Palma Shaw

Radiation exposure and pregnancy

INTRODUCTION The effect of radiation on the fetus has been derived primarily from animal studies and human exposures to diagnostic and therapeutic radiation as well as atomic bomb exposure. Given the variety of sources, there is controversy over the dose of radiation in addition to the other environmental conditions that surrounded these events and their relationship to exposure today. METHODS The effects of ionizing radiation on the fetus, the prenatal period, parental exposure, the pregnant clinician, and the pregnant patient are discussed in the context of their exposure to radiation. RESULTS The fetus is most sensitive to radiation effects between 8 and 15 weeks of pregnancy. Stepping away from the table and using movable shields help reduce the exposure by a factor of four for every doubling of the distance between the operator and the radiation source. CONCLUSION Proposed guidelines for pregnancy during vascular residency training involving fluoroscopic procedures can help bring about awareness, clarify maximal exposure, and better delineate the role of the pregnant resident.

Monitoring of fetal radiation exposure during pregnancy.

BACKGROUND One unique concern of vascular surgeons and trainees is radiation exposure associated with increased endovascular practice. The safety of childbearing is a particular worry for current and future women in vascular surgery. Little is known regarding actual fetal radiation exposure. This multi-institutional study aimed to evaluate the radiation dosages recorded on fetal dosimeter badges and compare them to external badges worn by the same cohort of women. METHODS All women who declared pregnancy with potential radiation exposure were required to wear two radiation monitors at each institution, one outside and the other inside the lead apron. Maternal (external) and fetal monitor dosimeter readings were analyzed. Maternal radiation exposures prior to, during, and postpregnancy were also assessed to determine any associated behavior modification. RESULTS Eighty-one women declared pregnancy from 2008 to 2011 and 32 had regular radiation exposure during pregnancy. Maternal whole-body exposures ranged from 21-731 mrem. The average fetal dosimeter recordings for the cohort rounded to zero. Only two women had positive fetal dosimeter recordings; one had a single recording of 3 mrem and the other had a single recording of 7 mrem. There was no significant difference between maternal exposures prior to, during, and postpregnancy. CONCLUSIONS Lack of knowledge of fetal radiation exposure has concerned many vascular surgeons, prompting them to wear double lead aprons during pregnancy, and perhaps prevented numerous other women from entering the field. Our study showed negligible radiation exposure on fetal monitoring suggesting that with the appropriate safety precautions, these concerns may be unwarranted.

Time for radiation safety program guidelines for pregnant trainees and vascular surgeons

OBJECTIVES The evolution of endovascular surgery has increased the vascular surgeons exposure to radiation, raising concern for female vascular trainees and staff of childbearing years. We developed surveys for female trainees, established vascular surgeons, and program directors in vascular surgery to determine current practices with respect to pregnancy and radiation exposure guidelines. METHODS Two surveys were conducted to evaluate radiation exposure during pregnancy. A survey of the members of the Association of Program Directors in Vascular Surgery was conducted in an attempt to gather information about existing program and institutional radiation policies and assess the need for standard guidelines. A second survey was given to women in vascular surgery in an effort to obtain opinions among concerned groups regarding establishment of a policy from women who were exposed to radiation during and after completion of vascular training. RESULTS Fifty-three of 181 female vascular surgeons (29% response rate) responded to the survey, with the majority (53% [28/53]) pregnant during training or practice. Though 68% of trainees and 82% of faculty performed endovascular procedures during pregnancy, only 42% of trainees and 50% of faculty wore a fetal badge. One trainee (3.7%) had complications during pregnancy that necessitated cessation of fluoroscopic procedures or limiting call. There were four practicing surgeons who had complications during their pregnancy. Of these, one was hospitalized with fetal decelerations secondary to excessive on-call obligations with double leading and heavy endovascular call coverage. The majority of women (>60%) felt supported by the program and that they were treated fairly. Over 90% of female trainees and faculty felt that establishment of guidelines for radiation safety for all vascular surgeons would be beneficial. Many (77%) felt that a policy would aid in the recruitment of talented women into the field. Thirty-two of 99 Association of Program Directors in Vascular Surgery program directors responded to the survey. Of the 32 program directors that responded (32% response rate), 75% would allow the pregnant trainee flexibility in rotation schedule. Finally, 75% of program directors support development of a national policy, and 81% would incorporate one into their program. CONCLUSIONS There is compelling interest to establish radiation safety guidelines for the pregnant trainee or vascular surgeon. Consideration should be given at the Society leadership level to develop and support radiation safety guidelines for all vascular surgeons.

Avoiding the Trap of Misdiagnosis: Valuable Teaching Points Derived from a Case of Longstanding Popliteal Artery Entrapment Syndrome

Popliteal artery entrapment syndrome (PAES), a condition predominantly affecting young individuals, is a rare clinical entity that can result in significant morbidity. The presence of lower limb pain and claudication in young, physically active individuals should prompt consideration for PAES. Early diagnosis and management is crucial to prevent long-term complications; however, diagnosis is fraught with challenges due to the rarity of the disease and its similar clinical presentation with more common conditions. We present a case of a young female with PAES who was misdiagnosed and underwent a tarsal tunnel release for suspected tarsal tunnel syndrome and subsequent fasciotomies for presumed chronic exertional compartment syndrome (CECS) without any relief. We outline the insidious undiagnosed course of her condition over a period of 12 years, discuss teaching points of how to recognize key differences of PAES and associated conditions, and provide recommendations for how to make the right diagnosis.

Open direct carotid artery access for coiling of an intracranial aneurysm under conscious sedation

We describe the case of a 61-year-old patient with significant medical co-morbidities and tortuous vascular anatomy presenting with a large middle cerebral artery aneurysm. To avoid the risks of general anesthesia and circumvent a majority of the tortuous vessels, the aneurysm was accessed by direct open exposure of the common carotid artery under conscious sedation and local anesthesia. We were able to achieve complete endovascular occlusion of the aneurysm and the patient tolerated the procedure well with no intra- or post-operative complications. Use of conscious sedation is possible and safe for direct open common carotid artery access in patients with significant vascular tortuosity that makes the standard trans-femoral approach difficult or impossible.