"Hands off": Best practice radiation safety is rarely achieved in microcatheter angiography

Microcatheter angiography (MA) is often performed immediately following access of the common femoral artery using a 4F micropuncture sheath directly attached to a 10 cubic centimeter (cc) syringe to evaluate the suitability of iliofemoral access. It can also be performed at the end of an operation to assess for access-related complications in procedures requiring large bore (≥12F) percutaneous access. The operator's hands are particularly vulnerable in MA, and we hypothesize that best practices in radiation safety are rarely achieved in MA.

A retrospective review was performed of all patients who underwent elective percutaneous endovascular aneurysm repair (pEVAR) at a single institution from 2020 to 2023. Operative reports and digital subtraction angiography were reviewed to determine the prevalence of "prelarge bore" and "postlarge bore" MA. The primary endpoint was the rate of direct operator exposure in MA. Secondary endpoints included the rate of intraoperative access complications and radiation dose area product.

One hundred forty-four patients underwent pEVAR with 282 percutaneous femoral access sites. Of the 282 percutaneous common femoral artery access sites, 9% (N = 25) underwent prelarge bore MA only, 24% (N = 67) underwent postlarge bore MA only, and 56% (N = 159) underwent both prelarge bore and postlarge bore MA for a total of 410 microcatheter angiograms. The overall rate of direct operator exposure was 56% (N = 231/410) for MA. Individual rates of operator exposure ranged from 51% to 71%, and the three most prevalent performers accumulated cumulative dose area product values of 342, 386, and 479 Gy cm² from MA alone during the study period. Operator exposure was not associated with laterality, C-arm angulation, sheath size, or body mass index. There were only 10 intraoperative or perioperative access complications (6.9% overall; 3.5% per access site) of which only four were specifically recognized by MA.

MA was routinely performed in elective pEVAR, and best practices in radiation safety were rarely achieved with a high rate of direct operator exposure to the beam of radiation. The overall rate of access-related complications in elective pEVAR is low, and the window for detecting access-related complications with MA is narrow. Because of the high rate of operator exposure, selective MA and the development of guidelines for best practice technique MA should be considered.