Comparison of a Suspended Radiation Protection System versus Standard Lead Apron for Radiation Exposure of a Simulated Interventionalist

The Effect of a Suspended Radiation Protection System on Occupational Radiation Doses During Infrarenal EVAR Procedures: A Randomised Controlled Study

OBJECTIVE

To compare the protective effect of Zero Gravity (ZG) with conventional radiation protection during endovascular aneurysm repair (EVAR). Secondly, user experience was surveyed with a questionnaire on ergonomics.

METHODS

This was a single centre, prospective, randomised, two arm trial where 71 consecutive elective infrarenal EVAR procedures were randomised into two groups: (1) operator using ZG and assistant using conventional protection (n = 36), and (2) operator and assistant using conventional radiation protection (n = 35). A movable floor unit ZG system consists of a lead shield (1.0 mm Pb equivalent) for the front of the body and 0.5 mm Pb equivalent acrylic shielding for the head and neck. The ZG also includes arm flaps of 0.5 mm Pb equivalent covering the arm up to the elbow. Deep dose equivalent values, Hp(10) were measured with direct ion storage dosimeters (DIS) placed on various anatomical regions of the operator (axilla, chest, abdomen, and lower leg). Personal dose equivalent values, Hp(3) to eye lenses were measured in the operating and assisting surgeon using thermoluminescence dosimeters. The study was registered at the US National Institute of Health #NCT04078165.

RESULTS

Protection with the standard protection was superior in chest (0.0 vs. 0.1 μSv), abdomen (0.0 vs. 0.6 μSv), and lower leg (0.4 vs. 2.2 μSv) (p < .001). On the other hand, the ZG system yielded better shielding for the axilla (1.5 vs. 0.0 μSv) and eyes (6.3 vs. 1.1 μSv) of the operator. The use of ZG hampered the deployment of ancillary shields, which is particularly relevant for protection of the assisting surgeon. Users found ZG more cumbersome than conventional garments, it also impaired communication and reduced field of view.

CONCLUSION

Both ZG and conventional radiation protection reduced radiation exposure. Conventional protection allows better manoeuvrability at the price of wider exposure of the upper arm and axilla. ZG indirectly impaired protection of the assistant.

Assessing and improving radiation safety in cardiac catheterization: a study from Cairo University Hospital

BACKGROUND

Catheter laboratories are high-radiation exposure environments, especially during X-ray procedures like percutaneous transluminal coronary angioplasty and electrophysiological studies. Radiation exposure poses risks of stochastic (e.g., cancer) and deterministic (e.g., skin changes) effects. This study assessed radiation safety and health practices in a cardiac catheterization unit to optimize radiation safety. A cross-sectional study in Cairo University Hospital (March-September 2019) evaluated 700 patients and healthcare workers. Real-time radiation measurements, educational lectures, and radiation protection measures were implemented in three phases. Data on radiation exposure, procedures, and compliance were collected and analyzed.

RESULTS

The total procedure time and fluoroscopy time per cardiologist did not significantly differ between phases, but there was a statistically significant reduction in the mean total cumulative radiation doses between Phase I and Phase III for cardiologists (P = 0.013). Among nurses and technicians, there was no significant difference in radiation doses between the two phases. Significant correlations were found between operators' radiation doses, procedure time, and fluoroscopy time. Patients' radiation doses decreased significantly from Phase I to Phase III, with correlations between dose, procedure time, and gender. Compliance with radiation protection measures was suboptimal.

CONCLUSIONS

Compliance with radiation safety standards in the cardiac catheterization unit at the Cairo University Hospital needs improvement. The study highlights the importance of adhering to radiation safety principles and optimizing protective measures to reduce radiation exposure for both patients and healthcare personnel. Despite low compliance, significant reductions in radiation doses were achieved with increased awareness and adherence to specific protection measures. Future efforts should focus on enhancing radiation safety protocols and organ-specific radiation impact assessments.

Lead aprons and thyroid collars: to be, or not to be?

Wearing lead aprons and thyroid collars for long periods of time has a subjective component: to balance the effective dose reduction with the effort of carrying a heavy load. Occupational radiation exposure has decreased dramatically in the last century within the health care system. During the same period the use of lead aprons and thyroid collars has also gone up. Therefore, a question that may be raised is: how safe is safe enough? In order to promote stakeholder involvement, the aim of the present study was to investigate staff's experience of discomforts associated with wearing lead aprons and thyroid collars for long periods of time, and also to investigate staff's willingness to tolerate personal dose equivalent (expressed as radiation dose) and the corresponding increase in future cancer risk to avoid wearing these protective tools. A questionnaire was developed and given to staff working in operating or angiography rooms at Skaraborg Hospital in Sweden. The results from the 245 respondents showed that 51% experienced bothersome warmth, 36% experienced fatigue and 26% experienced ache or pain that they believed was associated with wearing lead aprons. One third of the respondents would tolerate a personal dose equivalent of 1 mSv per year to avoid wearing lead aprons, but only a fifth would tolerate the corresponding increase in future cancer risk (from 43% to 43.2%). In conclusion, discomforts associated with wearing lead aprons and thyroid collars for long periods of time are common for the staff using them. At the same time, only a minority of the staff would tolerate a small increase in future cancer risk to avoid wearing them. The present study gives an example of stakeholder involvement and points at the difficulties in making reasonable decisions about the use of these protective tools.

Physical strain while wearing personal radiation protection systems in interventional radiology

Objectives

Multiple studies show orthopedic health problems for medical staff due to wearing radiation protection aprons. The aim of this study was to evaluate the weight pressure on the shoulder as a marker of physical strain caused by different radiation-protection devices.

Methods

For the weight pressure measurement, a pressure sensor (OMD-30-SE-100N, OptoForce, Budapest, Hungary) placed on the left and right shoulder was used. Wearing different radiation protection systems the force measurement system was used to quantify the weight pressure. Measurements were acquired in still standing position and during various movements.

Results

A mean significant decreasing weight pressure on the shoulder between 74% and 84% (p<0.001) was measured, when the free-hanging radiation protection system was used in comparison to one-piece and two-piece radiation protection aprons and coats. Using two-piece radiation protection aprons, the weight pressure was significantly lower than that of one-piece radiation protection coats. If a belt was used for the one-piece radiation protection coat, the weight pressure on the shoulder was reduced by 32.5% (p = 0.003). For a two-piece radiation protection apron and a one-piece radiation protection coat (with and without belt) a significant different weight pressure distribution between the right and left shoulder could be measured.

Conclusions

The free-hanging radiation protection system showed a significant lower weight pressure in comparison to the other radiation protection devices. Apart from this, use of a two-piece radiation protection apron or addition of a belt to a radiation protection coat proved to be further effective options to reduce weight pressure.

What are useful methods to reduce occupational radiation exposure among radiological medical workers, especially for interventional radiology personnel?

Protection against occupational radiation exposure in clinical settings is important. This paper clarifies the present status of medical occupational exposure protection and possible additional safety measures. Radiation injuries, such as cataracts, have been reported in physicians and staff who perform interventional radiology (IVR), thus, it is important that they use shielding devices (e.g., lead glasses and ceiling-suspended shields). Currently, there is no single perfect radiation shield; combinations of radiation shields are required. Radiological medical workers must be appropriately educated in terms of reducing radiation exposure among both patients and staff. They also need to be aware of the various methods available for estimating/reducing patient dose and occupational exposure. When the optimizing the dose to the patient, such as eliminating a patient dose that is higher than necessary, is applied, exposure of radiological medical workers also decreases without any loss of diagnostic benefit. Thus, decreasing the patient dose also reduces occupational exposure. We propose a novel four-point policy for protecting medical staff from radiation: patient dose Optimization, Distance, Shielding, and Time (pdO-DST). Patient dose optimization means that the patient never receives a higher dose than is necessary, which also reduces the dose received by the staff. The patient dose must be optimized: shielding is critical, but it is only one component of protection from radiation used in medical procedures. Here, we review the radiation protection/reduction basics for radiological medical workers, especially for IVR staff.

Radiation protection for the interventional cardiologist: Practical approach and innovations

Use of ionizing radiation during cardiac catheterization interventions adversely impacts both the patients and medical staff. In recent years, radiation dose in cardiac catheterization interventions has become a topic of increasing interest in interventional cardiology and there is a strong interest in reducing radiation exposure during the procedures. This review presents the current status of radiation protection in the cardiac catheterization laboratory and summarizes a practical approach for radiation dose management for minimizing radiation exposure. This review also presents recent innovations that have clinical potential for reducing radiation during cardiac interventions.

Process Technology for Development and Performance Improvement of Medical Radiation Shield Made of Eco-Friendly Oyster Shell Powder

As radiation-based techniques become increasingly important tools for medical diagnostics, medical professionals face increasing risk from the long-term effects of scattered radiation exposure. Although existing radiation-shielding products used in medicine are traditionally lead-based, recently, the development of more eco-friendly materials such as tungsten, bismuth, and barium sulfate has drawn attention. However, lead continues to be superior to the proposed alternative materials in terms of shielding efficiency and cost effectiveness. This study explores the feasibility of radiation shielding materials based on the shells of bivalve mollusks such as oysters that are discarded from aquaculture, thereby preventing them from going into landfills. In addition, a firing process for enhancing the shielding efficiency of the original material is proposed. Experiments show that shielding sheets comprising 0.3 mm thick layers of oyster shell achieve a shielding efficiency of 37.32% for the low-energy X-rays typically encountered in medical institutions. In addition, the shielding efficiency was improved by increasing the density of the powdered oyster shell via plastic working at 1200 °C. This raises the possibility of developing multi-material radiation shields and highlights a new potential avenue for recycling aquaculture waste.

Suspended lead suit and physician radiation doses during coronary angiography

OBJECTIVE

This study was performed to evaluate physician radiation doses with the use of a suspended lead suit.

BACKGROUND

Interventional cardiologists face substantial occupational risks from chronic radiation exposure and wearing heavy lead aprons.

METHODS

Head-level physician radiation doses, collected using real-time dosimeters during consecutive coronary angiography procedures, were compared with the use of a suspended lead suit versus conventional lead aprons. Multiple linear regression analyses were completed using physician radiation doses as the response and testing patient variables (body mass index, age, sex), procedural variables (right heart catheterization, fractional flow reserve, percutaneous coronary intervention, radial access), and shielding variables (radiation-absorbing pad, accessory lead shield, suspended lead suit) as the predictors.

RESULTS

Among 1054 coronary angiography procedures, 691 (65.6%) were performed with a suspended lead suit and 363 (34.4%) with lead aprons. There was no significant difference in dose area product between groups (61.7 [41.0, 94.9] mGy·cm² vs. 64.6 [42.9, 96.9] mGy·cm² , p = 0.20). Median head-level physician radiation doses were 10.2 [3.2, 35.5] μSv with lead aprons and 0.2 [0.1, 0.9] μSv with a suspended lead suit (p < 0.001), representing a 98.0% reduced dose with suspended lead. In the fully adjusted regression model, the use of a suspended lead suit was independently associated with a 93.8% reduction (95% confidence interval: -95.0, -92.3; p < 0.001) in physician radiation dose.

CONCLUSION

Compared to conventional lead aprons, the use of a suspended lead suit during coronary angiography was associated with marked reductions in head-level physician radiation doses.

Eye protection in interventional procedures

Data suggest that radiation-induced cataracts may form without a threshold and at low-radiation doses. Staff involved in interventional radiology and cardiology fluoroscopy-guided procedures have the potential to be exposed to radiation levels that may lead to eye lens injury and the occurrence of opacifications have been reported. Estimates of lens dose for various fluoroscopy procedures and predicted annual dosages have been provided in numerous publications. Available tools for eye lens radiation protection include accessory shields, drapes and glasses. While some tools are valuable, others provide limited protection to the eye. Reducing patient radiation dose will also reduce occupational exposure. Significant variability in reported dose measurements indicate dose levels are highly dependent on individual actions and exposure reduction is possible. Further follow-up studies of staff lens opacification are recommended along with eye lens dose measurements under current clinical practice conditions.

Ergonomics in Interventional Radiology: Awareness Is Mandatory

Ergonomics in interventional radiology has not been thoroughly evaluated. Like any operators, interventional radiologists are exposed to the risk of work-related musculoskeletal disorders. The use of lead shielding to radiation exposure and the lack of ergonomic principles developed so far contribute to these disorders, which may potentially affect their livelihoods, quality of life, and productivity. The objectives of this review were to describe the different situations encountered in interventional radiology and to compile the strategies both available to date and in development to improve ergonomics.

Pregnancy in the Cardiac Catheterization Laboratory: A Safe and Feasible Endeavor

Concerns over radiation exposure are ubiquitous to all interventional cardiologists; however, fear of exposure during childbearing years disproportionately deters women from entering the field. This review summarizes the available data on occupational radiation exposure during pregnancy with an emphasis on radiation quantification, the impact of exposure at various stages of fetal development, societal recommendations for safe levels of exposure during gestation, threshold levels necessary to induce fetal harm, and safe practices for the pregnant interventionalist. Reconciling the available information, we conclude that pregnancy in the cardiac catheterization laboratory is both safe and feasible. This review also highlights new technologies that may augment standard radiation safety techniques and are of particular interest to the pregnant interventional cardiologist. Finally, we propose steps to improve female representation in this field, underscoring the importance of a sex-balanced workforce.

Radiation Concerns for the Neuroanesthesiologists

With the advent of minimally invasive neurosurgical techniques and rapid innovations in the field of neurointervention, there has been a sharp rise in diagnostic and therapeutic modalities requiring radiation exposure. Neuroanesthesiologists are currently involved in various procedures inside as well as outside the operating room (OR) like intensive care units, interventional suites, and gamma knife units. The ambit expands from short-lasting diagnostic scans to lengthy therapeutic procedures performed under fluoroscopic guidance. Hence, a modern-day neuroanesthesiologist has to bear the brunt of the radiation exposure in both inside and outside the OR. However, obliviousness and nonadherence to the relevant radiation safety measures are still prevalent. Radiation protection and safety are topics that need to be discussed with new vigor in the light of current practice.

Ergonomics in IR

Ergonomic research in the field of interventional radiology remains limited. Existing literature suggests that operators are at increased risk for work-related musculoskeletal disorders related to the use of lead garments and incomplete knowledge of ergonomic principles. Data from existing surgical literature suggest that musculoskeletal disorders may contribute to physician burnout and female operators are at a higher risk of developing musculoskeletal disorders. This review article aims to summarize the existing ergonomic challenges faced by interventional radiologists, reiterate existing solutions to these challenges, and highlight the need for further ergonomic research in multiple areas, including burnout and gender.

Safety and Efficacy of Minimal- versus Zero-fluoroscopy Radiofrequency Catheter Ablation for Atrial Fibrillation: A Multicenter, Prospective Study

Radiofrequency catheter ablation (CA) is an effective treatment for atrial fibrillation (AF) that traditionally requires fluoroscopic imaging to guide catheter movement and positioning. However, advances in electroanatomic mapping (EAM) technology and intracardiac echocardiography (ICE) have reduced procedural reliance on fluoroscopy. We conducted a prospective registry study of 162 patients enrolled at five centers proficient in high-volume, minimal-fluoroscopy CA between March 2016 and March 2018 for the CA of symptomatic, drug-refractory paroxysmal, or persistent AF that sought to assess the safety and efficacy of minimal- versus zero-fluoroscopy AF CA. We evaluated procedural details, acute procedural outcomes and complications, and one-year follow-up data. All operators used an EAM system (CARTO^®; Biosense Webster, Irvine, CA, USA) and ICE. Ultimately, two patients did not pursue CA postenrollment. A total of 104 (66%) patients had paroxysmal AF with a mean ejection fraction of 58% ± 9%. Twenty-six (16.3%) patients were scheduled for repeat ablation. A total of 100 (63%) procedures were performed with zero fluoroscopy. The mean fluoroscopy time in the minimal-fluoroscopy group was 1.7 minutes ± 2.8 minutes. Further, the mean procedure duration was 192 minutes ± 37 minutes in the zero-fluoroscopy group and 201 minutes ± 29 minutes in the minimal-fluoroscopy group (p = 0.96). Pulmonary vein isolation was achieved in 153 patients (100%), with an acute procedural complication rate of 1.8%. One-year follow-up data were available for 152 (95%) patients with a mean follow-up time of 11.3 months ± 1.8 months. A total of 118 (76%) patients remained free from arrhythmia for up to 12 months, with no difference between the minimal- and zero-fluoroscopy cohorts (p = 0.18).

Comprehensive strategies to minimize radiation exposure during Interventional electrophysiology procedures: state-of-the-art review

INTRODUCTION

Cardiac electrophysiology (EP) procedures are frequently performed in patients with cardiac arrhythmias, chronic heart failure, and sudden cardiac death. Most EP procedures involve fluoroscopy, which results in radiation exposure to physicians, patients, and EP lab staff. Accumulated radiation exposure is a known health detriment to patients and physicians.

AREA COVERED

This review will summarize radiation exposure, dose metrics, complications of radiation exposure, factors affecting radiation exposure, minimizing radiation exposure, zero or near-zero fluoroscopy strategies, and up-to-date research in the area of reducing radiation exposure and best practices.

EXPERT COMMENTARY

Comprehensive strategies should be implemented in EP laboratories to minimize radiation exposure with standard fluoroscopy. There are routine techniques that can mitigate significant amounts of radiation exposure using standard equipment within the EP lab. The operators need to emphasize that EP practices routinely incorporate non-ionizing radiation sources for cardiac imaging (e.g. magnetic resonance imaging, advanced electroanatomical mapping systems, intracardiac ultrasonography) in addition to other novel technologies to mitigate radiation exposure to patients and physicians.

Radiation protection in the cardiac catheterization laboratory

The trend towards more minimally invasive procedures in the past few decades has resulted in an exponential growth in fluoroscopy-guided catheter-based cardiology procedures. As these techniques are becoming more commonly used and developed, the adverse effects of radiation exposure to the patient, operator, and ancillary staff have been a subject of concern. Although occupational radiation dose limits are being monitored and seldom reached, exposure to chronic, low dose radiation has been shown to have harmful biological effects that are not readily apparent until years after. Given this, it is imperative that reducing radiation dose exposure in the cardiac catheterization laboratory remains a priority. Staff education and training, radiation dose monitoring, ensuring use of proper personal protective equipment, employment of shields, and various procedural techniques in minimizing radiation must always be diligently employed. Special care and consideration should be extended to pregnant women working in the cardiac catheterization laboratory. This review article presents a practical approach to radiation dose management and discusses best practice recommendations in the cardiac catheterization laboratory.

Protective Efficacy of Different Ocular Radiation Protection Devices: A Phantom Study

PURPOSE

The aim of this study was to investigate the efficacy of different designs and types of ocular radiation protection devices depending on simulated varied body heights in a phantom-simulated thoracic intervention.

MATERIALS AND METHODS

A clinical angiography system with a standardized fluoroscopy protocol with an anthropomorphic chest phantom as a scattering object and optically stimulated luminescence dosimeters for measuring radiation dose were used. The dosimeters were placed at the position of eyes of an anthropomorphic head phantom simulating the examiner. The head phantom was placed on a height-adjustable stand simulating the height of the examiner from 160 to 200 cm with 10 cm increments. The dose values were then measured with no radiation protection, a weightless-like radiation protection garment, radiation protection glasses and visors.

RESULTS

The average dose reduction using radiation protection devices varied between 57.7 and 83.4% (p < 0.05) in comparison with no radiation protection. Some radiation protection glasses and visors showed a significant dose reduction for the eye lenses when the height of the examiner increased. The right eye was partially less protected, especially if the distances between the simulated examiner's head and the scatter object were small.

CONCLUSION

All the investigated protection devices showed a significant reduction in radiation exposure to the simulated examiner. For some devices, the radiation dose increased with decreasing distance to the scattering object, especially for the right eye lens.

Effectiveness of a new radiation protection system in the interventional radiology setting

OBJECTIVES

The goal of this study was to examine a new weightless-like radiation protection garment regarding its radiation protection efficacy and to compare it to a conventional two-piece apron suit plus thyroid collar and standard ancillary shields.

MATERIAL AND METHODS

All measurements were carried out using a clinical angiography system with a standardized fluoroscopy protocol for different C-arm angulations. An anthropomorphic torso phantom served as a scattering body. In addition, an ionization chamber was used to measure the radiation exposure on five different representative heights and at two different positions of an examiner during a typical fluoroscopic-guided intervention.

RESULTS

The new weightless-like radiation protection garment and the conventional protection concept showed a mean dose reduction of 98.1% (p < 0.01) and 90.1% (p < 0.01) when compared to no shielding, respectively. By adding ancillary shields to both systems, an average reduction of 99.0% (p < 0.01) and 98.2% (p < 0.01) was found. In addition, the efficacy of both systems varied depending on the height, the C-arm angulation and position of the examiner.

CONCLUSION

Combined with ancillary shields as an overall protection system, the recently introduced weightless-like radiation protection garment showed a significant better radiation protection efficacy when compared to conventional radiation protection measures.

Shields and garb for decreasing radiation exposure in the cath lab

INTRODUCTION

Decreasing radiation exposure of the cardiac catheterization laboratory staff is critical for minimizing radiation-related adverse outcomes and can be accomplished by decreasing patient dose and by shielding. Areas covered: protection from ionizing radiation can be achieved with architectural, equipment-mounted, and disposable shields, as well as with personal protective equipment. Expert commentary: Radiation protective aprons are the most commonly used personal protective equipment and provide robust radiation protection but can cause musculoskeletal strain. Use of a thyroid collar is recommended, as is use of 'shin guards', lead glasses and radioprotective caps, although the efficacy of the latter is being debated. Alternatives to lead aprons include shielding suspended from the ceiling and robotic percutaneous coronary intervention. Radiation protective gloves and cream can be used to protect the hands, but the best protection is to not directly expose them to the radiation beam. Devices that provide real time operator radiation dose monitoring can enable real time adjustments in positioning and shield placement, reducing radiation dose. Shielding can be achieved with architectural, equipment-mounted, and disposable shields. Equipment-mounted shielding includes ceiling-suspended shields, table-suspended drapes, and radioabsorbent drapes. Personal protective equipment and shielding should be consistently and judiciously utilized by all catheterization laboratory personnel.

Minimizing Radiation in the Modern Electrophysiology Laboratory

Historically, the electrophysiology laboratory has relied heavily on the use of ionizing radiation in the form of fluoroscopy for a broad range of interventions and diagnostics. As the harmful effects of radiation have become increasingly recognized and procedural technologies have advanced, electrophysiologists have adopted new workflows. The purpose of this article is to review the available literature and experience in minimizing radiation in the modern electrophysiology laboratory. This review first covers general approaches to reducing fluoroscopy radiation in the electrophysiology suite, with concepts that apply across all procedure types. These include the reduction of infrared emission through fastidious fluoroscopy settings, new and proven solutions for radiation shielding, and methods of creating distance between the radiation source and the operator to reduce exposure. Following this discussion, we review specific task-based techniques for reducing radiation during special electrophysiologic procedures and workflows such as vascular access, coronary sinus lead placement, catheter manipulation, and periprocedural planning studies.

The Eyes Have It

The ocular lens is one of the most susceptible structures in the body to radiation damage. Unfortunately, much of the traditional academic and regulatory thinking on thresholds to develop radiation-induced opacities or cataracts has proven to be false. Individual vulnerability to the effects of radiation is extremely variable, largely because each individual is variably genetically equipped to repair the damage caused by radiation. Therefore many people, including some unsuspecting interventional radiologists may have no, or almost no, threshold at all for cataract development after radiation injury. For most others, if there is a threshold it is a fraction of what was previously thought. These new data have become apparent during the same time period when unprecedented numbers of physicians and medical staff have been exposed to unprecedented doses of scatter radiation as the number and complexity of fluoroscopic guided procedures has exploded. Increased rates of radiation lens damage have already been documented in physicians and support staff working in interventional medicine. As there is a latency period of years to decades for lens injury to fully evolve it is quite possible the true incidence will not be known for some time. Strategies to minimize the potential risks encountered in interventional medicine include radiation safety best practices, passive and personal barrier protection, and philosophical approach to interventional radiology practice. Ignore this article at your peril.

Operator Radiation and the Efficacy of Ceiling-Suspended Lead Screen Shielding during Coronary Angiography: An Anthropomorphic Phantom Study Using Real-Time Dosimeters

Operator radiation and the radiation protection efficacy of a ceiling-suspended lead screen were assessed during coronary angiography (CA) in a catheterization laboratory. An anthropomorphic phantom was placed under the X-ray beam to simulate patient attenuation in eight CA projections. Using real-time dosimeters, radiation dose rates were measured on models mimicking a primary operator (PO) and an assistant. Subsequently, a ceiling-suspended lead screen was placed in three commonly used positions to compare the radiation protection efficacy. The radiation exposure to the PO was 2.3 to 227.9 (mean: 67.2 ± 49.0) μSv/min, with the left anterior oblique (LAO) 45°/cranial 25° and cranial 25° projections causing the highest and the lowest dose rates, respectively. The assistant experienced significantly less radiation overall (mean: 20.1 ± 19.6 μSv/min, P < 0.003), with the right anterior oblique (RAO) 30° and cranial 25° projections resulting in the highest and lowest exposure levels, respectively. Combined with table-side shielding, the ceiling-suspended lead screen reduced the radiation to the PO by 76.8%, 81.9% and 93.5% when placed close to the patient phantom, at the left side and close to the PO, respectively, and reduced the radiation to the assistant by 70.3%, 76.7% and 90.0%, respectively. When placed close to the PO, a ceiling-suspended lead screen provides substantial radiation protection during CA.

RADIATION PROTECTION IN AN INTERVENTIONAL LABORATORY: A COMPARATIVE STUDY OF AUSTRALIAN AND SAUDI ARABIAN HOSPITALS

This study aimed to investigate whether the use of protection devices and attitudes of interventional professionals (including radiologists, cardiologists, vascular surgeons, medical imaging technicians and nurses) towards radiation protection will differ between Saudi Arabian and Australian hospitals. Hard copies of an anonymous survey were distributed to 10 and 6 clinical departments in the Eastern province of Saudi Arabia and metropolitan hospitals in Western Australia, respectively. The overall response rate was 43 % comprising 110 Australian participants and 63 % comprising 147 Saudi participants. Analysis showed that Australian respondents differed significantly from Saudi respondents with respect to their usages of leaded glasses (p < 0.001), ceiling-suspended lead screen (p < 0.001) and lead drape suspended from the table (p < 0.001). This study indicates that the trained interventional professionals in Australia tend to adhere to benefit from having an array of tools for personal radiation protection than the corresponding group in Saudi Arabia.

Reduction of Fluoroscopy Time and Radiation Dosage During Catheter Ablation for Atrial Fibrillation

Radiofrequency catheter ablation has become the treatment of choice for atrial fibrillation (AF) that does not respond to antiarrhythmic drug therapy. During the procedure, fluoroscopy imaging is still considered essential to visualise catheters in real-time. However, radiation is often ignored by physicians since it is invisible and the long-term risks are underestimated. In this respect, it must be emphasised that radiation exposure has various potentially harmful effects, such as acute skin injury, malignancies and genetic disease, both to patients and physicians. For this reason, every electrophysiologist should be aware of the problem and should learn how to decrease radiation exposure by both changing the setting of the system and using complementary imaging technologies. In this review, we aim to discuss the basics of X-ray exposure and suggest practical instructions for how to reduce radiation dosage during AF ablation procedures.

Radiation Protection for the Fluoroscopy Operator and Staff

OBJECTIVE

The purposes of this article are to review available data regarding the range of protection devices and garments with a focus on eye protection and to summarize techniques for reducing scatter radiation exposure.

CONCLUSION

Fluoroscopy operators and staff can greatly reduce their radiation exposure by wearing properly fitted protective garments, positioning protective devices to block scatter radiation, and adhering to good radiation practices. By understanding the essentials of radiation physics, protective equipment, and the features of each imaging system, operators and staff can capitalize on opportunities for radiation protection while minimizing ergonomic strain. Practicing and promoting a culture of radiation safety can help fluoroscopy operators and staff enjoy long, productive careers helping patients.

A prospective case control comparison of the ZeroGravity system versus a standard lead apron as radiation protection strategy in neuroendovascular procedures

Background and purpose

We aimed to compare the performance of the ZeroGravity (ZG) system (radiation protection system composed by a suspended lead suit) against the use of standard protection (lead apron (LA), thyroid shield, lead eyeglasses, table skirts, and ceiling suspended shield) in neuroangiography procedures.

Materials and methods

Radiation exposure data were prospectively collected in consecutive neuroendovascular procedures between December 2014 and February 2015. Operator No 1 was assigned to the use of an LA (plus lead glasses, thyroid shield, and a 1 mm hanging shield at the groin) while operator No 2 utilized the ZG system. Dosimeters were used to measure peak skin dose for the head, thyroid, and left foot.

Results

The two operators performed a total of 122 procedures during the study period. The ZG operator was more commonly the primary operator compared with the LA operator (85% vs 71%; p=0.04). The mean anterior-posterior (AP), lateral, and cumulative dose area product (DAP) radiation exposure as well as the mean fluoroscopy time were not statistically different between the operators’ cases. The peak skin dose to the head of the operator with LA was 2.1 times higher (3380 vs 1600 μSv), while the thyroid was 13.9 (4460 vs 320 μSv), the mediastinum infinitely (520 vs 0 μSv), and the foot 3.3 times higher (4870 vs 1470 μSv) compared with the ZG operator, leading to an overall accumulated dose 4 times higher. The ratio of cumulative operator received dose/total cumulative DAP was 2.5 higher on the LA operator.

Conclusions

The ZG radiation protection system leads to substantially lower radiation exposure to the operator in neurointerventional procedures. However, substantial exposure may still occur at the level of the lens and thyroid to justify additional protection.

Editor's choice--Angulation of the C-arm during complex endovascular aortic procedures increases radiation exposure to the head

OBJECTIVES/BACKGROUND

The increased complexity of endovascular aortic repair necessitates longer procedural time and higher radiation exposure to the operator, particularly to exposed body parts. The aims were to measure directly exposure to radiation of the bodies and heads of the operating team during endovascular repair of thoracoabdominal aortic aneurysms (TAAA), and to identify factors that may increase exposure.

METHODS

This was a single-centre prospective study. Between October 2013 and July 2014, consecutive elective branched and fenestrated TAAA repairs performed in a hybrid operating room were studied. Electronic dosimeters were used to measure directly radiation exposure to the primary (PO) and assistant (AO) operator in three different areas (under-lead, over-lead, and head). Fluoroscopy and digital subtraction angiography (DSA) acquisition times, C-arm angulation, and PO/AO height were recorded.

RESULTS

Seventeen cases were analysed (Crawford II-IV), with a median operating time of 280 minutes (interquartile range 200-330 minutes). Median age was 76 years (range 71-81 years); median body mass index was 28 kg/m(2) (25-32 kg/m(2)). Stent-grafts incorporated branches only, fenestrations only, or a mixture of branches and fenestrations. A total of 21 branches and 38 fenestrations were cannulated and stented. Head dose was significantly higher in the PO compared with the AO (median 54 μSv [range 24-130 μSv] vs. 15 μSv [range 7-43 μSv], respectively; p = .022), as was over-lead body dose (median 80 μSv [range 37-163 μSv] vs. 32 μSv [range 6-48 μSv], respectively; p = .003). Corresponding under-lead doses were similar between operators (median 4 μSv [range 1-17 μSv] vs. 1 μSv [range 1-3 μSv], respectively; p = .222). Primary operator height, DSA acquisition time in left anterior oblique (LAO) position, and degrees of LAO angulation were independent predictors of PO head dose (p < .05).

CONCLUSIONS

The head is an unprotected area receiving a significant radiation dose during complex endovascular aortic repair. The deleterious effects of exposure to this area are not fully understood. Vascular interventionalists should be cognisant of head exposure increasing with C-arm angulation, and limit this manoeuvre.

Radiation safety and vascular access: attitudes among cardiologists worldwide

OBJECTIVES

To determine opinions and perceptions of interventional cardiologists on the topic of radiation and vascular access choice.

BACKGROUND

Transradial approach for cardiac catheterization has been increasing in popularity worldwide. There is evidence that transradial access (TRA) may be associated with increasing radiation doses compared to transfemoral access (TFA).

METHODS

We distributed a questionnaire to collect opinions of interventional cardiologists around the world.

RESULTS

Interventional cardiologists (n=5332) were contacted by email to complete an on-line survey from September to October 2013. The response rate was 20% (n=1084). TRA was used in 54% of percutaneous coronary interventions (PCIs). Most TRAs (80%) were performed with right radial access (RRA). Interventionalists perceived that TRA was associated with higher radiation exposure compared to TFA and that RRA was associated with higher radiation exposure that left radial access (LRA). Older interventionalists were more likely to use radiation protection equipment and those who underwent radiation safety training gave more importance to ALARA (as low as reasonably achievable). Nearly half the respondents stated they would perform more TRA if the radiation exposure was similar to TFA. While interventionalists in the United States placed less importance to certain radiation protective equipment, European operators were more concerned with physician and patient radiation.

CONCLUSIONS

Interventionalists worldwide reported higher perceived radiation doses with TRA compared to TFA and RRA compared to LRA. Efforts should be directed toward encouraging consistent radiation safety training. Major investment and application of novel radiation protection tools and radiation dose reduction strategies should be pursued.

The Growing Culture Of A Minimally Fluoroscopic Approach In Electrophysiology Lab

Most of interventional procedures in cardiology are carried out under fluoroscopic imaging guidance. Besides other peri-interventional risks, radiation exposure should be considered for its stochastic (inducing malignancy) and deterministic effects on health (tissue reactions like erythema, hair loss and cataracts). In this article we analized the radiation risk from cardiovascular imaging to both patients and medical staff and discusses how customize the X-ray system and how to implement shielding measures in the cath lab. Finally, we reviewed the most recent developments and the latest findings in catheter navigation and 3D electronatomical mapping systems that may help to reduce patient and operator exposure.

Use of digital dosemeters for supporting staff radiation safety in paediatric interventional radiology suites

Modern-day interventional radiology (IR) procedures impart a wide range of occupational radiation doses to team members. Unlike thermoluminescent badges, digital dosemeters provide real-time dose readings, making them ideal for identifying different components during IR procedures, which influence staff radiation safety. This study focused solely on paediatric IR (PIR) cases. Digital dosemeters measured the impact of imaging modality, shielding, patient and operator specific factors, on the radiation dose received during various simulated and real live PIR procedures. They recorded potential dose reductions of 10- to 100-fold to each staff member with appropriate use of shielding, choice of imaging method, staff position in the room and complex interplay of other factors. The digital dosemeters were well tolerated by staff. Results highlight some unique radiation safety challenges in PIR that arise from dose increases with magnification use and close proximity of staff to the X-ray beam.