Catheter strategy to ease the procedure and reduce radiation exposure when requiring neck access

Abstract

ObjectivesTo assess the potential occupational radiation reduction and technical feasibility in patients rotated 180° (upside-down) when requiring neck access for transcervical or trans-subclavian catheterisation.MethodsUpside-down positioning is defined as rotating patients in supine position by 180°, so that the feet come to rest where the head would otherwise be. We retrospectively evaluated all these procedures performed between March 2016 and May 2019. Furthermore, two different phantoms (paediatric and adult) were used prospectively to quantify the occupational dose between conventional or upside-down positioning. In this context, ambient dose equivalents were measured using real-time dosimeters. Three different projection angles were applied.Results44 patients with median age and body weight of 1.0 year (range 0–56) and 9.5 kg (range 1.3–74.3) underwent 63 procedures positioned upside-down. This position proved advantageous for practical reasons, since the length of the examination table could be optimally used. Additionally, it resulted in a significantly lower overall ambient dose equivalent for the primary operator (PO) of 94.8% (mean: 2569±807 vs 135±23 nSv; p<0.01) in the adult, and of 65.5% (mean: 351±104 vs 121±56 nSv; p<0.01) in the paediatric phantom, respectively.ConclusionUpside-down positioning facilitates handling in a straightforward manner when access from the neck is required. Moreover, it significantly reduces local radiation exposure for the PO in the paediatric and, most impressively, in the adult phantom.

Expanding the Reach of Pediatric Transcatheter Pacing

“…The specific steps taken to optimize room setup for planned neck access are informative, although, given the bulky delivery system, it may be worthwhile to consider inverted patient positioning (head/foot reversal) as has been described for interventional catheterization procedures. 10 The authors' observations of the implications of the limited "unsheathing distance" in small patients are likely to be helpful to implanters more experienced with larger patients.…”

“…In this particular case, leadless pacing was considered a firstline treatment option in an individual without contraindications to traditional transvenous or epicardial implant approaches. Previous publications [8][9][10][11][12][13] have cited limitations to conventional implants due to patient-related circumstances or medical complexities, thereby driving the decision to pursue leadless pacing as a secondary option.…”

“…Femoral and internal jugular venous approaches have been used during pediatric Micra™ implantation with excellent implant success rates and good postimplant device stability and function. Though our collective experience is still fairly limited, published cases [8][9][10][11][12][13] have demonstrated successful and functional leadless pacing from the right ventricle (RV) in pediatric patients across a broad spectrum of sizes. Perhaps the foremost question in pediatric implants is whether the leadless pacemaker is too large to go through the lower vasculature.…”