ALARA in Urology: Steps to Minimise Radiation Exposure During All Parts of the Endourological Journey.

PURPOSE OF THE REVIEW: The global burden of kidney stone disease (KSD) and its management relies on ionising radiation. This includes the diagnosis, treatment and follow-up of KSD patients. The concept 'As Low As Reasonably Achievable' (ALARA) developed in response to the radiation risks and the key principles include optimisation, justification and limitation of radiation. This article provides an overview of the topic including background to the risks and steps that can be taken during all stages of endourological management. RECENT FINDINGS: Our review suggests that ionising radiation is an invaluable tool in delineating the anatomy, localising disease, guiding manoeuvres and monitoring treatment in patients with KSD. It therefore plays an integral role in many stages of patient care; preoperatively, intraoperatively and postoperatively. The reduction of radiation pre- and post-surgical intervention relies on the use of low-radiation CT scan and ultrasound scan. It can also be achieved through various intraoperative techniques or fluoroless techniques in selected patients/procedures, customised to the patients and procedural complexity. There are many parts of the patient journey where exposure to radiation can take place. Urologists must be diligent to minimise and mitigate this wherever possible as they too face exposure risks. Implementation of strategies such as teaching programmes, fluoroscopy checklists and judicious use of CT imaging among other things is a step towards improving practice in this area.

Radiation exposure in fluoroscopy-guided anterior total hip arthroplasty: a systematic review.

PURPOSE: To investigate the average fluoroscopy time, as well as the patient and surgical staff average radiation exposure in the context of intraoperative fluoroscopy use during anterior total hip arthroplasty (THA). METHODS: PubMed, Cochrane, Embase, Web of Science and Scopus were systematically searched for studies pertaining to intraoperative anterior THA fluoroscopy (PROSPERO ID 258049). The comprehensive literary search was conducted using "THA," "fluoroscopy" and "radiation exposure" as the search criteria, which resulted in 187 total papers. Of these 187 papers, 11 studies were included in this systematic review as they involved anterior THA and specifically contained data regarding radiation exposure dose and/or time. RESULTS: Eleven studies were included, enrolling 1839 patients. The average fluoroscopy time was 21.4 (95% confidence interval [CI] 16.6-26.1) seconds, whereas the average patient radiation dose was 1.8 × 10-3 (95% CI 7.4 × 10-4-2.9 × 10-3) Gy. CONCLUSIONS: Although several studies fail to report fluoroscopy time and radiation dose in THA patients, fluoroscopy-guided THA has emerged as a safe procedure. Additional studies may analyze if radiation exposure during the surgeon's THA learning curve is significantly higher, as well as what protocols may potentially reduce radiation exposure even further.

Progress in zero-fluoroscopy implantation of cardiac electronic device.

Fluoroscopy is the imaging modality routinely used for cardiac device implantation. Due to the rising concern regarding the harmful effects of radiation exposure to both the patients and operation staffs, many efforts have been made to develop alternative techniques to achieve zero-fluoroscopy implantation. In this review, we describe the different methods aimed at avoiding the application of fluoroscopy in recent years, and evaluate their feasibility and safety in cardiac electronic device implantation.

Radiation exposure of patients during endourological procedures: IAEA-SEGUR study.

Fluoroscopy is increasingly used to guide minimally invasive endourological procedures and optimised protocols are needed to minimise radiation exposure while achieving best treatment results. This multi-center study of radiation exposure of patients was conducted by the South-Eastern European Group for Urolithiasis Research (SEGUR), in cooperation with the International Atomic Energy Agency. Seven clinical centers from the SEGUR group collected data for 325 procedures performed within a three-months period, including standard percutaneous nephrolithotomy (PCNL), mini PCNL, retrograde intrarenal surgery (RIRS), semirigid ureterorenoscopy (URS) and flexible URS. Data included: air kerma area product (PKA), air kerma at the patient entrance reference point (Ka,r), fluoroscopy time (FT), number of radiographic images (N) and fluoroscopy pulse rate, as well as total procedure duration, size and location of stones. Data were centrally analysed and statistically compared. MedianPKAvalues per center varied 2-fold for RIRS (0.80-1.79 Gy cm2), 7.1 fold for mini-PCNL (1.39-9.90 Gy cm2), 7.3 fold for PCNL (2.40-17.50 Gy cm2), 19 fold (0.13-2.51 Gy cm2) for semi-rigid URS and 29-fold for flexible URS (0.10-2.90 Gy cm2). LowerPKAandKa,rwere associated with use of lower FT,Nand lower fluoroscopy pulse rate. FT varied from 0.1 to 14 min, a small fraction of the total procedure time, ranging from 10 to 225 min. HigherNwas associated with higherPKAandKa,r. Higher medianPKAin PCNL was associated with the use of supine compared to prone position. No correlation was found between the concrement size and procedure duration, FT,PKAorKa,r. Dose values for RIRS were significantly lower compared to PCNL. The maximumKa,rvalue of 377 mGy was under the threshold for radiation induced skin erythema. The study demonstrated a potential for patient dose reduction by lowering FT andN, using pulsed fluoroscopy and beam collimation.

Radiation Safety Education and Practices in Urology: A Review.

Introduction: Radiation safety education is important as fluoroscopy is commonly used for diagnostic and therapeutic purposes. Exposure to high levels of ionizing radiation is associated with an increased risk of cancer and other adverse health effects; therefore, it is essential that urologists and trainees are educated on the safe use of radiation. Unfortunately, radiation education and occupational safety is not standardized for this group and there are currently no review studies examining radiation safety for urologists in the clinical setting. This review aims at investigating the various levels of radiation safety education and practices used in urology. Methods: MEDLINE and EMBASE databases were searched for relevant publications reporting on radiation knowledge and randomized controlled trials, non-randomized comparative studies, and observational studies were included. Reviews, abstracts, editorial comments, non-urologic studies, and incomplete articles were excluded. Results: Within these articles, there were 16 observational studies. Frequency of radiation exposure ranged from <1 × to >15 × /week. There were higher rates of adherence to use of lead aprons and thyroid shields than lead eyeglasses and gloves. Radiation safety education was infrequent. Radiation safety knowledge was especially low for the risks of radiation exposure. Most studies highlight the need for increased awareness and training on radiation safety for both urology trainees and consultants. Conclusions: Radiation safety education and practices are an important issue in urology. Improvements to education and compliance to radiation safety practices are critical to ensuring urologists and trainees use ionizing radiation in a safe and responsible manner.

Orthopaedic surgeons' knowledge and practice of radiation safety when using fluoroscopy during procedures: A narrative review.

OBJECTIVES: The fluoroscopy environment poses a potential occupational radiation exposure risk to theatre personnel. Risks can be mitigated with effective application of radiation protection knowledge and methods. This review aimed to determine the link between orthopaedic surgeon's knowledge and the use of appropriate safety methods when using fluoroscopy. KEY FINDINGS: A keyword search of three databases discovered six articles, totalling 2209 orthopaedic surgeons, who completed surveys to assess knowledge on various aspects of radiation safety and training. Participants had varying levels of experience. Moreover 1981 participants always wore a lead gown (89 %), while only 1052 participants wore thyroid protection (47 %). 449 participants (20 %) received some form of training. CONCLUSION: Although surveys asked a range of questions it appeared that there was low knowledge of the ALARP principles. Usage of protective equipment is a legal requirement and thus was observed throughout, however, there were a number of incidences of disregarding some protective measures. Although there appeared to be limited knowledge surrounding radiation protection measures and lack of training provided, no clear link was demonstrated between compliance with protective methods and knowledge of the risks. IMPLICATIONS FOR PRACTICE: Formal and continuous training should be provided for the enhancement of knowledge to ensure the safety of all staff and help prevent the long-term effects of ionising radiation when using fluoroscopy.

Influence of surgeon's experience on fluoroscopy time during endourological interventions.

INTRODUCTION AND OBJECTIVE: Fluoroscopy time influences radiation exposure of both surgeons and patients during endourological interventions. Changes in fluoroscopy habits of endourological surgeons after being informed about their fluoroscopy times were evaluated depending on their endourological experience. MATERIALS AND METHODS: From April 2010 to April 2011, 402 endourological interventions in 337 Patients were assessed. Evaluated interventions were ureter stent placement (USP), ureter stent change (USC) nephrostomy change (NC), ureterorenoscopy (URS) and percutaneous nephrolithotomy (PCNL). Fluoroscopy time (FT) and operation time (OT) were recorded. For USP, USC and NC, the surgeons were divided into two groups: group I with >2 years of endourological experience and group II with <2 years experience. URS and PCNL only were performed by experienced surgeons. After 6 months, all surgeons were informed about their mean detected results. Both groups were compared, and changes in FT and OT in the second part of the study were analysed. RESULTS: Surgeons reduced their median fluoroscopy times up to 55 % after being informed about their fluoroscopy manners. Experienced surgeons reduced both operation and fluoroscopy times significantly for USP, USC and NC. For URS and PCNL, and OT and FT, the differences were not statistically significant. Inexperienced surgeons were not able to reduce both OT and FT significantly. CONCLUSION: If experienced surgeons are informed about their fluoroscopy time during endourological interventions, fluoroscopy times can be reduced significantly in easy procedures, which leads to less radiation exposure of surgeons and patients. Inexperienced surgeons have less possibility to influence their fluoroscopy manners.

Fluoroscopic Removal of Embedded Esophageal Self-Expanding Metal Stents: Stent-in-Stent Combined with Guidewire Lasso Technique.

We report the use of the guidewire lasso technique for the removal of an embedded esophageal self-expanding metal stent (SEMS), following a failure of distal to proximal invagination by removal hook caused by stent incorporation. During a removal procedure of an embedded SEMS using the hook retrieval device, the strut fractured and the stent retained. Attempts to pull up the retained stent using hook were not effective. Thus, the lasso technique with a guidewire over the retained stent was performed and successfully removed with no procedure-related complications. The patient is alive without dysphagia after 3 months follow-up.

A systematic review of interventions for reducing pain and distress in children undergoing voiding cystourethrography.

UNLABELLED: Voiding cystourethrography (VCUG) is commonly performed to screen for vesicoureteric reflux or other urological anomalies but has a potential to provoke distress in infants and children. We performed a systematic review of randomized controlled trials of interventions to reduce distress, pain or anxiety during VCUG. Eight trials (591 participants) met the inclusion criteria. CONCLUSION: Conscious sedation with midazolam effectively alleviates the distress of VCUG in children older than 1 year of age. Psychological preparation and warmed contrast medium may also be effective. Nitrous oxide 50% may be an alternative to midazolam, but further evidence is needed.

CT-Guided Femoral Approach for Psoas Muscle Abscess Drainage.

PURPOSE: To evaluate the feasibility and safety of the computed tomography (CT)-guided femoral approach for draining a psoas muscle abscess (PMA). MATERIALS AND METHODS: Between January 2014 and November 2018, the CT-guided femoral approach was employed for 9 abscesses in 8 patients who could not tolerate the prone position because of advanced age or other underlying conditions. A 17-gauge blunt metal needle was used to puncture the iliacus muscle below the groin under CT fluoroscopic guidance. A drainage catheter was then placed within the abscess cavity in the psoas major muscle. Technical success, clinical success, complications, the drainage therapy duration, susceptibility to antibiotics, survival, and recurrence were evaluated. RESULTS: The technical success rate was 100% among all nine lesions. The clinical success rate was 89% among all eight patients. One patient died of concomitant meningitis 15 days after the procedure. No patients developed therapy-related complications. The median duration of the drainage therapy was 15 days (range 6-71 days). Appropriate antibiotics based on the culture susceptibility were achieved in all patients. Four patients survived, and the remaining four died at 15 to 758 days (median, 36 days) after the procedure; no therapy-related deaths occurred. No recurrence was seen. CONCLUSION: The CT-guided femoral approach seems feasible, effective, and safe for draining psoas muscle abscesses in ill patients who cannot tolerate the prone position.

Radiation exposure to the surgeon during percutaneous pedicle screw placement.

STUDY DESIGN: In-vitro radiation exposure study. OBJECTIVE: To determine the radiation exposure to the eyes, extremities, and deep tissue during percutaneous pedicle screw placement. SUMMARY OF BACKGROUND DATA: Image-guided minimally invasive spinal surgery is typically performed with the use of fluoroscopy, exposing the surgeon and patient to ionizing radiation. The radiation dose to the surgeon has not been reported and risk to the surgeon performing this procedure over the long term is uncertain. METHODS: Percutaneous pedicle screws were placed in a cadaveric specimen from L2-S1 bilaterally using a cannulated pedicle screw system. Two fluoroscopes were used in the anteroposterior and lateral planes. The surgeon wore a thermolucent dosimeter ring on the right hand and badge over the left chest beneath the lead apron. Complete surgical time was recorded and a computed tomography scan was performed to assess screw placement. Radiation exposure was measured for total time of fluoroscopy use; average exposure per screw, surgical level, and dose to the eyes was calculated. This data was used to define the safety of percutaneous pedicle screw placement. RESULTS: Total fluoroscope time for placement of 10 percutaneous pedicle screws was 4 minutes 56 seconds (29 s per screw). The protected dosimeter recorded less than the reportable dose. The ring dosimeter recorded 103 mREM, or 10.3 mREM per screw placed. All screws were within the bone confines with acceptable trajectory. Exposure to the eyes was 2.35 mREM per screw. CONCLUSIONS: On the basis of this data, percutaneous pedicle screw placement seems to be safe. A surgeon would exceed occupational exposure limit for the eyes and extremities by placing 4854 and 6396 screws percutaneously, respectively. Lead protected against radiation exposure during screw placement. The "hands-off" technique used in this study is recommended to minimize radiation exposure. Lead aprons, thyroid shields, and leaded glasses are recommended for this procedure.

Lead cap localization using ultrasound in deep brain stimulation surgery: technical note.

In deep brain stimulation (DBS) surgery, after intracranial lead implantation, lead caps are tunneled into the subgaleal space for later connection to internal pulse generator (IPG) extension wires. In the subsequent IPG implantation procedure, the lead cap must be localized by palpation in order to plan an incision in the scalp to complete this connection. However, if the IPG implantation is done the same day as the intracranial lead implantation, palpation of the lead cap may be challenging in a thick or postoperatively edematous scalp. Manufacturers suggest using fluoroscopy in these instances, but fluoroscopy provides poor soft tissue visualization, requires further unnecessary radiation exposure to both the patient and the surgical team, and can be cumbersome. Portable ultrasound (US) machines are readily available in many operating rooms, and can be used to easily and accurately localize the lead cap prior to IPG implantation.

Robot-assisted vs freehand cannulated screw placement in femoral neck fractures surgery: A systematic review and meta-analysis.

BACKGROUND: Several studies have reported that medical robot-assisted method (RA) might be superior to conventional freehand method (FH) in orthopedic surgery. Yet the results are still controversial, especially in terms of femoral neck fractures surgery. Here, 2 methods were assessed based on current evidence. METHODS: Electronic databases including Cochrane Library, PubMed, Web of Science. and EMBASE were selected to retrieved to identify eligible studies between freehand and RAs in femoral neck fractures, with 2 reviewers independently reviewing included studies as well as collecting data. RESULTS: A total of 5 studies with 331 patients were included. Results indicated that 2 surgical methods were equivalent in terms of surgical duration, Harris score, fracture healing time, fracture healing proportion and complications, while RA showed clinical benefits in radiation exposure, intraoperative bleeding, total drilling times, and screw parallelism. CONCLUSIONS: Current literature revealed significantly difference between 2 techniques and suggested that RA might be beneficial for patients than freehand method.

Evaluation of protective equipment for the reduction of radiation exposure to physicians performing fluoroscopically guided lumbar transforaminal epidural steroid injections: A randomized controlled trial.

BACKGROUND: Spine interventionists frequently employ fluoroscopy to guide injection procedures. The increase in fluoroscopically guided procedures in recent years has led to a growing concern about radiation exposure. A new method of covering the C-arm tube with a lead apron has been suggested to reduce radiation exposure. This study aimed to compare the radiation exposure when performing lumbar transforaminal epidural steroid injections (TFESIs) using this new method to a control group. METHODS: A total of 200 patients who underwent lumbar TFESIs by a single physician were recruited. Patients were divided into 2 groups, the new method group (group A) and the control group (group C), and the amount of radiation exposure was compared. The dosimetry badge locations were marked as outside of apron, inside of apron, outside of thyroid collar, inside of thyroid collar, ring, and glasses. RESULTS: The cumulative dose equivalents of all the measurement sites were reduced in group A compared with group C, and the most reduced site was inside the thyroid collar. CONCLUSIONS: Covering the C-arm tube with a lead apron can be effective in reducing the cumulative radiation exposure when performing fluoroscopically guided TFESIs.

Orthopaedic Surgeon Brain Radiation During Fluoroscopy: A Cadaver Model.

BACKGROUND: The aims of this study were to quantify exposure of the surgeon's brain to radiation during short cephalomedullary (SC) nailing, to extrapolate lifetime dose, and to determine the effects of personal protective equipment (PPE) on brain dose. METHODS: Two cadaveric specimens were used: (1) a whole cadaveric body representing the patient, with a left nail inserted to act as the scatter medium, and (2) an isolated head-and-neck cadaveric specimen representing a surgeon, with radiation dosimeters placed in specific locations in the brain. The "patient" cadaver's left hip was exposed in posteroanterior and lateral radiographic planes. Measurements were performed without shielding of the head-and-neck specimen and then repeated sequentially with different PPE configurations. An average surgeon career was estimated to be 40 years (ages 25 to 65 years) with the caseload obtained from the department's billing data. RESULTS: The mean radiation dose to the surgeon brain without PPE was 3.35 µGy (95% confidence interval [CI]: 2.4 to 4.3) per nail procedure. This was significantly reduced with use of a thyroid collar (2.94 µGy [95% CI: 1.91 to 3.91], p = 0.04). Compared with use of the thyroid collar in isolation, there was no significant additional reduction in radiation when the collar was used with leaded glasses (2.96 µGy [95% CI: 2.15 to 3.76], p = 0.97), with a lead cap (3.22 µGy [95% CI: 2.31 to 4.13], p = 0.55), or with both (2.31 µGy [95% CI: 1.61 to 3.01], p = 0.15). The extrapolated lifetime dose over 40 working years for SC nailing without PPE was 2,146 µGy (95% CI: 1,539 to 2,753), with an effective dose of 21.5 µSv. CONCLUSIONS: The extrapolated cumulative lifetime radiation to a surgeon's brain from SC nailing based on our institution's workload and technology is low and comparable with radiation during a one-way flight from London to New York. Of note, we studied only one of many fluoroscopy-aided procedures and likely underestimated total lifetime exposure if exposures from other procedures are included. This study also demonstrates that thyroid collars significantly reduce brain dose for this procedure whereas other head/neck PPE such as lead caps appear to have minimal additional effect. This study provides a methodology for future studies to quantify brain dose for other common orthopaedic procedures. CLINICAL RELEVANCE: This study, based on our institutional data, demonstrates that although the lifetime brain dose from SC nailing is low, thyroid collars significantly reduce this dose further. As such, in accordance with the "as low as reasonably achievable" radiation exposure principle, radiation safety programs and individual surgeons should consider use of thyroid collars in this setting.

Skin injuries caused by fluoroscopically guided interventional procedures: case-based review and self-assessment module.

OBJECTIVE: Fluoroscopically guided interventional procedures are performed in cardiology, and complex interventions are performed in cerebral as well as peripheral circulation. These procedures sometimes deliver a high radiation dose to the patient's skin and can cause serious skin injuries. CONCLUSION: Interventionalists are often unaware of the high radiation doses to which a patient's skin may be subjected. Most are unaware that such injuries can occur even with the use of modern equipment. Therefore, they and other physicians, including dermatologists, often do not recognize such skin injuries as being related to an interventional procedure.

A randomised clinical trial of transnasal endoscopy versus fluoroscopy for the placement of nasojejunal feeding tubes in patients with severe acute pancreatitis.

OBJECTIVES: To compare transnasal endoscopy with fluoroscopy for the placement of nasojejunal feeding tubes (NJTs) in patients with severe acute pancreatitis. METHODS: 100 patients were randomised to receive NJTs by transnasal endoscopy or fluoroscopy. Successful placement was confirmed by abdominal radiograph. RESULTS: The success rate was 96% using transnasal endoscopy and 94% using fluoroscopy (p>0.05). The mean (SEM) time to perform a successful procedure was 12.7 (5.1) min for transnasal endoscopy and 7.9 (5.9) min for fluoroscopy (p<0.05). No complications were reported using fluoroscopy, whereas there was one case of tachypnoea and four cases of abdominal distension related to transnasal endoscopy (p<0.05). For transnasal endoscopy, the mean (SEM) visual analogue scale comfort score was 3.2 (1.3) before, 8.7 (1.5) during, and 3.6 (1.3) after a successful procedure. The corresponding values for fluoroscopy were 3.1 (1.2), 5.4 (1.6) and 3.7 (1.4). The difference in scores during the procedure was significant (p<0.05). CONCLUSIONS: Transnasal endoscopic and fluoroscopic placement of NJTs can safely and accurately be performed in patients with severe acute pancreatitis. The results of this study show no significant difference in success and complication rates between the two procedures. However, the procedure time for fluoroscopic placement was shorter than for transnasal endoscopic placement, and patients experienced less discomfort.

A new method for reducing operation time and radiation exposure in the placement of Jamshidi needles: Technical note.

Percutaneous pedicle screws have been used in the treatment of thoracolumbar fractures for decades, and conventional fluoroscopy is commonly used to confirm the positions of the Jamshidi needles during the procedure. In this article, a modified method is reported for the placement of Jamshidi needles. The attending surgeons did not receive any radiation during the procedure and the fluoroscopy time for the patients was little. In our method, all six Jamshidi needles were placed on the pedicles and hammered 2 mm into each entry site. When the verification images were acquired, the medical personnel went behind a lead-lined wall. The positions of the needles were first reviewed and adjusted as needed based on the anterior-posterior (AP) image. Then, the C-arm was rotated and lateral images were obtained to further verify the needle placement. The rest of the screw placement procedure remained the same. The proposed technique was applied in 45 patients with thoracolumbar fractures. It took an average (range) of 5 (4-7) single-shot images to ensure all the needles were positioned at the ideal entry site and 12 (10-17) minutes to complete this step. No neurological symptoms were reported by the patients. Using the proposed technique, the radiation exposure for the surgeons is zero, and the patients are well-protected from excessive radiation exposure. This modified method of embedding all the Jamshidi needles at the entry sites before fluoroscopy is an improved technique compared with the conventional method.

The Influence of Local Anesthesia Depth on Procedural Pain During Fluoroscopically Guided Lumbar Transforaminal Epidural Injections: A Randomized Clinical Trial.

OBJECTIVES: The aim of the study was to evaluate the influence of the depth of local anesthesia application on procedural pain during lumbar transforaminal epidural steroid injection. DESIGN: Sixty-eight patients were enrolled who were scheduled for single-level, unilateral fluoroscopically guided lumbar transforaminal epidural steroid injection. Patients were randomly allocated to receive either subcutaneous local anesthesia (group S) or deep local anesthesia (group D) for transforaminal epidural steroid injection. The data related to pain and technical performance during the procedure was compared. In addition, the incidence of injection site soreness was assessed 2 wks after transforaminal epidural steroid injection. RESULTS: Sixty-seven patients completed all assessments (group S, n = 33; group D, n = 34). There was no significant difference in procedural pain and discomfort level between the groups (P = 0.151, P = 0.183, respectively). Patients in group D showed lower behavioral pain scores (P = 0.017). There was no significant difference in the numbers of needle manipulations, fluoroscopy time, and radiation dose during the procedure between the groups. Two patients in group S and three in group D complained of injection site soreness after transforaminal epidural steroid injection for a few days, but there was no significant difference in its incidence (P = 0.667). CONCLUSIONS: Deep local anesthesia to reduce procedural pain during transforaminal epidural steroid injection seems to have no significant clinical benefit compared with conventional subcutaneous local anesthesia. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Reduce procedural pain by considering clinical factors of the patient during fluoroscopically guided lumbar transforaminal epidural injections.Upon completion of this article, the reader should be able to: (1) Understand the potential impact of procedural pain on the performance of transforaminal epidural steroid injections; (2) Distinguish cutaneous nociceptive afferents from nociceptive afferents in muscle; and (3) Explain the factors to reduce procedural pain during fluoroscopically guided lumbar transforaminal epidural injections. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Transcatheter device closure of atrial septal defects guided completely by transthoracic echocardiography: A single cardiac center experience with 152 cases.

OBJECTIVE: This study aimed to assess the safety and feasibility of transcatheter device closure of atrial septal defects (ASDs) guided completely by transthoracic echocardiography (TTE). METHODS: A total of 152 patients underwent transcatheter device closure of ASDs guided completely by TTE in our center from September 2014 to June 2017. We used routine delivery sheaths during the procedure and then closed the ASDs by releasing a domestic occluder. RESULTS: The closure was successful in 150 patients, and surgical repair was required in two patients. The size of the deployed occluder ranged from 10 mm to 38 mm (21.4±8.5 mm), and the procedure duration ranged from 30 to 90 min (38.2±21.4 min). No fatal complications were observed. Minor complications included transient arrhythmias (n=12) during the process of device deployment. The follow-up period was 3 months to 2 years, with no occluder dislodgment, residual fistula, or thrombus-related complications. In our comparative studies, no statistically significant differences were observed in success rates and complications. CONCLUSION: Transcatheter device closure of ASDs guided completely by TTE may be safe and effective and can be an alternative to traditional methods.