Ryan D. Madder, MD, Interventional Cardiologist, Spectrum Health, Grand Rapids, Michigan
As an interventional cardiologist with Spectrum Health, I am fortunate to be working with an organization that is as committed to staff safety as they are to the health and well-being of their patients. This is evidenced by the adoption of several radiation safety initiatives including a robotic PCI program which Spectrum Health launched two years ago.
My interest in radiation safety began early in my career. During fellowship, I witnessed two of my mentors suffer through a diagnosis and subsequent treatment of cancer. Although a causal link between radiation exposure and these malignancies was not definitive, the negative impact that these cancers had on the lives of these two individuals was definitive. Shortly after each diagnosis was made, one could not help but wonder what role occupational radiation exposure played in each case. Unfortunately, such cases may not be unique, as an ongoing registry is compiling an alarming number of brain tumors amongst interventionalists. It is notable that 85 percent of reported brain tumors in interventionalists occur on the left side of the brain, the side closest to the radiation source in the cath lab. This 85% incidence of left-sided brain malignancies among interventionalists is in stark contrast to the general population, where brain cancers are evenly distributed between the right and left sides.
In addition to the risks interventionalists face from extended exposure to ionizing radiation, the standard heavy, lead-lined personal protective gear meant to mitigate the radiation risk increases our risk of orthopedic problems. Results from the 2014 SCAI survey of interventional cardiologists demonstrated that nearly 50% of interventionalists have suffered an orthopedic injury during their careers. The high rate of lumbar and cervical spine disease reported in these survey results is equally alarming. The data indicate that the risk of such orthopedic injuries increases with procedural volume and may also increase with the number of years in practice.
The emerging data regarding cancer risk and orthopedic injuries associated with the traditional approach to performing PCI (i.e. standing in the radiation field wearing a heavy lead garment) have motivated me to seek novel methods to protect myself in the cath lab. I have found that robotic PCI is a safe and viable option to limit exposure to both radiation and lead apparel. In the PRECISE study robotic PCI was associated with technical and procedural success rates of approximately 98%. These high success rates with robotic PCI were achieved in conjunction with a dramatic reduction in radiation exposure to the robotic operator. Hence, as compared to exposure at the bedside, radiation exposure in the robotic cockpit was reduced by 95%.
Considering the significant reduction in radiation exposure robotic PCI provides, I view robotic PCI as a core technology to providing a safer work environment. As early users of robotic PCI, my partners and I have been optimizing our processes and identifying novel uses for the tool. Much of my ongoing research is focused on the capabilities of robotic-assistance in the cath lab, both for safety and for clinical utility.
Spectrum Health has a large cath lab staff. Several of our technologists have a passion for novel technology and have developed very advanced skills with the robot. We have seen that a successful robotics program requires capability and interest from all stakeholders and the success of our technologists has helped fuel the success of our program. We have many technologists that are very progressive and always looking for ways to increase their skill set. The CorPath Vascular Robotic System is a natural fit for them to expand the skills they possess and get more hands-on with these procedures.
There are several benefits to robotic PCI over manual procedures. For example, there is a level of precision achieved with the robot that may not be consistently achieved manually. The robot allows you to move a stent forward and backward in millimeter increments, which can be very helpful in cases where positioning of the stent is crucial with respect to anatomy such as side branches or the ostium. Additionally, the robotic system enables you to obtain very accurate measurements of the patient’s anatomy so the correct stent length can be selected without relying solely on visual estimation. By selecting the most appropriate stent length and leveraging robotic-assistance for precise stent positioning, it is conceivable that robotic-PCI may improve patient outcomes and reduce the number of stents used per case.
Let alone the potential clinical benefits, the radiation exposure savings alone is reason enough for interventional cardiologists to consider adopting robotic technology in their cath labs. Considering the risks associated with both long-term radiation exposure and long-term lead usage, adopting robotic-assistance for routine use is a clear choice for the future of my practice. Luckily, I have never suffered an orthopedic injury related to lead and have never had a radiation-induced malignancy. My perspective is, why wait for such a problem to occur when I can employ preventative solutions today?