Determinants of Radiation Exposure and Radiation Overexposure During Percutaneous Coronary Intervention. A Real-World Study of 10,634 Procedures With Development of a Pragmatic Radiation-Alert Risk Score
- 1Centre Cardiologique du Nord
Abstract
BackgroundIonizing radiation is inherent to percutaneous coronary intervention (PCI) and may reach radiation-alert thresholds during complex procedures. Real-world data translating dose determinants into a usable planning-stage alert tool remain scarce.
AimsTo determine the prevalence and predictors of radiation overexposure (RO) during PCI and to develop a pragmatic radiation-alert risk score usable before substantial dose accumulates.
MethodsWe analysed 10,634 consecutive PCI procedures performed between January 2008 and May 2018. Complex PCI was defined as unprotected left main, rotational atherectomy, chronic total occlusion (CTO), or bifurcation/trifurcation PCI. The composite RO endpoint was a dose-area product >500 Gy{middle dot}cm{superscript 2}, cumulative reference-point air kerma (AK) >5 Gy, or fluoroscopy time >60 minutes. A pragmatic score was built from early procedural variables.
ResultsOverall, 3,457 procedures (32.5%) were complex, and RO occurred in 99 (0.93%). Complex PCI showed higher RO rates than standard PCI (2.1% vs 0.4%; p<0.001). In multivariable analysis, body mass index (BMI), male sex, CTO, rotational atherectomy, bifurcation, and treatment of [≥]2 vessels independently predicted higher AK. A pragmatic score derived from early clinical and procedural variables showed good discrimination (area under the curve 0.772; 95% bootstrap CI 0.725-0.818) and was well calibrated (Brier score 0.0091; observed-to-expected ratio 0.994) for the composite RO endpoint.
ConclusionsRadiation-alert thresholds were exceeded in approximately 1% of PCI procedures, but fivefold more often during complex PCI. A pragmatic, internally assessed score based on early procedural variables identified high-risk cases with good discrimination, supporting planning-stage risk stratification to activate dose-sparing strategies before substantial radiation has accumulated.
Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABSIn 10,634 consecutive percutaneous coronary interventions, professional-society radiation-alert thresholds (dose-area product >500 Gy{middle dot}cm{superscript 2}, air kerma >5 Gy, or fluoroscopy time >60 minutes) were exceeded in 0.93% of procedures, five times more often during complex intervention, and the three metrics identified largely non-overlapping events.
The RADAR-PCI score, an integer score based on seven characteristics available after diagnostic angiography, identified procedures at risk of radiation overexposure with good discrimination and calibration, and also stratified exceedance of the 2 Gy and 3 Gy air-kerma levels used for patient information.
What Are the Clinical Implications?Because the score uses information available early in the procedure, radioprotective measures and structured post-procedural skin surveillance can be planned in advance for the minority of patients who need them most, rather than reactively once substantial dose has accumulated.
A freely accessible online calculator (https://radar-pci.netlify.app) returns the score, the calibrated probability of exceeding each alert threshold, and model-based estimates of the expected dose metrics; external validation is warranted before broad adoption.
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BibTeX
@misc{digne2026determinants,
title = {{Determinants of Radiation Exposure and Radiation Overexposure During Percutaneous Coronary Intervention. A Real-World Study of 10,634 Procedures With Development of a Pragmatic Radiation-Alert Risk Score}},
author = {f. digne and A. Darmon and v. stratiev and M. Abdellaoui and J. Dreyfus and m. taramasso and F. Nappi and M. Nejjari},
howpublished = {medRxiv},
year = {2026},
month = sep,
doi = {10.64898/2026.09.18.26363451},
url = {https://www.medrxiv.org/content/10.64898/2026.09.18.26363451v1},
note = {CC BY-NC-ND},
}
RIS
TY - UNPB
TI - Determinants of Radiation Exposure and Radiation Overexposure During Percutaneous Coronary Intervention. A Real-World Study of 10,634 Procedures With Development of a Pragmatic Radiation-Alert Risk Score
AU - f. digne
AU - A. Darmon
AU - v. stratiev
AU - M. Abdellaoui
AU - J. Dreyfus
AU - m. taramasso
AU - F. Nappi
AU - M. Nejjari
PY - 2026
DA - 2026/09/18
PB - medRxiv
DO - 10.64898/2026.09.18.26363451
UR - https://www.medrxiv.org/content/10.64898/2026.09.18.26363451v1
AB - BackgroundIonizing radiation is inherent to percutaneous coronary intervention (PCI) and may reach radiation-alert thresholds during complex procedures. Real-world data translating dose determinants into a usable planning-stage alert tool remain scarce. AimsTo determine the prevalence and predictors of radiation overexposure (RO) during PCI and to develop a pragmatic radiation-alert risk score usable before substantial dose accumulates. MethodsWe analysed 10,634 consecutive PCI procedures performed between January 2008 and May 2018. Complex PCI was defined as unprotected left main, rotational atherectomy, chronic total occlusion (CTO), or bifurcation/trifurcation PCI. The composite RO endpoint was a dose-area product >500 Gy{middle dot}cm{superscript 2}, cumulative reference-point air kerma (AK) >5 Gy, or fluoroscopy time >60 minutes. A pragmatic score was built from early procedural variables. ResultsOverall, 3,457 procedures (32.5%) were complex, and RO occurred in 99 (0.93%). Complex PCI showed higher RO rates than standard PCI (2.1% vs 0.4%; p<0.001). In multivariable analysis, body mass index (BMI), male sex, CTO, rotational atherectomy, bifurcation, and treatment of [≥]2 vessels independently predicted higher AK. A pragmatic score derived from early clinical and procedural variables showed good discrimination (area under the curve 0.772; 95% bootstrap CI 0.725-0.818) and was well calibrated (Brier score 0.0091; observed-to-expected ratio 0.994) for the composite RO endpoint. ConclusionsRadiation-alert thresholds were exceeded in approximately 1% of PCI procedures, but fivefold more often during complex PCI. A pragmatic, internally assessed score based on early procedural variables identified high-risk cases with good discrimination, supporting planning-stage risk stratification to activate dose-sparing strategies before substantial radiation has accumulated. Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABSIn 10,634 consecutive percutaneous coronary interventions, professional-society radiation-alert thresholds (dose-area product >500 Gy{middle dot}cm{superscript 2}, air kerma >5 Gy, or fluoroscopy time >60 minutes) were exceeded in 0.93% of procedures, five times more often during complex intervention, and the three metrics identified largely non-overlapping events. The RADAR-PCI score, an integer score based on seven characteristics available after diagnostic angiography, identified procedures at risk of radiation overexposure with good discrimination and calibration, and also stratified exceedance of the 2 Gy and 3 Gy air-kerma levels used for patient information. What Are the Clinical Implications?Because the score uses information available early in the procedure, radioprotective measures and structured post-procedural skin surveillance can be planned in advance for the minority of patients who need them most, rather than reactively once substantial dose has accumulated. A freely accessible online calculator (https://radar-pci.netlify.app) returns the score, the calibrated probability of exceeding each alert threshold, and model-based estimates of the expected dose metrics; external validation is warranted before broad adoption.
ER -