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Clauss N, Kuntz S, Colvard B, Ohana M, Mertz L, Lejay A, Chakfe N. Intraoperative Staff Radiation Exposure During Aortic Endovascular Procedures. Ann Vasc Surg 2024; 106:16-24. [PMID: 38641000 DOI: 10.1016/j.avsg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/30/2023] [Accepted: 01/01/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND The risk of radiation exposure in the surgical operating room (OR) and/or catheterization laboratory is now well established. Complex endovascular procedures often require multiple approaches and different positioning of the staff members around the patient, potentially increasing the levels of radiations exposure. Our goal was to evaluate the levels of radiation exposure of the members of the staff during endovascular aortic procedures in order to propose radioprotection optimization. METHODS We included 41 aortic endovascular procedures out of 114 procedures performed between January 12, 2014, and August 31, 2015, including 24 standard endovascular aortic aneurysm repair (EVAR), 7 EVAR with iliac branch (EVARib), 8 complex fenestrated/branched EVAR (F/B EVAR), and 2 thoracic EVAR (TEVAR). Procedures were performed in an OR equipped with a carbon fiber table and a mobile fluoroscopy C-arm. We collected the usual dosimetry data given by the C-arm as well as the patient's peak skin dose (PSD). In all staff members, radiation exposure was measured with thermoluminescent chip dosimeters placed on both temples, on posterior sides of both hands, and on both lower legs. RESULTS PSD levels were low for EVAR because 24 patients had values below the reading threshold. PSD significantly increased with more complex procedures. Main operator (MO) received the higher level of irradiation on whole body, hands, and ankles. Eye lenses irradiation was higher on both assistant operators (AOs). Other members received low levels of irradiation. We found a high ranges of radiation exposure with a high risk of exposure for the AO, mainly for F/B EVAR and EVARib. CONCLUSIONS Even if all personal protections are used, staff positioning is a major point that must be considered. If MO is supposed to be the most exposed to X-rays, specific conditions of positioning of the AO may be at risk of exposure.
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Affiliation(s)
- Nicolas Clauss
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Salomé Kuntz
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Benjamin Colvard
- University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH
| | - Mickael Ohana
- Department of Radiology, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Luc Mertz
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Anne Lejay
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France; GEPROMED, Strasbourg, France; Fédération de Médecine Translationelle (FMTS), Faculté de Médecine, Institut de Physiologie, Equipe d'Accueil EA3072 "Mitochondrie, Stress Oxydant et Protection Musculaire", Université de Strasbourg, Strasbourg, France
| | - Nabil Chakfe
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France; GEPROMED, Strasbourg, France; Fédération de Médecine Translationelle (FMTS), Faculté de Médecine, Institut de Physiologie, Equipe d'Accueil EA3072 "Mitochondrie, Stress Oxydant et Protection Musculaire", Université de Strasbourg, Strasbourg, France.
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2
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Modarai B, Haulon S, Ainsbury E, Böckler D, Vano-Carruana E, Dawson J, Farber M, Van Herzeele I, Hertault A, van Herwaarden J, Patel A, Wanhainen A, Weiss S, Esvs Guidelines Committee, Bastos Gonçalves F, Björck M, Chakfé N, de Borst GJ, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kakkos SK, Koncar IB, Kolh P, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Document Reviewers, Bacher K, Brountzos E, Fanelli F, Fidalgo Domingos LA, Gargiulo M, Mani K, Mastracci TM, Maurel B, Morgan RA, Schneider P. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Radiation Safety. Eur J Vasc Endovasc Surg 2023; 65:171-222. [PMID: 36130680 DOI: 10.1016/j.ejvs.2022.09.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/15/2022] [Indexed: 01/24/2023]
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3
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Massey PA, Myers ME, Guedry RD, Lowery MT, Perry KJ, Barton RS. Improved Radiation Exposure Monitoring of Orthopaedic Residents After Institution of a Personalized Lead Protocol. JB JS Open Access 2022; 7:JBJSOA-D-21-00115. [PMID: 35355780 PMCID: PMC8939914 DOI: 10.2106/jbjs.oa.21.00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Radiation exposure of orthopaedic residents should be accurately monitored to monitor and mitigate risk. The purpose of this study was to determine whether a personalized lead protocol (PLP) with a radiation monitoring officer would improve radiation exposure monitoring of orthopaedic surgery residents. Materials and Methods: This was a retrospective case-control study of 15 orthopaedic surgery residents monitored for radiation exposure during a 2-year period (March 2017 until February 2019). During the first 12-month period (phase 1), residents were given monthly radiation dosimeter badges and instructed to attach them daily to the communal lead aprons hanging outside the operating rooms. During the second 12-month period (phase 2), a PLP (PLP group) was instituted in which residents were given lead aprons embroidered with their individual names. A radiation safety officer was appointed who placed the badges monthly on all lead aprons and collected them at the end of the month, whereas faculty ensured residents wore their personalized lead apron. Data collected included fluoroscopy use time and radiation dosimeter readings during all orthopaedic surgeries in the study period. Results: There were 1,252 orthopaedic surgeries using fluoroscopy during phase 1 in the control group and 1,269 during phase 2 in the PLP group. The total monthly fluoroscopy exposure time for all cases averaged 190 minutes during phase 1 and 169 minutes during phase 2, with no significant difference between the groups (p < 0.45). During phase 1, 73.1% of the dosimeters reported radiation exposure, whereas during phase 2, 88.7% of the dosimeters reported radiation exposure (p < 0.001). During phase 1, the average monthly resident dosimeter exposure reading was 7.26 millirems (mrem) ± 37.07, vs. 19.00 mrem ± 51.16 during phase 2, which was significantly higher (p < 0.036). Conclusions: Institution of a PLP increased the compliance and exposure readings of radiation dosimeter badges for orthopaedic surgery residents, whereas the actual monthly fluoroscopy time did not change. Teaching hospitals should consider implementing a PLP to more accurately monitor exposure. Level of Evidence: 3.
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Affiliation(s)
- Patrick A Massey
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana
| | - Mitchell E Myers
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana
| | - Ryan D Guedry
- School of Medicine, Louisiana State University, Shreveport, Louisiana
| | - Michael T Lowery
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana
| | - Kevin J Perry
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana
| | - R Shane Barton
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana
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4
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Udroiu I, Sgura A, Chendi A, Lasagni L, Bertolini M, Fioroni F, Piccagli V, Moramarco A, Romano MG, Fontana L, D'Alessio D, Bruzzaniti V, Rosi A, Grande S, Palma A, Giliberti C, Iori M, Piergallini L, Sumini M, Isolan L, Cucchi G, Compagnone G, Strigari L. DNA damage in lens epithelial cells exposed to occupationally-relevant X-ray doses and role in cataract formation. Sci Rep 2020; 10:21693. [PMID: 33303795 PMCID: PMC7728785 DOI: 10.1038/s41598-020-78383-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 10/28/2020] [Indexed: 11/09/2022] Open
Abstract
The current framework of radiological protection of occupational exposed medical workers reduced the eye-lens equivalent dose limit from 150 to 20 mSv per year requiring an accurate dosimetric evaluation and an increase understanding of radiation induced effects on Lens cells considering the typical scenario of occupational exposed medical operators. Indeed, it is widely accepted that genomic damage of Lens epithelial cells (LEC) is a key mechanism of cataractogenesis. However, the relationship between apoptosis and cataractogenesis is still controversial. In this study biological and physical data are combined to improve the understanding of radiation induced effects on LEC. To characterize the occupational exposure of medical workers during angiographic procedures an INNOVA 4100 (General Electric Healthcare) equipment was used (scenario A). Additional experiments were conducted using a research tube (scenario B). For both scenarios, the frequencies of binucleated cells, micronuclei, p21-positive cells were assessed with different doses and dose rates. A Monte-Carlo study was conducted using a model for the photon generation with the X-ray tubes and with the Petri dishes considering the two different scenarios (A and B) to reproduce the experimental conditions and validate the irradiation setups to the cells. The simulation results have been tallied using the Monte Carlo code MCNP6. The spectral characteristics of the different X-ray beams have been estimated. All irradiated samples showed frequencies of micronuclei and p21-positive cells higher than the unirradiated controls. Differences in frequencies increased with the delivered dose measured with Gafchromic films XR-RV3. The spectrum incident on eye lens and Petri, as estimated with MCNP6, was in good agreement in the scenario A (confirming the experimental setup), while the mean energy spectrum was higher in the scenario B. Nevertheless, the response of LEC seemed mainly related to the measured absorbed dose. No effects on viability were detected. Our results support the hypothesis that apoptosis is not responsible for cataract induced by low doses of X-ray (i.e. 25 mGy) while the induction of transient p21 may interfere with the disassembly of the nuclear envelop in differentiating LEC, leading to cataract formation. Further studies are needed to better clarify the relationship we suggested between DNA damage, transient p21 induction and the inability of LEC enucleation.
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Affiliation(s)
- Ion Udroiu
- Department of Science, University of Rome "Roma Tre", Rome, Italy
| | - Antonella Sgura
- Department of Science, University of Rome "Roma Tre", Rome, Italy
| | - Agnese Chendi
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio, Italy.,Postgraduate School in Medical Physics, University of Bologna, Bologna, Italy
| | - Lorenzo Lasagni
- Postgraduate School in Medical Physics, University of Firenze, Florence, Italy
| | - Marco Bertolini
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio, Italy
| | - Federica Fioroni
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio, Italy
| | - Vando Piccagli
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio, Italy
| | - Antonio Moramarco
- Ophthalmology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio, Italy
| | | | - Luigi Fontana
- Ophthalmology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio, Italy
| | - Daniela D'Alessio
- Department of Medical Physics, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Vicente Bruzzaniti
- Laboratory of Medical Physics and Expert Systems, Regina Elena Cancer Institute IRCCS, Rome, Italy
| | - Antonella Rosi
- Istituto Superiore di Sanità, Centro Nazionale Tecnologie Innovative in Sanità Pubblica, Rome, Italy
| | - Sveva Grande
- Istituto Superiore di Sanità, Centro Nazionale Tecnologie Innovative in Sanità Pubblica, Rome, Italy
| | - Alessandra Palma
- Istituto Superiore di Sanità, Centro Nazionale Tecnologie Innovative in Sanità Pubblica, Rome, Italy
| | - Claudia Giliberti
- Inail-Dipartimento Innovazioni Tecnologiche e Sicurezza degli Impianti, Prodotti ed Insediamenti Antropici, Rome, Italy
| | - Mauro Iori
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio, Italy
| | - Lorenzo Piergallini
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio, Italy.,Montecuccolino Laboratory, Industrial Engineering Department, University of Bologna, Bologna, Italy
| | - Marco Sumini
- Montecuccolino Laboratory, Industrial Engineering Department, University of Bologna, Bologna, Italy.,INFN, Bologna, Italy.,Interdepartmental Center "L. Galvani" CIG, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - Lorenzo Isolan
- Montecuccolino Laboratory, Industrial Engineering Department, University of Bologna, Bologna, Italy.,Interdepartmental Center "L. Galvani" CIG, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - Giorgio Cucchi
- Montecuccolino Laboratory, Industrial Engineering Department, University of Bologna, Bologna, Italy.,Interdepartmental Center "L. Galvani" CIG, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - Gaetano Compagnone
- Department of Medical Physics, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Lidia Strigari
- Department of Medical Physics, St. Orsola-Malpighi University Hospital, Bologna, Italy.
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Digital Variance Angiography in Lower-Limb Angiography with Metal Implants. Cardiovasc Intervent Radiol 2020; 44:452-459. [PMID: 33145701 PMCID: PMC7864852 DOI: 10.1007/s00270-020-02697-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 09/18/2020] [Indexed: 11/18/2022]
Abstract
Purpose The presence of metal implants may reduce angiographic image quality due to automated beam adjustments. Digital variance angiography (DVA) is reported to be superior to digital subtraction angiography (DSA) with increased contrast-to-noise ratio (CNR) and better image quality. The aim of the study was to evaluate whether DVA could counterbalance the image quality impairment of lower-limb angiographies with metal implants. Materials and Methods From November 2019 to January 2020, 85 raw lower-limb iodine contrast angiograms of 12 patients with metal implants were processed retrospectively with DVA analyses. For objective comparison, CNR of DSA and DVA images was calculated and the ratio CNRDVA/CNRDSA was determined. Visual image quality was evaluated in a paired comparison and by a five-grade Likert scale by three experienced radiologists. Results The CNR was calculated and compared in 1252 regions of interest in 37 image pairs containing metal implants. The median ratio of CNRDVA/CNRDSA was 1.84 with an interquartile range of 1.35–2.32. Paired comparison resulted in 84.5% in favour of DVA with an interrater agreement of 83.2% (Fleiss κ 0.454, p < 0.001). The overall image quality scores for DSA and DVA were 3.64 ± 0.08 and 4.43 ± 0.06, respectively (p < 0.001, Wilcoxon signed-rank test) with consistently higher individual ratings for DVA. Conclusion Our small-sample pilot study shows that DVA provides significantly improved image quality in lower-limb angiography with metal implants, compared to DSA imaging. The improved CNR suggest that this approach could reduce radiation exposure for lower-limb angiography with metal implants. Level of Evidence Level 4, case studies
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6
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Bohari A, Hashim S, Mohd Mustafa SN. SCATTER RADIATION IN THE FLUOROSCOPY-GUIDED INTERVENTIONAL ROOM. RADIATION PROTECTION DOSIMETRY 2020; 188:397-402. [PMID: 31950168 DOI: 10.1093/rpd/ncz299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 11/22/2019] [Accepted: 12/16/2019] [Indexed: 06/10/2023]
Abstract
Radiation scattered throughout the room during fluoroscopy-guided interventional (FGI) procedures was quantified at different locations using nanoDot optically stimulated luminescence dosemeters. All the tube angulation imaging shows that the radiation spectrum resembled a single peak distribution. The left anterior oblique 90° shows the highest single peak distribution (28.65 mSv/h). The single peak distribution for standard anteroposterior, left anterior oblique 45° and right anterior oblique 45° imaging was 13.32, 22.99 and 17.40 mSv/h, respectively. All tube angulation shows that the position of the interventional radiologist experienced a higher radiation level compared to other staffs. The doses of radiation varied widely around the perimeter of the patient's table and changed in accordance to imaging angles during procedures. Knowledge pertaining to radiation exposure levels is integral in order to avoid adverse risks, particularly among staff.
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Affiliation(s)
- Asmah Bohari
- Department of Physics, Faculty of Science, Universiti Teknologi Malaysia, 81310 UTM Skudai, Johor, Malaysia
| | - Suhairul Hashim
- Department of Physics, Faculty of Science, Universiti Teknologi Malaysia, 81310 UTM Skudai, Johor, Malaysia
- Centre for Sustainable Nanomaterials (CSNano), Ibnu Sina Institute for Scientific and Industrial Research (ISI-SIR), Universiti Teknologi Malaysia, 81310 UTM Skudai, Johor, Malaysia
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7
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Wilson‐Stewart K, Shanahan M, Fontanarosa D, Davidson R. Occupational radiation exposure to nursing staff during cardiovascular fluoroscopic procedures: A review of the literature. J Appl Clin Med Phys 2018; 19:282-297. [PMID: 30294978 PMCID: PMC6236819 DOI: 10.1002/acm2.12461] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/19/2018] [Accepted: 07/14/2018] [Indexed: 11/16/2022] Open
Abstract
Fluoroscopy is a method used to provide real time x-ray imaging of the body during medical procedures to assist with medical diagnosis and treatment. Recent technological advances have seen an increase in the number of fluoroscopic examinations being performed. Nurses are an integral part of the team conducting fluoroscopic investigations and are often located close to the patient resulting in an occupational exposure to radiation. The purpose of this review was to examine recent literature which investigates occupational exposure received by nursing staff during cardiovascular fluoroscopic procedures. Articles published between 2011 and 2017 have been searched and comprehensively reviewed on the referenced medical search engines. Twenty-four relevant studies were identified among which seventeen investigated nursing dose comparative to operator dose. Seven researched the effectiveness of interventions in reducing occupational exposure to nursing staff. While doctors remain at the highest risk of exposure during procedures, evidence suggests that nursing staff may be at risk of exceeding recommended dose limits in some circumstances. There is also evidence of inconsistent use of personal protection such as lead glasses and skull caps by nursing staff to minimize radiation exposure. Conclusions: The review has highlighted a lack of published literature focussing on dose to nurses. There is a need for future research in this area to inform nursing staff of factors which may contribute to high occupational doses and of methods for minimizing the risk of exposure, particularly regarding the importance of utilizing radiation protective equipment.
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Affiliation(s)
- Kelly Wilson‐Stewart
- School of Clinical SciencesQueensland University of TechnologyBrisbaneQldAustralia
- Cardiovascular SuitesGreenslopes Private HospitalBrisbaneQldAustralia
- Faculty of HealthUniversity of CanberraCanberraACTAustralia
| | | | - Davide Fontanarosa
- School of Clinical SciencesQueensland University of TechnologyBrisbaneQldAustralia
- Institute of Health and Biomedical InnovationQueensland University of TechnologyBrisbaneQldAustralia
| | - Rob Davidson
- Faculty of HealthUniversity of CanberraCanberraACTAustralia
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8
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de Ruiter QM, Gijsberts CM, Hazenberg CE, Moll FL, van Herwaarden JA. Radiation Awareness for Endovascular Abdominal Aortic Aneurysm Repair in the Hybrid Operating Room. An Instant Patient Risk Chart for Daily Practice. J Endovasc Ther 2017; 24:425-434. [PMID: 28393672 PMCID: PMC5438080 DOI: 10.1177/1526602817697188] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: To determine which patient and C-arm characteristics are the strongest predictors of intraoperative patient radiation dose rates (DRs) during endovascular aneurysm repair (EVAR) procedures and create a patient risk chart. Methods: A retrospective analysis was performed of 74 EVAR procedures, including 16,889 X-ray runs using fixed C-arm imaging equipment. Four multivariate log-linear mixed models (with patient as a random effect) were constructed. Mean air kerma DR (DRAK, mGy/s) and the mean dose area product DR (DRDAP, mGycm2/s) were the outcome variables utilized for fluoroscopy as differentiated from digital subtraction angiography (DSA). These models were used to predict the maximum radiation duration allowed before a 2-Gy skin threshold (for DRAK) or a 500-Gycm2 threshold (for DRDAP) was reached. Results: The strongest predictor of DRAK and DRDAP for fluoroscopy imaging was the radiation protocol, with an increase of 200% when changing from “low” to “medium” and 410% from “low” to “normal.” The strongest predictors of DRAK and DRDAP for DSA were C-arm angulation, with an increase of 47% per 30° of angulation, and body mass index (BMI), with an increase of 58% for every 5-point increase in BMI. Based on these models, a patient with a BMI of 30 kg/m2, combined with 45° of rotation and a field size of 800 cm2 in the medium fluoroscopy protocol has a predicted DRAK of 0.39 mGy/s (or 85.5 minutes until the 2-Gy skin threshold is reached). While using comparable settings but switching the acquisition to a DSA with a “2 frames per second” protocol, the predicted DRAK will be 6.6 mGy/s (or 5.0 minutes until the 2-Gy threshold is reached). Conclusion: X-ray radiation DRs are constantly fluctuating during and between patients based on BMI, the protocols, C-arm position, and the image acquisitions that are used. An instant patient risk chart visualizes these radiation dose fluctuations and provides an overview of the expected duration of X-ray radiation, which can be used to predict when follow-up dose thresholds are reached during abdominal endovascular procedures.
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Affiliation(s)
- Quirina M de Ruiter
- 1 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Crystel M Gijsberts
- 2 ICIN-Netherlands Heart Institute, Utrecht, the Netherlands.,3 Laboratory of Experimental Cardiology, University Medical Center Utrecht, the Netherlands
| | | | - Frans L Moll
- 1 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
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9
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Goldsweig AM, Abbott JD, Aronow HD. Physician and Patient Radiation Exposure During Endovascular Procedures. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:10. [PMID: 28275940 DOI: 10.1007/s11936-017-0507-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OPINION STATEMENT Endovascular procedures expose both patients and physicians to fluoroscopic ionizing radiation that carries a dose-dependent risk of acute toxicity and a small, but demonstrable, long-term risk of malignancy due to resultant genetic mutations. Exposure doses vary widely based upon patient-related factors including body size and anatomic complexity, operator technique, procedure type (diagnostic vs. therapeutic), vascular bed imaged, and imaging equipment employed. Effective dosage may vary as much as 200-fold for physicians and 20-fold for patients depending upon the procedure: for example, complex aortic interventions with branched graft devices may convey mean effective doses of more than 0.4 mSv for physicians and 100 mSv for patients, whereas distal, small-vessel angiography may entail mean effective doses of less than 0.002 mSv for physicians and 5 mSv for patients. Particular attention is given to physicians' ocular exposure, which may cause cataract development, and to hand exposure, which is significantly higher than total body exposure when operators work near the x-ray beam. Given the risks of radiation exposure, numerous strategies have been developed to reduce both physician and patient doses. These measures include physician education about dose-reducing imaging techniques, development of low-dose imaging equipment, introduction of new radiation shielding drapes and caps, and real-time dose monitoring. Here, we review physician and patient effective doses of radiation by procedure type as reported in the literature and present recent data regarding dose-reduction strategies.
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Affiliation(s)
- Andrew M Goldsweig
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 731, Providence, RI, 02903, USA
| | - J Dawn Abbott
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 731, Providence, RI, 02903, USA
| | - Herbert D Aronow
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 731, Providence, RI, 02903, USA.
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10
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Jia Q, Chen Z, Jiang X, Zhao Z, Huang M, Li J, Zhuang J, Liu X, Hu T, Liang W. Operator Radiation and the Efficacy of Ceiling-Suspended Lead Screen Shielding during Coronary Angiography: An Anthropomorphic Phantom Study Using Real-Time Dosimeters. Sci Rep 2017; 7:42077. [PMID: 28169334 PMCID: PMC5294580 DOI: 10.1038/srep42077] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/05/2017] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Qianjun Jia
- Department of Cardiac Catheterization Lab, Guangdong Cardiovascular institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou 510100, China
| | - Ziman Chen
- Department of Cardiac Catheterization Lab, Guangdong Cardiovascular institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou 510100, China
| | - Xianxian Jiang
- Image Guided Therapy Systems, Philips Healthcare Australia, 747 Lytton Rd, Murarrie QLD 4172, Australia
| | - Zhenjun Zhao
- Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou 510100, China
| | - Meiping Huang
- Department of Cardiac Catheterization Lab, Guangdong Cardiovascular institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou 510100, China
| | - Jiahua Li
- Department of Cardiac Catheterization Lab, Guangdong Cardiovascular institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou 510100, China
| | - Jian Zhuang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease Guangdong General Hospital, Guangdong Academy of Medical Science, 96 Dongchuan Road, Guangzhou 510100, China
| | - Xiaoqing Liu
- Epidemiology Division, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China, 96 Dongchuan Road, Guangzhou 510100, China
| | - Tianyu Hu
- Department of Cardiac Catheterization Lab, Guangdong Cardiovascular institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou 510100, China
| | - Wensheng Liang
- Department of Cardiac Catheterization Lab, Guangdong Cardiovascular institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou 510100, China
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11
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Real-Time Patient and Staff Radiation Dose Monitoring in IR Practice. Cardiovasc Intervent Radiol 2016; 40:421-429. [PMID: 27942927 PMCID: PMC5288431 DOI: 10.1007/s00270-016-1526-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/01/2016] [Indexed: 10/29/2022]
Abstract
PURPOSE Knowledge of medical radiation exposure permits application of radiation protection principles. In our center, the first dedicated real-time, automated patient and staff dose monitoring system (DoseWise Portal, Philips Healthcare) was installed. Aim of this study was to obtain insight in the procedural and occupational doses. MATERIALS AND METHODS All interventional radiologists, vascular surgeons, and technicians wore personal dose meters (PDMs, DoseAware, Philips Healthcare). The dose monitoring system simultaneously registered for each procedure dose-related data as the dose area product (DAP) and effective staff dose (E) from PDMs. Use and type of shielding were recorded separately. All procedures were analyzed according to procedure type; these included among others cerebral interventions (n = 112), iliac and/or caval venous recanalization procedures (n = 68), endovascular aortic repair procedures (n = 63), biliary duct interventions (n = 58), and percutaneous gastrostomy procedure (n = 28). RESULTS Median (±IQR) DAP doses ranged from 2.0 (0.8-3.1) (percutaneous gastrostomy) to 84 (53-147) Gy cm2 (aortic repair procedures). Median (±IQR) first operator doses ranged from 1.6 (1.1-5.0) μSv to 33.4 (12.1-125.0) for these procedures, respectively. The relative exposure, determined as first operator dose normalized to procedural DAP, ranged from 1.9 in biliary interventions to 0.1 μSv/Gy cm2 in cerebral interventions, indicating large variation in staff dose per unit DAP among the procedure types. CONCLUSION Real-time dose monitoring was able to identify the types of interventions with either an absolute or relatively high staff dose, and may allow for specific optimization of radiation protection.
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Ferrari P, Becker F, Carinou E, Chumak V, Farah J, Jovanovic Z, Krstic D, Morgun A, Principi S, Teles P. Monte Carlo study of the scattered radiation field near the eyes of the operator in interventional procedures. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2016; 36:902-921. [PMID: 27861170 DOI: 10.1088/0952-4746/36/4/902] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Interventional radiology and cardiology guarantee high benefits for patients, but are known to be associated with a high level of radiation exposure of medical staff. The recently suggested decrease of the annual dose limit for the eye lens, from 150 to 20 mSv, caused a need for a reconsideration of practices ensuring sufficient protection for the lens of the eyes of medical staff. In such context the study of the scattered radiation around the operator's head could help in finding the best solutions to be adopted for the ceiling-suspended shield and lead glasses in the most common situations in interventional practices. MCNPX Monte Carlo code was employed with anthropomorphic mathematical phantoms to simulate interventional practice projections. For each projection the effect of changing selected parameters on the evaluated scattered radiation towards the operator's head has been calculated. The variety of modelled situations provides plentiful material regarding the spatial distribution of the scattered radiation, useful to improve eye lens radiation protection, such as the following: (a) Glasses, which provide shielding from both lateral and bottom-up scattered radiation, can reduce by ten times the exposure to the most exposed eyes; (b) The ceiling-suspended shield offers valuable protection, but such effectiveness can diminish by 90% if the shielding is not correctly positioned; (c) The transition from femoral to radial access usually intensifies the scattered radiation toward the operator head (a factor of 1.5 for AP projection), but for RAO projections, a reduction of the order by two to three times, in the case of radial access, can be seen, due to the protection provided by the image receptor. The detailed fluence outcomes show that there is a preferential direction of the impinging scattered radiation that should be considered when radiation protection options are evaluated or when a dedicated eye lens dosemeter is used for monitoring.
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Affiliation(s)
- Paolo Ferrari
- ENEA- Radiation Protection Institute, 4 Via Martiri di Monte Sole, 40129 Bologna (BO), Italy
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13
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de Ruiter QMB, Reitsma JB, Moll FL, van Herwaarden JA. Meta-analysis of Cumulative Radiation Duration and Dose During EVAR Using Mobile, Fixed, or Fixed/3D Fusion C-Arms. J Endovasc Ther 2016; 23:944-956. [DOI: 10.1177/1526602816668305] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Purpose: To investigate the total fluoroscopy time and radiation exposure dose during endovascular aortic repairs using mobile, fixed, or fixed C-arms with 3-dimensional image fusion (3D-IF). Methods: A systematic search was performed to identify original articles reporting fluoroscopy time (FT) and the kerma area product (KAP) during endovascular aortic repairs. Data were grouped by noncomplex or complex (fenestrated, branched, or chimney) repairs and stratified by type of C-arm. The search identified 27 articles containing 51 study groups (35 noncomplex and 16 complex) that included 3444 patients. Random-effects meta-analysis and meta-regression models were used to calculate the pooled mean estimates of KAP and FT, as well as any effect of equipment or type of intervention. Results are presented with the 95% confidence interval and the statistical heterogeneity ( I2). Results: Within the noncomplex procedure studies, a significant (p<0.001) increase was found in the pooled mean KAP estimate in the fixed C-arm group (181 Gy·cm2, 95% CI 129 to 233; I2=99.7) compared with the mobile C-arm (78 Gy·cm2, 95% CI 59.6 to 97.3; I2=99.6). For complex cases, use of 3D-IF showed a significantly (p<0.001) lower mean KAP (139 Gy·cm2, 95% CI 85 to 191; I2=94%) compared to using fixed C-arms without 3D-IF (487 Gy·cm2, 95% CI 331 to 643; I2=94%). Conclusion: For equivalent fluoroscopy times, the use of a fixed C-arm in noncomplex procedures leads to higher patient radiation doses compared to a mobile C-arm. Complex procedures, which are predominantly performed using fixed C-arms, are associated with the highest radiation dose per intervention. Using fixed C-arms combined with 3D-IF techniques during complex cases might seem an adequate method to compensate for the higher radiation doses measured when a fixed C-arm is used.
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Affiliation(s)
| | - Johannes B. Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
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14
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Radiation exposure in endovascular repair of abdominal and thoracic aortic aneurysms. J Vasc Surg 2015; 62:753-61. [DOI: 10.1016/j.jvs.2015.05.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 05/14/2015] [Indexed: 11/22/2022]
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15
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Kirkwood ML, Guild JB, Arbique GM, Anderson JA, Valentine RJ, Timaran C. Surgeon radiation dose during complex endovascular procedures. J Vasc Surg 2015; 62:457-63. [DOI: 10.1016/j.jvs.2015.02.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
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Almén A, Sandblom V, Båth M, Lundh C. Optimisation of occupational radiological protection in image-guided interventions: potential impact of dose rate measurements. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2015; 35:47-62. [PMID: 25517218 DOI: 10.1088/0952-4746/35/1/47] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The optimisation of occupational radiological protection is challenging and a variety of factors have to be considered. Physicians performing image-guided interventions are working in an environment with one of the highest radiation risk levels in healthcare. Appropriate knowledge about the radiation environment is a prerequisite for conducting the optimisation process. Information about the dose rate variation during the interventions could provide valuable input to this process. The overall purpose of this study was to explore the prerequisite and feasibility to measure dose rate in scattered radiation and to assess the usefulness of such data in the optimisation process.Using an active dosimeter system, the dose rate in the unshielded scattered radiation field was measured in a fixed point close to the patient undergoing an image-guided intervention. The measurements were performed with a time resolution of one second and the dose rate data was continuously timed in a data log. In two treatment rooms, data was collected during a 6 month time period, resulting in data from 380 image-guided interventions and vascular treatments in the abdomen, arms and legs. These procedures were categorised into eight types according to the purpose of the treatment and the anatomical region involved.The dose rate varied substantially between treatment types, both regarding the levels and the distribution during the procedure. The maximum dose rate for different types of interventions varied typically between 5 and 100 mSv h(-1), but substantially higher and lower dose rates were also registered. The average dose rate during a complete procedure was however substantially lower and varied typically between 0.05 and 1 mSv h(-1). An analysis of the distribution disclosed that for a large part of the treatment types, the major amount of the total accumulated dose for a procedure was delivered in less than 10% of the exposure time and in less than 1% of the total procedure time.The present study shows that systematic dose rate measurements are feasible. Such measurements can be used to give a general indication of the exposure level to the staff and could serve as a first risk assessment tool when introducing new treatment types or x-ray equipment in the clinic. For example, it could provide an indication for when detailed eye dose measurements are needed. It also gives input to risk management considerations and the development of efficient routines for other radiological protection measures.
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Affiliation(s)
- A Almén
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden. Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden
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Sailer AM, Schurink GWH, Bol ME, de Haan MW, van Zwam WH, Wildberger JE, Jeukens CRLPN. Occupational Radiation Exposure During Endovascular Aortic Repair. Cardiovasc Intervent Radiol 2014; 38:827-32. [PMID: 25476871 DOI: 10.1007/s00270-014-1025-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 09/23/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of the study was to evaluate the radiation exposure to operating room personnel and to assess determinants for high personal doses during endovascular aortic repair. MATERIALS AND METHODS Occupational radiation exposure was prospectively evaluated during 22 infra-renal aortic repair procedures (EVAR), 11 thoracic aortic repair procedures (TEVAR), and 11 fenestrated or branched aortic repair procedures (FEVAR). Real-time over-lead dosimeters attached to the left breast pocket measured personal doses for the first operators (FO) and second operators (SO), radiology technicians (RT), scrub nurses (SN), anesthesiologists (AN), and non-sterile nurses (NSN). Besides protective apron and thyroid collar, no additional radiation shielding was used. Procedural dose area product (DAP), iodinated contrast volume, fluoroscopy time, patient's body weight, and C-arm angulation were documented. RESULTS Average procedural FO dose was significantly higher during FEVAR (0.34 ± 0.28 mSv) compared to EVAR (0.11 ± 0.21 mSv) and TEVAR (0.06 ± 0.05 mSv; p = 0.003). Average personnel doses were 0.17 ± 0.21 mSv (FO), 0.042 ± 0.045 mSv (SO), 0.019 ± 0.042 mSv (RT), 0.017 ± 0.031 mSv (SN), 0.006 ± 0.007 mSv (AN), and 0.004 ± 0.009 mSv (NSN). SO and AN doses were strongly correlated with FO dose (p = 0.003 and p < 0.001). There was a significant correlation between FO dose and procedural DAP (R = 0.69, p < 0.001), iodinated contrast volume (R = 0.67, p < 0.001) and left-anterior C-arm projections >60° (p = 0.02), and a weak correlation with fluoroscopy time (R = 0.40, p = 0.049). CONCLUSION Average FO dose was a factor four higher than SO dose. Predictors for high personal doses are procedural DAP, iodinated contrast volume, and left-anterior C-arm projections greater than 60°.
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Affiliation(s)
- Anna M Sailer
- Department of Radiology, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands,
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