Cath Lab Digest

I’d bet a dime most readers would agree that advances with diagnostic imaging are the foundation for many if not most good things happening in contemporary medicine. And nowhere is this truer than in the “aortic space” where specialists (such as myself) have come to depend heavily on CT scans (with and without 3D reconstructions) for diagnosis, measurements and sizing, procedure planning, and patient follow-up in the context of endovascular repair of aneurysms and other aortic pathologies.

Unfortunately, these patients require relatively intense surveillance and follow-up, meaning that they may be exposed to an enormous cumulative amount of radiation across many years to come. Driven by such concerns, I penned a VDM editorial in 2009 (Ref. 1). The following excerpts represent the substance of the message therein contained:

“We now use this imaging capability (CT scanning) for diagnosis, pre-operative assessment and procedure planning, stent-graft device sizing, as well as patient follow-up and surveillance — lifelong. Furthermore, it is clear that the impact of modern medical imaging is being felt much beyond aortic intervention, inducing transformational influence in — essentially — every anatomy-centered area of medicine. Today, a great number of patients enjoy the advantages of precise diagnosis and treatment with less invasive technologies in a manner that is increasingly safe and successful. Importantly, though, and on the downside, these patients are also being exposed to significant doses of radiation over time. Fazel et al focused on this very issue in a recent study (Ref. 2). They found that, indeed, ‘imaging procedures are an important source of exposure to ionizing radiation in the United States and can result in high cumulative effective doses of radiation’. Computed tomography (CT) scans and nuclear imaging accounted for 75.4%
of the cumulative effective dose, and more than 80% of the procedures were done in an outpatient setting. In addition to radiation, economic costs are another source of concern related to the widespread and ever-increasing use of medical imaging in this country.

It was almost too good to be true, wasn’t it? Just when we were finally feeling at the very top of our game… we are now beginning to hear this should perhaps be slowed down and that we ought to re-think some of the diagnostic and surveillance strategies. I, for one, would not be surprised to see attempts (from various corners) to restrict and/or micro-manage physicians’ ability to order and perform imaging procedures in the near future. From that perspective, it would be in our best interest to become proactive in proposing and implementing reasonable guidelines that experts and professional societies can hopefully agree on — as opposed to impositions coming from outside entities. It may well be our best chance to retain the ability to use advanced imaging modalities in a manner that contributes to the ultimate goal of best patient care but, at the same time, minimizes costs in terms of economic expense and excessive exposure to radiation.”

References
1. Criado FJ. Medical imaging in the XXI Century: Too much of a good thing? Vasc Dis Management 2009;6:A4.
2. Fazel R, Krumholz HM, Wang Y, et al. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med 2009;361:849-857.