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Tsitsiou Y, Velan B, Ross R, Lakshminarayan R, Rogers A, Hamady M. National UK Survey of Radiation Doses During Endovascular Aortic Interventions. Cardiovasc Intervent Radiol 2024; 47:92-100. [PMID: 37968425 PMCID: PMC10770209 DOI: 10.1007/s00270-023-03592-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/11/2023] [Indexed: 11/17/2023]
Abstract
PURPOSE Endovascular aortic repair (EAR) interventions, endovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR), are associated with significant radiation exposures. We aimed to investigate the radiation doses from real-world practice and propose diagnostic reference level (DRL) for the UK. MATERIALS AND METHODS Radiation data and essential demographics were retrospectively collected from 24 vascular and interventional radiology centres in the UK for all patients undergoing EAR-standard EVAR or complex, branched/fenestrated (BEVAR/FEVAR), and TEVAR-between 2018 and 2021. The data set was further categorised according to X-ray unit type, either fixed or mobile. The proposed national DRL is the 75th percentile of the collective medians for procedure KAP (kerma area product), cumulative air kerma (CAK), fluoroscopy KAP and CAK. RESULTS Data from 3712 endovascular aortic procedures were collected, including 2062 cases were standard EVAR, 906 cases of BEVAR/FEVAR and 509 cases of TEVAR. The majority of endovascular procedures (3477/3712) were performed on fixed X-ray units. The proposed DRL for KAP was 162 Gy cm2, 175 Gy cm2 and 266 Gy cm2 for standard EVAR, TEVAR and BEVAR/FEVAR, respectively. CONCLUSION The development of DRLs is pertinent to EAR procedures as the first step to optimise the radiation risks to patients and staff while maintaining the highest patient care and paving the way for steps to reduce radiation exposures.
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Affiliation(s)
- Yvonne Tsitsiou
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK.
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Bar Velan
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK
| | - Rebecca Ross
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK
| | | | - Andy Rogers
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mohamad Hamady
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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2
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Lamanna A, Mitreski G, Maingard J, Owen A, Schelleman T, Goodwin M, Ranatunga D. Ultrasound-guided portal vein puncture during Transjugular Intrahepatic Portosystemic Shunt: Technique and experience of a quaternary liver transplant hospital. J Med Imaging Radiat Oncol 2021; 66:60-67. [PMID: 34278730 DOI: 10.1111/1754-9485.13288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/24/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Portal hypertension (PH) is associated with complications including refractory ascites and variceal haemorrhage and can be treated endovascularly with a Transjugular Intrahepatic Portosystemic Shunt (TIPS). Portal vein puncture during TIPS using real-time transabdominal ultrasound guidance is one of many portal vein puncture techniques and is seldom used compared with other methods. The purpose of this manuscript is to describe this technique and its associated procedural outcomes at a quaternary liver transplant hospital. METHODS Clinical data of all patients who underwent ultrasound-guided TIPS at our institution between 1 January 2009 and 1 January 2019 were retrospectively obtained from electronic medical records and reviewed. Patient demographics, indications, procedural outcomes and complications were recorded. RESULTS Forty-four ultrasound-guided TIPS procedures were performed during the study period. The most common indication for TIPS was refractory ascites (n = 26; 57%) and variceal haemorrhage (n = 12; 26%). Technical success rate was 100%. No intraprocedural complications occurred. Periprocedural complication rate was 35% (n = 16) with encephalopathy (n = 8; 17%) and sepsis (n = 5; 11%) the most common. One patient with sepsis died. No other TIPS-related deaths occurred. Median fluoroscopy time, contrast volume, air kerma and dose area product values for all procedures were 35 minutes (IQR 24-51), 100 ml (IQR 70-160), 0.95 Gy (IQR 0.50-1.53) and 127 Gycm2 (IQR 68.75-206), respectively. CONCLUSION Transabdominal ultrasound-guided portal vein puncture during TIPS is safe and technically feasible. When compared to fluoroscopically guided methods, it is associated with lower intraprocedural complication rates, fluoroscopy times, contrast volumes and radiation doses in our experience. Radiation doses, FTs and contrast volumes were also considerably lower than recommended limits.
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Affiliation(s)
- Anthony Lamanna
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Goran Mitreski
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Julian Maingard
- Department of Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Andrew Owen
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia.,Interventional Radiology Service - Department of Radiology, Barwon Health, Geelong, Victoria, Australia
| | - Tony Schelleman
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Mark Goodwin
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Dinesh Ranatunga
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
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O'Hora L, Ryan ML, Rainford L. SURVEY OF KEY RADIATION SAFETY PRACTICES IN INTERVENTIONAL RADIOLOGY: AN IRISH AND ENGLISH STUDY. RADIATION PROTECTION DOSIMETRY 2019; 183:431-442. [PMID: 30247702 DOI: 10.1093/rpd/ncy162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/06/2018] [Accepted: 09/11/2018] [Indexed: 06/08/2023]
Abstract
Interventional radiology is a rapidly evolving speciality with potential to deliver high patient radiation doses, as a result high standards of radiation safety practice are imperative. IR radiation safety practice must be considered before during and after procedures through appropriate patient consent, dose monitoring and patient follow-up. This questionnaire-based study surveyed fixed IR departments across Ireland and England to establish clinical practice in relation to radiation safety. Pre-procedure IR patient consent includes all radiation effects in 11% of cases. The patient skin dose surrogate parameter of Kerma to air at a reference point (Kar) is under-reported. Only 39% of respondents use a substantial radiation dose level and inform patients after these have been reached. Poor compliance with unambiguous, readily available best practice guidance was observed throughout highlighting patient communication, patient dose quantification and subsequent patient dose management concerns.
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Affiliation(s)
| | - M L Ryan
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - L Rainford
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
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Kiang SC, Ahmed KA, Cha VJ, Farley DV, Oyoyo UE, Abou-Zamzam AM, Tomihama RT. Analysis of intraoperative radiation use in vascular surgery: Catalyst for quality improvement in patient and personnel safety. Vascular 2018; 27:144-152. [PMID: 30336745 DOI: 10.1177/1708538118806749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES There is paucity in the literature reporting radiation usage analysis in vascular surgery. In the era of endovascular surgeries, analyzing the surgeons' use of radiation in vascular procedures can help establish quality improvement initiatives. METHODS A retrospective review was undertaken of intraoperative fluoroscopic-guided vascular surgery procedures at a single institution from 2010 to 2017. Mobile C-arms were utilized to gather the six radiation usage metrics and cases were categorized into 6 anatomic surgical fields and 10 surgical procedure types. RESULTS Three hundred and eighteen vascular surgery cases were analyzed and notable trends in all radiation usage metrics were identified both across the surgical field location and type of surgical procedure. The highest cumulative dose was identified in embolization cases with a mean of 932.5 mGy. The highest fluoroscopic time was seen in atherectomies with a mean of 2629.6 s. In terms of surgical field, the highest cumulative does and fluoroscopic time was identified in abdomen/pelvis procedures with a mean of 352.1 mGy and 1186.8 s, respectively. Analysis of dose reduction techniques also demonstrated notable trends. CONCLUSIONS There were notable trends in the analyzed radiation usage variables both across the surgical field location and type of surgical procedure. Specifically, cases that involve the abdomen/pelvis, embolization and atherectomy have the highest radiation use. These types of cases can be targeted for future improved dose reduction techniques or staged procedures. This data can serve as baseline information for future quality improvement initiatives for patient and personnel radiation exposure safety.
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Affiliation(s)
- Sharon C Kiang
- 1 Department of Surgery, Division of Vascular Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA.,2 Department of Surgery, Division of Vascular Surgery, VA Loma Linda Healthcare System, Redlands, CA, USA
| | - Khwaja A Ahmed
- 3 Department of Radiology, Section of Vascular and Interventional Radiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Victoria J Cha
- 3 Department of Radiology, Section of Vascular and Interventional Radiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Donald V Farley
- 3 Department of Radiology, Section of Vascular and Interventional Radiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Udochukwu E Oyoyo
- 3 Department of Radiology, Section of Vascular and Interventional Radiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Ahmed M Abou-Zamzam
- 1 Department of Surgery, Division of Vascular Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Roger T Tomihama
- 3 Department of Radiology, Section of Vascular and Interventional Radiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
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Wunderle KA, Chung MK, Rayadurgam S, Miller MA, Obuchowski NA, Lindsay BD. Occupational and patient radiation doses in a modern cardiac electrophysiology laboratory. J Interv Card Electrophysiol 2018; 56:183-190. [PMID: 30280302 DOI: 10.1007/s10840-018-0462-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/25/2018] [Indexed: 01/30/2023]
Abstract
PURPOSE Technological advancements have greatly expanded the field of cardiac electrophysiology, requiring greater demands on imaging systems and potentially delivering higher radiation doses to patients and operators. With little contemporary research on occupational and patient radiation risk in the electrophysiology laboratory, the aim of this study was to analyze radiation doses, including occupational fetal doses, over approximately the last decade. We benchmarked the occupational data to our patient radiation dose data to allow for comparison and to put into perspective the associated radiation risks. METHODS Occupational radiation dosimetry analyzed included data from an 11-year period for physicians, a 7-year period for nurses, and a 9-year period for fetal doses. Patient-related dose metrics over an 8-year period were also analyzed. RESULTS In the physician and nursing groups, there was a nearly 70% decrease in the average occupational radiation doses over the given periods. Within the electrophysiology department, the average fetal occupational doses were very low, close to 0 μSv. The average reference point air kerma per patient for all electrophysiology procedures decreased from nearly 600 mGy/procedure in 2010 to just over 100 mGy/procedure in 2017. CONCLUSIONS Patient and occupational radiation doses in our laboratories significantly decreased over the periods analyzed as a result of clinical and technical staff efforts as well as advances in imaging technology. The radiation-related risk to individuals working in our electrophysiology laboratories, including pregnant women, is very low. Data reported herein could be used by other institutions to evaluate their occupational and patient radiation safety practices.
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Affiliation(s)
- Kevin A Wunderle
- Department of Radiology, Cleveland Clinic, 25900 Science Park Dr., AC211, Beachwood, OH, 44122, USA.
| | - Mina K Chung
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Mark A Miller
- Department of Radiation Safety, Cleveland Clinic, Cleveland, OH, USA
| | - Nancy A Obuchowski
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce D Lindsay
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
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Marshall EL, Borrego D, Tran T, Fudge JC, Bolch WE. Evaluation of the UF/NCI hybrid computational phantoms for use in organ dosimetry of pediatric patients undergoing fluoroscopically guided cardiac procedures. Phys Med Biol 2018; 63:055006. [PMID: 29405126 DOI: 10.1088/1361-6560/aaad1d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Epidemiologic data demonstrate that pediatric patients face a higher relative risk of radiation induced cancers than their adult counterparts at equivalent exposures. Infants and children with congenital heart defects are a critical patient population exposed to ionizing radiation during life-saving procedures. These patients will likely incur numerous procedures throughout their lifespan, each time increasing their cumulative radiation absorbed dose. As continued improvements in long-term prognosis of congenital heart defect patients is achieved, a better understanding of organ radiation dose following treatment becomes increasingly vital. Dosimetry of these patients can be accomplished using Monte Carlo radiation transport simulations, coupled with modern anatomical patient models. The aim of this study was to evaluate the performance of the University of Florida/National Cancer Institute (UF/NCI) pediatric hybrid computational phantom library for organ dose assessment of patients that have undergone fluoroscopically guided cardiac catheterizations. In this study, two types of simulations were modeled. A dose assessment was performed on 29 patient-specific voxel phantoms (taken as representing the patient's true anatomy), height/weight-matched hybrid library phantoms, and age-matched reference phantoms. Two exposure studies were conducted for each phantom type. First, a parametric study was constructed by the attending pediatric interventional cardiologist at the University of Florida to model the range of parameters seen clinically. Second, four clinical cardiac procedures were simulated based upon internal logfiles captured by a Toshiba Infinix-i Cardiac Bi-Plane fluoroscopic unit. Performance of the phantom library was quantified by computing both the percent difference in individual organ doses, as well as the organ dose root mean square values for overall phantom assessment between the matched phantoms (UF/NCI library or reference) and the patient-specific phantoms. The UF/NCI hybrid phantoms performed at percent differences of between 15% and 30% for the parametric set of irradiation events. Among internal logfile reconstructed procedures, the UF/NCI hybrid phantoms performed with RMS organ dose values between 7% and 29%. Percent improvement in organ dosimetry via the use of hybrid library phantoms over the reference phantoms ranged from 6.6% to 93%. The use of a hybrid phantom library, Monte Carlo radiation transport methods, and clinical information on irradiation events provide a means for tracking organ dose in these radiosensitive patients undergoing fluoroscopically guided cardiac procedures.
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Affiliation(s)
- Emily L Marshall
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States of America. Present address: Diagnostic Physics Residency Program, Department of Radiology, University of Chicago, Chicago, IL 60637, United States of America
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Tavare AN, Wigham A, Hadjivassilou A, Alvi A, Papadopoulou A, Goode A, Woodward N, Patch D, Yu D, Davies N. Use of transabdominal ultrasound-guided transjugular portal vein puncture on radiation dose in transjugular intrahepatic portosystemic shunt formation. Diagn Interv Radiol 2018; 23:206-210. [PMID: 28223261 DOI: 10.5152/dir.2016.15601] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE Transjugular intrahepatic portosystemic shunt (TIPS) creation is used to treat portal hypertension complications. Often the most challenging and time-consuming step in the procedure is the portal vein (PV) puncture. TIPS procedures are associated with prolonged fluoroscopy time and high patient radiation exposures. We measured the impact of transabdominal ultrasound guidance for PV puncture on duration of fluoroscopy time and dose. METHODS We retrospectively analyzed the radiation dose for all TIPS performed over a four-year period with transabdominal ultrasound guidance for PV puncture (n=212, with 210 performed successfully and data available for 206); fluoroscopy time, dose area product (DAP) and skin dose were recorded. RESULTS Mean fluoroscopy time was 12 min 9 s (SD, ±14 min 38 s), mean DAP was 40.3±73.1 Gy·cm2, and mean skin dose was 404.3±464.8 mGy. CONCLUSION Our results demonstrate that ultrasound-guided PV puncture results in low fluoroscopy times and radiation doses, which are markedly lower than the only published dose reference levels.
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Affiliation(s)
- Aniket N Tavare
- Departments of Radiology, Royal Free London NHS Foundation Trust, London, UK.
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8
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Tuthill E, O'Hora L, O'Donohoe M, Panci S, Gilligan P, Campion D, Trenti R, Fox E, Catania D, Rainford L. Investigation of reference levels and radiation dose associated with abdominal EVAR (endovascular aneurysm repair) procedures across several European Centres. Eur Radiol 2017; 27:4846-4856. [PMID: 28523354 DOI: 10.1007/s00330-017-4791-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 02/02/2017] [Accepted: 03/06/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Endovascular aneurysm repair (EVAR) is considered the treatment of choice for abdominal aortic aneurysms with suitable anatomy. In order to improve radiation safety, European Directive (2013/59) requires member states to implement diagnostic reference levels (DRLs) in radio-diagnostic and interventional procedures. This study aimed to determine local DRLs for EVAR across five European centres and identify an interim European DRL, which currently remains unestablished. METHODS Retrospective data was collected for 180 standard EVARs performed between January 2014 and July 2015 from five specialist centres in Ireland (n=2) and Italy (n=3). Data capture included: air kerma-area product (PKA), total air kerma at the reference point (Ka,r), fluoroscopic time (FT), number of acquisitions, frame rate of acquisition, type of acquisition, patient height, weight, and gender. RESULTS The mean values for each site A, B, C, D, and E were: PKAs of 4343 ± 994 μGym2, 18,200 ± 2141 μGym2, 11,423 ± 1390 μGym2, 7796 ± 704 μGym2, 31,897 ± 5798 μGym2; FTs of 816 ± 92 s, 950 ± 150 s, 708 ± 70 s, 972 ± 61 s, 827 ± 118 s; and number of acquisitions of 6.72 ± 0.56, 10.38 ± 1.54, 4.74 ± 0.19, 5.64 ± 0.36, 7.28 ± 0.65, respectively. The overall pooled 75th percentile PKA was 15,849 μGym2. CONCLUSION Local reference levels were identified. The pooled data has been used to establish an interim European DRL for EVAR procedures. KEY POINTS • Abdominal endovascular aneurysm repair (EVAR) requires the use of ionising radiation. • EVAR is a minimally invasive procedure for the treatment of abdominal aortic aneurysms. • Diagnostic reference levels (DRLs) are used to monitor patient radiation exposure. • Radiation dose data was collected from five European centres for EVAR procedures. • Local DRLs have been determined and an interim European DRL is proposed.
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Affiliation(s)
- E Tuthill
- Diagnostic Imaging, School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
| | - L O'Hora
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - M O'Donohoe
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - S Panci
- San Giovanni di Dio Hospital, Florence, Italy
| | | | - D Campion
- Mauriziano-Umberto Hospital, Turin, Italy
| | - R Trenti
- Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - E Fox
- Mater Private Hospital, Dublin, Ireland
| | - D Catania
- AITRI, Association of Italian Interventional Radiographers, Milan, Italy
| | - L Rainford
- Diagnostic Imaging, School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
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Heilmaier C, Niklaus Z, Berthold C, Kara L, Weishaupt D. Improving Patient Safety: Implementing Dose Monitoring Software in Fluoroscopically Guided Interventions. J Vasc Interv Radiol 2015; 26:1699-709. [DOI: 10.1016/j.jvir.2015.08.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/02/2015] [Accepted: 08/04/2015] [Indexed: 11/25/2022] Open
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Vañó E, Fernández JM, Sánchez RM, Dauer LT. Realistic approach to estimate lens doses and cataract radiation risk in cardiology when personal dosimeters have not been regularly used. HEALTH PHYSICS 2013; 105:330-339. [PMID: 23982609 DOI: 10.1097/hp.0b013e318299b5d9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Interventional fluoroscopic guided cardiac procedures lead to radiation exposure to the lenses of the eyes of cardiologists, which over time may be associated with an increased risk of cataracts. This study derives radiation doses to the lens of the eye in cardiac catheterization laboratories from measurements of individual procedures to allow for estimates of such doses for those cases when personal dosimeters have not been used regularly. Using active electronic dosimeters at the C-arm (at 95 cm from the isocenter), scatter radiation doses have been measured for cardiac procedures and estimated radiation doses to the lenses of the cardiologists for different groups of procedures (diagnostic, PTCAs, and valvular). Correlation factors with kerma area product included in the patient dose reports have been derived. The mean, median, and third quartile scatter dose values per procedure at the C-arm for 1,969 procedures were 0.99, 0.78 and 1.25 mSv, respectively; for coronary angiography, 0.51, 0.45, and 0.61 mSv, respectively; for PTCAs, 1.29, 1.07, and 1.56 mSv; and for valvular procedures, 1.64, 1.45, and 2.66 mSv, respectively. For all the procedures, the ratio between the scatter dose at the C-arm and the kerma area product resulted in between 10.3-11.3 μSv Gy cm. The experimental results of this study allow for realistic estimations of the dose to the lenses of the eyes from the workload of the cardiologists and from the level of use of radiation protection tools when personal dosimeters have not been regularly used.
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Affiliation(s)
- Eliseo Vañó
- Medical Physics Service, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain.
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Gupta A, Grünhagen T. Live MR angiographic roadmapping for uterine artery embolization: a feasibility study. J Vasc Interv Radiol 2013; 24:1690-7. [PMID: 23993741 DOI: 10.1016/j.jvir.2013.07.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 07/04/2013] [Accepted: 07/11/2013] [Indexed: 10/26/2022] Open
Abstract
PURPOSE To assess the feasibility of live magnetic resonance (MR) angiography roadmapping guidance for uterine artery (UA) embolization (UAE) for fibroid tumors. MATERIALS AND METHODS Twenty patients underwent UAE with live MR angiographic roadmapping. The pre-acquired MR angiography scan was coregistered with the live intraprocedural fluoroscopy stream to create a visual roadmap to direct the microcatheter during UAE. Patient radiation dose, as measured by dose-area product (DAP), procedure time, contrast medium volume, and fluoroscopy time, was recorded. For the first 10 patients, an additional parameter of contrast medium volume needed to catheterize each UA was recorded. RESULTS In all 20 patients (40 UAs), the MR angiography overlay on live fluoroscopy was accurate and allowed for successful catheterization of the UA, resulting in a technical success rate of 100%. In the subset of the initial 20 UAs (ie, the first 10 patients) in which this data point was recorded, 17 (85%) were successfully catheterized with no iodinated contrast medium at all, by purely relying on the MR angiography roadmap. Mean procedure time was 45 minutes (range, 30-99 min), mean contrast agent dose was 75 mL (range, 46-199 mL), and mean DAP was 155 Gy · cm(2) (range, 37-501 Gy · cm(2)). CONCLUSIONS Live MR angiographic roadmapping is feasible and accurate for catheter guidance during UAE.
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Affiliation(s)
- Atul Gupta
- Department of Interventional Radiology, Paoli Hospital, 255 W. Lancaster Ave., Paoli, PA 19301.
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Kirkwood ML, Arbique GM, Guild JB, Timaran C, Chung J, Anderson JA, Valentine RJ. Surgeon education decreases radiation dose in complex endovascular procedures and improves patient safety. J Vasc Surg 2013; 58:715-21. [PMID: 23688628 DOI: 10.1016/j.jvs.2013.04.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 03/28/2013] [Accepted: 04/01/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Complex endovascular procedures such as fenestrated endovascular aneurysm repair (FEVAR) are associated with higher radiation doses compared with other fluoroscopically guided interventions (FGIs). The purpose of this study was to determine whether surgeon education on radiation dose control can lead to lower reference air kerma (RAK) and peak skin dose (PSD) levels in high-dose procedures. METHODS Radiation dose and operating factors were recorded for FGI performed in a hybrid room over a 16-month period. Cases exceeding 6 Gy RAK were investigated according to institutional policy. Information obtained from these investigations led to surgeon education focused on reducing patient dose. Points addressed included increasing table height, utilizing collimation and angulation, decreasing magnification modes, and maintaining minimal patient-to-detector distance. Procedural RAK doses and operating factors were compared 8 months pre- (group A) and 8 months post- (group B) educational intervention using analysis of variance with Tukey pairwise comparisons and t-tests. PSD distributions were calculated using custom software employing input data from fluoroscopic machine logs. RESULTS Of 447 procedures performed, 300 FGIs had sufficient data to be included in the analysis (54% lower extremity, 11% thoracic endovascular aneurysm repair, 10% cerebral, 8% FEVAR, 7% endovascular aneurysm repair, 5% visceral, and 5% embolization). Twenty-one cases were investigated for exceeding 6 Gy RAK. FEVAR comprised 70% of the investigated cases and had a significantly higher median RAK dose compared with all other FGIs (P < .0001). There was no difference in body mass index between groups A and B; however, increasing body mass index was an indicator for increased RAK. PSD calculations were performed for the 122 procedures that focused on the thorax and abdomen (group A, 80 patients; group B, 42 patients). Surgeon education most strongly affected table height, with an average table height elevation of 10 cm per case after education (P < .0001). The dose index (PSD/RAK ratio) was used to track changes in operating practices, and it decreased from 1.14 to 0.79 after education (P < .0001). These changes resulted in an estimated 16% reduction in PSD. There was a trend toward a decrease in patient to detector distance, and the use of collimation increased from 25% to 40% (P < .001) for all cases; however, these did not result in a decrease in PSD. The number of cases that exceeded 6 Gy RAK did not change after education; however, the proportion of non-FEVAR cases that exceeded 6 Gy decreased from 40% to 20%. CONCLUSIONS Surgeon education on the appropriate use of technical factors during FGIs improved operating practice, reduced patient radiation dose, and decreased the number of non-FEVAR cases that exceeded 6 Gy. It is essential that vascular surgeons be educated in best operating practices to lower PSD; nonetheless, FEVAR remains a high-dose procedure.
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Affiliation(s)
- Melissa L Kirkwood
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390-9157, USA.
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Khodadadegan Y, Zhang M, Pavlicek W, Paden RG, Chong B, Huettl EA, Schueler BA, Fetterly KA, Langer SG, Wu T. Validation and Initial Clinical Use of Automatic Peak Skin Dose Localization with Fluoroscopic and Interventional Procedures. Radiology 2013; 266:246-55. [DOI: 10.1148/radiol.12112295] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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14
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Balter S, Miller DL, Schueler BA. Radiation dose measurements and monitoring for fluoroscopically guided interventional procedures. J Am Coll Radiol 2012; 9:595-7. [PMID: 22863472 DOI: 10.1016/j.jacr.2012.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 05/03/2012] [Indexed: 11/24/2022]
Affiliation(s)
- Stephen Balter
- Departments of Medicine and Radiology, Columbia University, 630 W. 168th St, New York, NY 10021, USA.
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Pitton MB, Kloeckner R, Schneider J, Ruckes C, Bersch A, Düber C. Radiation exposure in vascular angiographic procedures. J Vasc Interv Radiol 2012; 23:1487-95. [PMID: 22840684 DOI: 10.1016/j.jvir.2012.05.048] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 05/17/2012] [Accepted: 05/21/2012] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To evaluate dose reduction in vascular angiographic procedures by using fluoroscopy capture instead of digital subtraction angiography frames for documentation. MATERIALS AND METHODS A total of 764 consecutive vascular interventional procedures performed over a period of 1 year were retrospectively analyzed with respect to the fluoroscopy time and the resulting dose-area product (DAP), the DAP of the radiographic frames, and the overall DAP. RESULTS A total of 70% of the total DAP was a result of the acquisition of radiographic frames, leaving only 30% being applied by fluoroscopy. CONCLUSIONS Fluoroscopy capture should be used for documentation whenever possible. A registry of radiation exposure should not only comprise a sufficiently large number of interventions but also different intervention types to allow the development of interventional reference levels.
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Affiliation(s)
- Michael Bernhard Pitton
- Department of Diagnostic and Interventional Radiology, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
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16
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Greene DJ, Tenggadjaja CF, Bowman RJ, Agarwal G, Ebrahimi KY, Baldwin DD. Comparison of a Reduced Radiation Fluoroscopy Protocol to Conventional Fluoroscopy During Uncomplicated Ureteroscopy. Urology 2011; 78:286-90. [DOI: 10.1016/j.urology.2010.11.020] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 10/01/2010] [Accepted: 11/14/2010] [Indexed: 10/18/2022]
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17
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Khodadadegan Y, Zhang M, Pavlicek W, Paden RG, Chong B, Schueler BA, Fetterly KA, Langer SG, Wu T. Automatic monitoring of localized skin dose with fluoroscopic and interventional procedures. J Digit Imaging 2011; 24:626-39. [PMID: 20706859 PMCID: PMC3138926 DOI: 10.1007/s10278-010-9320-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
This software tool locates and computes the intensity of radiation skin dose resulting from fluoroscopically guided interventional procedures. It is comprised of multiple modules. Using standardized body specific geometric values, a software module defines a set of male and female patients arbitarily positioned on a fluoroscopy table. Simulated X-ray angiographic (XA) equipment includes XRII and digital detectors with or without bi-plane configurations and left and right facing tables. Skin dose estimates are localized by computing the exposure to each 0.01 × 0.01 m(2) on the surface of a patient irradiated by the X-ray beam. Digital Imaging and Communications in Medicine (DICOM) Structured Report Dose data sent to a modular dosimetry database automatically extracts the 11 XA tags necessary for peak skin dose computation. Skin dose calculation software uses these tags (gantry angles, air kerma at the patient entrance reference point, etc.) and applies appropriate corrections of exposure and beam location based on each irradiation event (fluoroscopy and acquistions). A physicist screen records the initial validation of the accuracy, patient and equipment geometry, DICOM compliance, exposure output calibration, backscatter factor, and table and pad attenuation once per system. A technologist screen specifies patient positioning, patient height and weight, and physician user. Peak skin dose is computed and localized; additionally, fluoroscopy duration and kerma area product values are electronically recorded and sent to the XA database. This approach fully addresses current limitations in meeting accreditation criteria, eliminates the need for paper logs at a XA console, and provides a method where automated ALARA montoring is possible including email and pager alerts.
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Affiliation(s)
- Yasaman Khodadadegan
- School of Computing, Informatics and Decision Systems Engineering, Arizona State University, Tempe, AZ 85281 USA
| | - Muhong Zhang
- School of Computing, Informatics and Decision Systems Engineering, Arizona State University, Tempe, AZ 85281 USA
| | - William Pavlicek
- Department of Radiology, Mayo Clinic Arizona, 13400 East Shea Blvd, Scottsdale, AZ 85258 USA
| | - Robert G. Paden
- Department of Radiology, Mayo Clinic Arizona, 13400 East Shea Blvd, Scottsdale, AZ 85258 USA
| | - Brian Chong
- Department of Radiology, Mayo Clinic Arizona, 13400 East Shea Blvd, Scottsdale, AZ 85258 USA
| | - Beth A. Schueler
- Department of Radiology, Mayo Clinic Rochester, 200 First St. SW, Rochester, MN 55905 USA
| | - Kenneth A. Fetterly
- Department of Cardiology, Mayo Clinic Rochester, 200 First St. SW, Rochester, MN 55905 USA
| | - Steve G. Langer
- Department of Radiology, Mayo Clinic Rochester, 200 First St. SW, Rochester, MN 55905 USA
| | - Teresa Wu
- School of Computing, Informatics and Decision Systems Engineering, Arizona State University, Tempe, AZ 85281 USA
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18
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Radiation Exposure in Nonvascular Fluoroscopy-Guided Interventional Procedures. Cardiovasc Intervent Radiol 2011; 35:613-20. [DOI: 10.1007/s00270-011-0206-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 05/27/2011] [Indexed: 11/27/2022]
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19
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Compagnone G, Ortolani P, Domenichelli S, Ovi V, Califano G, Dall'Ara G, Marzocchi A. Effective and equivalent organ doses in patients undergoing coronary angiography and percutaneous coronary interventions. Med Phys 2011; 38:2168-75. [DOI: 10.1118/1.3561508] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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20
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Bednarek DR, Barbarits J, Rana VK, Nagaraja SP, Josan MS, Rudin S. Verification of the performance accuracy of a real-time skin-dose tracking system for interventional fluoroscopic procedures. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2011; 7961:796127_1. [PMID: 21731400 PMCID: PMC3127243 DOI: 10.1117/12.877677] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A tracking system has been developed to provide real-time feedback of skin dose and dose rate during interventional fluoroscopic procedures. The dose tracking system (DTS) calculates the radiation dose rate to the patient's skin using the exposure technique parameters and exposure geometry obtained from the x-ray imaging system digital network (Toshiba Infinix) and presents the cumulative results in a color mapping on a 3D graphic of the patient. We performed a number of tests to verify the accuracy of the dose representation of this system. These tests included comparison of system-calculated dose-rate values with ionization-chamber (6 cc PTW) measured values with change in kVp, beam filter, field size, source-to-skin distance and beam angulation. To simulate a cardiac catheterization procedure, the ionization chamber was also placed at various positions on an Alderson Rando torso phantom and the dose agreement compared for a range of projection angles with the heart at isocenter. To assess the accuracy of the dose distribution representation, Gafchromic film (XR-RV3, ISP) was exposed with the beam at different locations. The DTS and film distributions were compared and excellent visual agreement was obtained within the cm-sized surface elements used for the patient graphic. The dose (rate) values agreed within about 10% for the range of variables tested. Correction factors could be applied to obtain even closer agreement since the variable values are known in real-time. The DTS provides skin-dose values and dose mapping with sufficient accuracy for use in monitoring diagnostic and interventional x-ray procedures.
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Affiliation(s)
- Daniel R. Bednarek
- University at Buffalo (State University of New York), Toshiba Stroke Research Center, 3435 Main St., Buffalo, NY USA 14214
| | - Jeffery Barbarits
- University at Buffalo (State University of New York), Toshiba Stroke Research Center, 3435 Main St., Buffalo, NY USA 14214
| | - Vijay K. Rana
- University at Buffalo (State University of New York), Toshiba Stroke Research Center, 3435 Main St., Buffalo, NY USA 14214
| | - Srikanta P. Nagaraja
- University at Buffalo (State University of New York), Toshiba Stroke Research Center, 3435 Main St., Buffalo, NY USA 14214
| | - Madhur S. Josan
- University at Buffalo (State University of New York), Toshiba Stroke Research Center, 3435 Main St., Buffalo, NY USA 14214
| | - Stephen Rudin
- University at Buffalo (State University of New York), Toshiba Stroke Research Center, 3435 Main St., Buffalo, NY USA 14214
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Dauer LT, Thornton R, Boylan DC, Holahan B, Prins R, Quinn B, St. Germain J. Organ and effective dose estimates for patients undergoing hepatic arterial embolization for treatment of liver malignancy. Med Phys 2011; 38:736-42. [DOI: 10.1118/1.3533685] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Miller DL, Kwon D, Bonavia GH. Reference levels for patient radiation doses in interventional radiology: proposed initial values for U.S. practice. Radiology 2009; 253:753-64. [PMID: 19789226 DOI: 10.1148/radiol.2533090354] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To propose initial values for patient reference levels for fluoroscopically guided procedures in the United States. MATERIALS AND METHODS This secondary analysis of data from the Radiation Doses in Interventional Radiology Procedures (RAD-IR) study was conducted under a protocol approved by the institutional review board and was HIPAA compliant. Dose distributions (percentiles) were calculated for each type of procedure in the RAD-IR study where there were data from at least 30 cases. Confidence intervals for the dose distributions were determined by using bootstrap resampling. Weight banding and size correction methods for normalizing dose to patient body habitus were tested. RESULTS The different methods for normalizing patient radiation dose according to patient weight gave results that were not significantly different (P > .05). The 75th percentile patient radiation doses normalized with weight banding were not significantly different from those that were uncorrected for body habitus. Proposed initial reference levels for various interventional procedures are provided for reference air kerma, kerma-area product, fluoroscopy time, and number of images. CONCLUSION Sufficient data exist to permit an initial proposal of values for reference levels for interventional radiologic procedures in the United States. For ease of use, reference levels without correction for body habitus are recommended. A national registry of radiation-dose data for interventional radiologic procedures is a necessary next step to refine these reference levels.
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Affiliation(s)
- Donald L Miller
- Department of Radiology, National Naval Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889-5601, USA.
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Estimating Radiation Doses to the Skin from Interventional Radiology Procedures for a Patient Population with Cancer. J Vasc Interv Radiol 2009; 20:782-8; quiz 789. [DOI: 10.1016/j.jvir.2009.03.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 02/27/2009] [Accepted: 03/02/2009] [Indexed: 11/21/2022] Open
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