8
2,660.4
10,396.9
Kap cine, µGym2
0.02
Group A
7,002.8 (1,877.7-26,215.6)
7,871.4±4,319.6
4,612.0
10,334.0
Group B
5,169.2 (1,230.8-18,580.3)
6,384.6±3,911.5
3,719.2
8,319.7
Iak, total dose
0.04
Group A
3,198 (648-19,284)
3,886.8±2,943.7
2,015
4,766
Group B
2,780 (507-9,268)
2,940.3±1,841.0
1,488
3,774
Iak fluoro, mGy
0.10
Group A
1,682 (209-16,629)
2,347.7±2,423.1
898
2,989
Group B
1,346 (156-5,706)
1,703.0±1,286.6
640
2,476
Iak cine, mGy
0.03
Group A
1,723 (420-5,967)
1,961.1±1,079.6
1,213
2,507
Group B
1,388 (337-8,308)
1,654.6±1,230.9
839
2,259
Total fluoroscopy time
0.0009
Group A
21.5 (7.9-96.2)
23.2±13.17
14.5
27.9
Group B
14.4 (4.7-53.3)
17.1±9.68
10.7
21.1
Cine fluoroscopy time
0.0001
Group A
2.7 (1.5-4.9)
2.7±0.78
2.1
3.2
Group B
2.0 (1.1-3.9)
2.2±0.68
1.7
2.7
Cine projections
0.0001
Group A
44 (20-79)
44.9±14.9
33
51
Group B
28 (11-77)
32.7±17.9
22
77
To evaluate the impact of the number of stent implants in one artery on radiological rates and technical parameters, a comparative sub analysis was performed in the two groups, with one or two stent implanted in one artery. In patients undergoing one stent implantation, there was a statistically significant difference in Group A (n=30) compared with Group B (n=39) in fluoroscopy time (18.4 minutes vs. 12.8 minutes; p=0.03), total 15f/s frames (1,775 frames vs. 1,521 frames, p=0.01), and total projections (33 projections vs. 27 projections, p=0.001). In patients with two stents in one artery, there was a statistically significant difference in Group A (n=19) as compared to Group B (n=16) in fluoroscopy time (24.6 minutes vs. 20.9 minutes; p=0.02), and in total projections (49 projections vs. 35 projections, p=0.004) (
Q1: lower quartile; Q3: upper quartile; Kap: kerma area product; Iak: incident air kerma.
Variables per group
Implant of one stent in one artery Group A=30 staged; Group B=39 ad hoc
Implant of two stents in one artery Group A=24 staged; Group B=17 ad hoc
Median (minimum – maximum)
Interquartile range
p value
Median (minimum – maximum)
Interquartile range
p value
Q1
Q3
Q1
Q3
Scoping time
0.03
0.02
Group A
18.4 (7.9-37.4)
12.2
24.1
24.6 (11.1-43.9)
19.3
32.5
Group B
12.8 (4.7-53.3)
8.3
19.4
20.9 (8.6-35.0)
14.2
23.5
Kap total, µGym2
0.25
0.77
Group A
10,436.9 (4,031.0-29,264.3)
6,796.5
15,566.3
19,551.4 (3,054.8-49,107.6)
13,751.1
26,780.6
Group B
8,299.9 (2,002.4-32,968.5)
5,990.8
13,442.4
14,961.2 (4,738.0-35,663.5)
12,159.8
18,635.3
Kap fluoro. µGym2
0.36
0.18
Group A
5,486.5 (1,888.0-19,065.9)
3,197.7
9,188.2
11,378.8 (1,177.1-30,217.5)
7,552.9
16,688.1
Group B
4,348.8 (788.4-24,434.1)
2,273.5
9,239.8
8,444.7 (2,069.0-22,440.6)
5,651.5
11,840.2
Iak total. mGy
0.29
0.30
Group A
2,366.0 (1,039.0-6,433.0)
1,644.0
3,801.0
4,370.0 (648.0-11,819.0)
3,450.0
6,130.5
Group B
2,052.0 (507.0-6,262.0)
1,188.5
3,591.5
3,920.0 (1,000.0-9,268.0)
2,465.0
9,268.0
Iak fluoro. mGy
0.43
0.33
Group A
1,071.7 (389.4-4,349.8)
761.1
2,262.5
2,699.9 (227.2-7,152.0)
1,828.2
3,646.4
Group B
989.8 (156.6-4,300.3)
497.9
2,417.8
2,286.3 (336.8-5,706.5)
1,187.8
3,001.3
Cine 15 frames
0.01
0.08
Group A
1,775 (800-3,039)
1,541
2,219
2,346 (71-3,336)
1,889
2,687
Group B
1,521 (365-2,993)
1,282
1,785
2,055 (477-2,679)
1,597
2,399
Projections
0.004
0.01
Group A
33 (20-62)
28
43
49 (29-79)
44
57
Group B
27 (11-75)
22
33
35 (19-77)
28
46
Differing from other publications our study compared all radiological variables collected from the records of patients undergoing coronary angiography and staged or ad hoc PCI performed via radial access. All first operators were physicians and highly experienced radial operators. The data showed that patients undergoing ad hoc PCI were less exposed to radiation than those undergoing staged PCI, in agreement with the study by Truffa et al., who also observed lower radiological exposure rates in the ad hoc approach.
The lower exposure to radiation in ad hoc interventions, compared with staged interventions, can be explained by the use of the same access for the diagnostic procedure, thus eliminating the need for another fluoroscopy for catheter placement, since the guidewire is already positioned in the aorta, and only a catheter replacement is performed; by the lower frequency of left ventriculography; by the awareness of the best projection to properly visualize the lesion, avoiding unnecessary image acquisitions; by the lower incidence of revascularized patients; by the fact that the same operator performs the procedure and controls the amount of contrast and radiation used.
In our study, no statistically significant difference between the two groups was observed in lesion classification, but the number of stent implants and the number of revascularized patients were higher in staged PCI when compared with ad hoc PCI. This could also have influenced the results obtained, explaining the greater amount of radiation delivered to the patients in staged procedures. A sub analysis was performed separating the groups according to the number of stents implanted per artery. In staged PCI with one or two stent implants per vessel, when compared with ad hoc PCI, a statistically significant difference was observed only in the variables fluoroscopy time, total 15f/s frames, and total projections. The fact that no change was observed in Kap and Iak can be explained by the small size of the sample.
According to the recommendations of the International Atomic Energy Agency (IAEA), Report 59, the following reference levels for the dose delivered to the patient should be observed based on Kap values: 50 Gycm2 for coronary angiography, and 125 Gycm2 for PCI.
In 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) added a recommendation that a 15 Gy fluoroscopy skin dose (Iak) is a sentinel event. Doses above 2 Gy should be included in the patients’ medical records, and doses above 5 Gy require the patient to be followed-up.
The decision-making process regarding whether to intervene immediately or to stage the procedure should also be based on renal function, avoiding exceeding safe limits for the patient.
This was an observational, sequential, non-randomized study. The procedures were performed in a single center, with a reduced number of patients. A higher prevalence of individuals with a history of coronary artery bypass grafting and stable angina was observed in Group A. The procedures were performed by more than one operator, although all operators had extensive experience in the radial technique.
Radiological rates in ad hoc percutaneous coronary interventions are lower than in staged percutaneous coronary interventions, when the procedures are performed via radial access. The results suggest that lower doses of radiation may be interpreted as a potential benefit of the ad hoc approach.
SOURCE OF FINANCING
None
Este artigo representa parte da dissertação de Mestrado de Luciana Aparecida Salgado Rodrigues pelo Programa de Pós-Graduação em Ciências da Saúde do Instituto de Assistência Médica ao Servidor Público Estadual.
CONFLITOS DE INTERESSE
Os autores declaram não haver conflitos de interesse.
A intervenção coronária percutânea
Quando comparados os Grupos A e B, observamos índice de massa corporal de 27,83±4,20kg/m2 vs. 26,88±4,14kg/m2 (p=0,3); Pka total de 16.222,5±10.613,5µGym2 vs. 12.029,2±7.360,6µGym2 (p=0,01); Kai total de 3.886,8±2.946,7mGy vs. 2.940,3±1.841,0mGy (p=0,04); tempo de escopia total de 23,2±13,17 minutos vs. 17,1±9,68 minutos (p=0,0009), escore SYNTAX de 14,7±8,3 vs. 13,7±8,9 (p=0,54).
As taxas radiológicas das intervenções coronárias percutâneas
A evolução tecnológica e o advento de novos instrumentais tornaram a intervenção coronária percutânea (ICP)
A quase totalidade dos dados disponíveis na literatura sobre a ICP
A utilização do acesso radial para realização de coronariografias e ICP tem aumentado de forma expressiva nos últimos anos. As vantagens dessa abordagem incluem menores taxas de sangramento e de complicações vasculares, e maior conforto aos pacientes, com significativa redução dos custos hospitalares e do tempo de internação.
Os potenciais efeitos nocivos da radiação ionizante são os determinísticos, que ocorrem quando o limiar de exposição é excedido, aumentando a probabilidade de dano celular, e os estocásticos, que ocorrem sem limiar, vinculados à sensibilidade celular do indivíduo exposto, sendo que, mesmo em baixas doses crônicas, eles podem provocar danos ao DNA somático. O risco é cumulativo para pacientes e profissionais, e, quanto maior o número de procedimentos realizados, maiores as doses e os riscos potenciais.
São escassas, na literatura médica, as informações sobre as doses de radiação para pacientes e profissionais de saúde utilizando a ICP
Trata-se de estudo observacional, sequencial, prospectivo, comparativo das variáveis radiológicas de exposição à radiação obtidas no equipamento AXIOM Artis (Siemens Healthcare GmbH, Erlangen, DE, Alemanha). O estudo foi realizado no período de agosto de 2014 a setembro de 2015, em 120 pacientes divididos em dois grupos iguais submetidos à coronariografia e à ICP estadiadas (Grupo A) ou
O estudo foi aprovado pelo Comitê de Ética em Pesquisa do IAMSPE, parecer 868.337, e foi dispensado o uso de Termo de Consentimento Livre e Esclarecido, por se tratar de registro de dados e protocolo do equipamento, e pelos procedimentos ocorrerem independentemente da pesquisa.
Foram critérios para inclusão os pacientes submetidos aos procedimentos de coronariografia e de ICP realizadas pelo acesso radial, estadiados ou
Os casos foram selecionados sequencialmente, a partir das variáveis via de acesso radial e tipo de procedimento (estadiado ou
Os procedimentos foram realizados de acordo com a rotina do serviço e dos operadores, experientes com a técnica radial, cegos quanto à inclusão dos pacientes no protocolo. A realização da ICP
O termo “dose”, no presente estudo, está relacionado à quantidade de radiação entregue ao paciente (radiação primária) e para o ambiente, bem como a radiação espalhada (radiação secundária), durante os procedimentos realizados. O cálculo da dose fornecida pelo equipamento é obtido por câmara de ionização Diamentor© PTW DALI (Freiburg), acoplada na saída do colimador primário (
Foram coletados em formulário específico os dados clínicos e dos procedimentos, e foram analisadas as variáveis comparativamente entre os dois grupos. No formulário das taxas radiológicas, foram coletados os dados referentes às imagens no modo cine e à somatória total de doses. As variáveis coletadas e analisadas foram número de projeções cine (projeções); quantidade de frames cine de 15f/s e 30f/s; tempo de fluoroscopia (TF) total; tempo de escopia cine (TEC); kilovolt (kV) – tensão da ampola; miliampere (mA) – corrente da ampola; milissegundo (ms) – largura do pulso;
Para o cálculo do tamanho da amostra, foi utilizado o
No período de agosto de 2014 a setembro de 2015 foram realizados 1.936 procedimentos em 1.460 pacientes, dos quais 368 realizaram coronariografia e ICP, sendo 203 eletivos e 165 emergenciais. Dos 368 pacientes, 248 foram excluídos por não preencherem os critérios de inclusão, permanecendo 120 pacientes que se submeteram aos 2 procedimentos por acesso radial, divididos em dois grupos iguais, estadiados (Grupo A) e
Quando comparadas as características clínicas dos Grupos A e B, não houve diferença estatisticamente significativa entre as variáveis (
Resultados expressos por média ± desvio padrão, ou n. IAM: infarto agudo do miocárido; SCA: síndrome coronária aguda.
Variáveis
Grupo A (n=60)
Grupo B (n=60)
Valor de p
Idade, anos
70±8
66±11
0,99
Sexo, masculino
36
35
0,85
Índice de massa corporal
27,8±4,2
26,8±4,1
0,28
Tabagismo atual
14
12
0,66
Hipercolesterolemia
39
30
0,09
Hipertensão arterial sistêmica
47
51
0,34
Diabetes melito insulinodependente
6
4
0,50
Diabetes melito não insulinodependente
18
16
0,68
IAM prévio
17
14
0,53
Cirurgia de revascularização miocárdica
9
1
0,008
Angina estável
28
6
0,0001
Isquemia silenciosa
13
7
0,24
SCA sem supradesnivelamento do segmento ST
17
38
0,0001
IAM com supradesnivelamento do segmento ST
3
9
0,06
Resultados expressos em n ou em média ± desvio padrão. NS: não significativo.
Variáveis
Grupo A (n=60)
Grupo B (n=60)
Valor de p
Artéria tratada
Tronco da coronária esquerda
0
1
NS
Descendente anterior
29
29
NS
Circunflexa
15
15
NS
Coronária direita
16
15
NS
Implante de stent
97
80
0,02
Classificação das lesões
B1
13
17
NS
B2
18
21
NS
C
29
22
NS
Escore SYNTAX
14,7±8,3
13,7±8,9
NS
A análise comparativa para avaliar o impacto dos procedimentos na função renal entre os dois grupos mostrou que, apesar de o Grupo B ter utilizado maior volume de contraste radiológico (p=0,03), não houve diferença estatisticamente significativa nas dosagens de creatinina 48 horas após o procedimento (
DP: desvio padrão; Qi: quartil inferior; Qs: quartil superior.
Variáveis por grupos
Mediana (mínimo - máximo)
Média ± DP
Intervalos interquartis
Valor de p
Qi
Qs
Duração do exame, minutos
0,03
Grupo A
60 (7-135)
61,23±26,20
45
75
Grupo B
50 (10-130)
53,35±29,54
30
65
Volume de contraste, mL
0,32
Grupo A
170 (60-420)
178±78
135
230
Grupo B
160 (20-340)
165±75
110
220
Creatinina basal, mg/dL
0,28
Grupo A
1,0 (0,5-2,4)
1,04±0,38
0,8
1,2
Grupo B
1,1 (0,7-4,7)
1,10±0,43
0,9
1,2
Creatinina 48 horas, mg/dL
0,28
Grupo A
1,0 (0,6-2,5)
1,07±0,40
0,8
1,3
Grupo B
1,05 (0,6-5,6)
1,16±0,67
0,8
1,3
Quando analisadas as taxas radiológicas e os parâmetros técnicos dos grupos, observamos valores estatisticamente maiores no Grupo A em relação ao Grupo B no Pka dose total, Pka fluoro, Pka cine, Kai dose total, Kai fluoro, Kai cine, tempo de escopia total, TEC e número de projeções (
DP: desvio padrão; Qi: quartil inferior; Qs: quartil superior; Pka: produto kerma área; Kai: kerma no ar incidente.
Variáveis por grupos
Mediana (mínimo - máximo)
Média ± DP
Intervalos interquartis
Valor de p
Qi
Qs
Pka dose total, µGym2
0,01
Grupo A
13.751,1 (3.054,8-63.522,2)
16.222,5±10.613,5
9.374,8
20.245,4
Grupo B
12.009,9 (2.002,4-35.663,5)
12.029,2±7.360,6
6.375,9
35.663,5
Pka fluoroscopia, µGym2
0,04
Grupo A
7.338,4 (117,1-53.589,6)
9.936,4±8.381,6
3.744,6
13.262,3
Grupo B
5.976,2 (788,4-24.434,1)
7.169,0±5.303,8
2.660,4
10.396,9
Pka cinegrafia, µGym2
0,02
Grupo A
7.002,8 (1.877,7-26.215,6)
7.871,4±4.319,6
4.612,0
10.334,0
Grupo B
5.169,2 (1.230,8-18.580,3)
6.384,6±3.911,5
3.719,2
8.319,7
Kai, dose total
0,04
Grupo A
3.198 (648-19.284)
3.886,8±2.943,7
2.015
4.766
Grupo B
2.780 (507-9.268)
2.940,3±1.841,0
1.488
3.774
Kai fluoroscopia, mGy
0,10
Grupo A
1.682 (209-16.629)
2.347,7±2.423,1
898
2.989
Grupo B
1.346 (156-5.706)
1.703,0±1.286,6
640
2.476
Kai cinegrafia, mGy
0,03
Grupo A
1.723 (420-5.967)
1.961,1±1.079,6
1.213
2.507
Grupo B
1.388 (337-8.308)
1.654,6±1.230,9
839
2.259
Tempo de escopia total
0,0009
Grupo A
21,5 (7,9-96,2)
23,2±13,17
14,5
27,9
Grupo B
14,4 (4,7-53,3)
17,1±9,68
10,7
21,1
Tempo de escopia cinegrafia
0,0001
Grupo A
2,7 (1,5-4,9)
2,7±0,78
2,1
3,2
Grupo B
2,0 (1,1-3,9)
2,2±0,68
1,7
2,7
Projeções cinegrafia
0,0001
Grupo A
44 (20-79)
44,9±14,9
33
51
Grupo B
28 (11-77)
32,7±17,9
22
77
Para avaliar o impacto do número de stents implantados em uma artéria nas taxas radiológicas e nos parâmetros técnicos, foi realizada subanálise comparativa entre os dois grupos, com implante de um ou dois stents em uma artéria. Nos pacientes submetidos ao implante de um stent, ocorreu diferença estatisticamente significativa no Grupo A (n=30) em relação ao Grupo B (n=39) no tempo de escopia (18,4 minutos vs. 12,8 minutos; p=0,03), total de frames de 15f/s (1.775 frames vs. 1.521 frames; p=0,01) e no total de projeções (33 projeções vs. 27 projeções; p=0,001). Nos pacientes com implante de dois stents em uma artéria, ocorreu diferença estatisticamente significativa no Grupo A (n=19) em relação ao Grupo B (n=16) no tempo de escopia (24,6 minutos vs. 20,9 minutos; p=0,02) e no total de projeções (49 projeções vs. 35 projeções; p=0,004) (
Qi: quartil inferior; Qs: quartil superior; Pka: produto kerma área; Kai: kerma no ar incidente.
Variáveis por grupos
Implante de um stent em uma artéria Grupo A=30 estadiados; Grupo B=39
Implante de dois stents em uma artéria Grupo A=24 estadiados; Grupo B=17
Mediana (mínimo - máximo)
Intervalos interquartis
Valor de p
Mediana (mínimo - máximo)
Intervalos interquartis
Valor de p
Qi
Qs
Qi
Qs
Tempo de escopia
0,03
0,02
Grupo A
18,4 (7,9-37,4)
12,2
24,1
24,6 (11,1-43,9)
19,3
32,5
Grupo B
12,8 (4,7-53,3)
8,3
19,4
20,9 (8,6-35,0)
14,2
23,5
Pka total, µGym2
0,25
0,77
Grupo A
10.436,9 (4.031,0-29.264,3)
6.796,5
15.566,3
19.551,4 (3.054,8-49.107,6)
13.751,1
26.780,6
Grupo B
8.299,9 (2.002,4-32.968,5)
5.990,8
13.442,4
14.961,2 (4.738,0-35.663,5)
12.159,8
18.635,3
Pka fluoroscopia, µGym2
0,36
0,18
Grupo A
5.486,5 (1.888,0-19.065,9)
3.197,7
9.188,2
11.378,8 (1.177,1-30.217,5)
7.552,9
16.688,1
Grupo B
4.348,8 (788,4-24.434,1)
2.273,5
9.239,8
8.444,7 (2.069,0-22.440,6)
5.651,5
11.840,2
Kai total, mGy
0,29
0,30
Grupo A
2.366,0 (1.039,0-6.433,0)
1.644,0
3.801,0
4.370,0 (648,0-11.819,0)
3.450,0
6.130,5
Grupo B
2.052,0 (507,0-6.262,0)
1.188,5
3.591,5
3.920,0 (1.000,0-9.268,0)
2.465,0
9.268,0
Kai fluoroscopia, mGy
0,43
0,33
Grupo A
1.071,7 (389,4-4.349,8)
761,1
2.262,5
2.699,9 (227,2-7.152,0)
1.828,2
3.646,4
Grupo B
989,8 (156,6-4.300,3)
497,9
2.417,8
2.286,3 (336,8-5.706,5)
1.187,8
3.001,3
Frames cinegrafia 15
0,01
0,08
Grupo A
1.775 (800-3.039)
1.541
2.219
2.346 (71-3.336)
1.889
2.687
Grupo B
1.521 (365-2.993)
1.282
1.785
2.055 (477-2.679)
1.597
2.399
Projeções
0,004
0,01
Grupo A
33 (20-62)
28
43
49 (29-79)
44
57
Grupo B
27 (11-75)
22
33
35 (19-77)
28
46
O presente estudo teve como diferencial, em relação a outras publicações, a comparação de todas as variáveis radiológicas obtidas dos registros de pacientes, submetidos à coronariografia e à ICP estadiadas ou
A menor exposição à radiação nas intervenções
No presente estudo, não se observou diferença estatisticamente significativa quanto à classificação das lesões entre os dois grupos, porém a quantidade de stents implantados e de pacientes revascularizados foi maior no grupo ICP estadiada em comparação com à ICP
De acordo com as recomendações da
Em 2006, o
A tomada de decisão de intervir imediatamente ou estadiar o procedimento deve também ser baseada na função renal, evitando ultrapassar os limites seguros para o paciente.
Estudo observacional, sequencial, não randomizado. Os procedimentos foram realizados em centro único, com número reduzido de pacientes, maior prevalência de indivíduos com antecedente de revascularização miocárdica e angina estável no Grupo A e procedimentos realizados por mais de um operador, embora todos com vasta experiência na técnica radial.
As taxas radiológicas nas intervenções coronárias percutâneas
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