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Mehta NK, France J, Shah K, Kutinsky I, Williamson B, Goel A, Dixon S, Haines DE. REDEFINE: A Prospective Randomized Evaluation of the ControlRad System to Reduce Radiation Exposure During Cardiac Implantable Device Procedures. JACC Clin Electrophysiol 2023; 9:713-714. [PMID: 37225313 DOI: 10.1016/j.jacep.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/09/2023] [Accepted: 02/15/2023] [Indexed: 05/26/2023]
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Keenen TL, Demirel S, Gheen A, Casabarro B, Fleishman D. Intraoperative Fluoroscopy Radiation Using OEC 9900 Elite C-arm: Risk and Method for Decreasing Exposure. HEALTH PHYSICS 2023; 124:380-390. [PMID: 36880954 DOI: 10.1097/hp.0000000000001679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
ABSTRACT The use of intraoperative fluoroscopy in surgery produces scattered radiation that can expose all operating room personnel to measurable and, in some cases, substantial radiation doses. The goal of this work is to assess and document potential radiation doses to various staff positions in a simulated standard operating room environment. Adult-sized mannequins wearing standard lead protective aprons were placed at seven positions around large and small BMI cadavers. Doses were recorded in real time at thyroid level with Bluetooth-enabled dosimeters for a variety of fluoroscope settings and imaging views. A total of 320 images were acquired, resulting in 2,240 dosimeter readings from the seven mannequins. Doses were compared to cumulative air kerma (CAK) calculations provided by the fluoroscope. There was a strong correlation between the CAK and the recorded scattered radiation doses ( P < 0.001). Radiation doses could be reduced by manipulating C-arm manual technique settings [e.g., turning off the automatic exposure control (AEC) and using pulse (PULSE) or low dose (LD) settings]. Staff position and patient size also affected the recorded doses. The highest radiation doses were recorded across all settings for the mannequin positioned immediately adjacent to the C-arm x-ray tube. The larger BMI cadaver generated greater scattered radiation than the smaller BMI cadaver for all views and settings. This work provides suggestions for reducing exposure to operating room personnel beyond standard techniques of reducing beam-on time, increasing the distance from the radiation source, and use of shielding. Simple changes in C-arm settings (turning AEC off, avoiding DS setting, use of PULSE or LD settings) can markedly reduce dose to staff.
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Affiliation(s)
- Timothy L Keenen
- Oregon Health and Sciences University, Dept of Orthopedics and Rehabilitation, Portland, OR
| | | | | | - Benjamin Casabarro
- Indiana University Richard M. Fairbanks School of Public Health, 1050 Wishard Blvd., Indianapolis, IN 46202
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Cammann VL, Schweiger V, Cieslik M, Seifert B, Gilhofer T, Koleva I, Würdinger M, Candreva A, Gajic M, Michel J, Jakob P, Stehli J, Stähli B, Templin C, Gotschy A. Effectiveness of radiation protection systems in the cardiac catheterization laboratory: a comparative study. Clin Res Cardiol 2023; 112:605-613. [PMID: 36646858 PMCID: PMC10160176 DOI: 10.1007/s00392-022-02142-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/19/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND As numbers and complexity of percutaneous coronary interventions are constantly increasing, optimal radiation protection is required to ensure operator safety. Suspended radiation protection systems (SRPS) and protective scatter-radiation absorbing drapes (PAD) are novel methods to mitigate fluoroscopic scattered radiation exposure. The aim of the study was to investigate the effectiveness regarding radiation protection of a SRPS and a PAD in comparison with conventional protection. METHODS A total of 229 cardiac catheterization procedures with SRPS (N = 73), PAD (N = 82) and standard radiation protection (N = 74) were prospectively included. Real-time dosimeter data were collected from the first operator and the assistant. Endpoints were the cumulative operator exposure relative to the dose area product [standardized operator exposure (SOE)] for the first operator and the assistant. RESULTS For the first operator, the SRPS and the PAD significantly decreased the overall SOE compared to conventional shielding by 93.9% and 66.4%, respectively (P < 0.001). The protective effect of the SRPS was significantly higher compared to the PAD (P < 0.001). For the assistant, the SRPS and the PAD provided a not statistically significant reduction compared to conventional shielding in the overall SOE by 38.0% and 30.6%, respectively. CONCLUSIONS The SRPS and the PAD enhance radiation protection significantly compared to conventional protection. In most clinical scenarios, the protective effect of SRPS is significantly higher than the additional protection provided by the PAD. Comparison of the additional radiation protection provided by protective scatter-radiation absorbing drapes (PAD) and the suspended radiation protection system (SRPS) system over standard protection with lead aprons.
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Affiliation(s)
- Victoria L Cammann
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Victor Schweiger
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Maciej Cieslik
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Burkhardt Seifert
- Division of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Thomas Gilhofer
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Iva Koleva
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Michael Würdinger
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alessandro Candreva
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland.,PolitoBIO Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Marko Gajic
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Jonathan Michel
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Philipp Jakob
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Julia Stehli
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Barbara Stähli
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Christian Templin
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland. .,University of Zurich, Zurich, Switzerland.
| | - Alexander Gotschy
- Department of Cardiology, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091, Zurich, Switzerland.,Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland.,Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
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Jansen MM, Koster A, van Herwaarden JA, Hazenberg CEVB. Reduction of Occupational Radiation Exposure During Endovascular Treatment of Peripheral Artery Disease Using Radiation Absorbing Drapes. Ann Vasc Surg 2022; 84:336-343. [PMID: 35257909 DOI: 10.1016/j.avsg.2022.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/20/2022] [Accepted: 01/23/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND A chronic exposure to low dose radiation, as encountered in endovascular procedures, may impact the health of surgeons and radiologists over a timespan of several months to a lifetime. This study evaluates the feasibility and efficacy of a radiation absorbing sterile drape (RADPAD) to reduce operator exposure during the endovascular treatment of obstructive peripheral artery disease (PAD). METHODS Between February 2016 and September 2017, patients with PAD who received percutaneous transluminal angioplasty, stent placement, remote endarterectomy, or a combination thereof were included in this nonrandomized study. Patients were equally divided over a study cohort (with RADPAD) and a control cohort (without RADPAD). The unshielded body dose (E) of the staff was measured via electronic dosimeters placed at a chest height of the first operator (FO), second operator (SO), and sterile nurse (SN). A virtual maximum operator (MO) dose was constructed, yielding the highest dose per fluoroscopy run for either of the operators. Simultaneously, the dose area product (DAP) and C-arm settings for each fluoroscopy run were extracted. Staff exposures of the study cohort and control cohort were compared in terms of relative exposure (E/DAP). A secondary analysis involved an analysis of the individual fluoroscopy runs using a multivariate generalized linear mixed effect model. RESULTS In total, 49 patients were included in this study. The use of RADPAD was technically feasible. Significant reductions of relative exposure were observed when comparing the study cohort with the control cohort. The relative exposure of the FO was reduced with 66.5% (1.82 vs. 0.61 μSv/Gycm2, P < 0.001), the relative exposure of the SO with 68.3% (0.55 vs. 0.17 μSv/Gycm2, P = 0.02), and the relative exposure of the MO with 65.8% (2.06 vs. 0.71 μSv/Gycm2, P < 0.001). Dose levels of SN were too low to draw conclusions under the current sample size. The multivariate generalized linear mixed effect model showed a significant correlation between absolute exposure of the MO and the use of the RADPAD (odds: 0.51, P < 0.001). CONCLUSIONS Usage of a radiation absorbing drape (RADPAD) during endovascular treatment of PAD results in statistically significant reduction in a relative operator dose while presenting no drawbacks. The use of these drapes is advised in future peripheral endovascular procedures.
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Affiliation(s)
- Marloes M Jansen
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Arjan Koster
- Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Ali M, Banavalikar B, Kanjwal K, Ghadei MK, Kottayan A, Padmanabhan D, Shenthar J. Effect of fluoroscopy frame rate on radiation exposure and in-hospital outcomes in cardiovascular implantable electronic device implantation procedures. RADIATION MEDICINE AND PROTECTION 2021. [DOI: 10.1016/j.radmp.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Lawson M, Kuganesan A, Parry G, Badawy MK. THE EFFICACY OF RADPAD AS A RADIATION PROTECTION TOOL IN CT FLUOROSCOPY GUIDED LUNG BIOPSIES. RADIATION PROTECTION DOSIMETRY 2020; 191:328-334. [PMID: 33120428 DOI: 10.1093/rpd/ncaa169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 06/11/2023]
Abstract
Computed tomography fluoroscopy is now the preferred technique for percutaneous lung biopsies. However, concern regarding operator and patient radiation dose remains, which warrants further exploration into dose optimisation tools. This phantom-study aims to assess the dose reduction capabilities of RADPAD, a single-use patient drape designed to decrease staff exposure to scattered radiation. Dosemeters at the waist and eye levels were used to determine the whole-body and lens exposure during simulated lung biopsy procedures while using RADPAD and other combinations of personal protective equipment. RADPAD resulted in a 36% and 38% dose reduction for whole-body and eye exposure, respectively. However, when used in combination with radioprotective eyewear and aprons, RADPAD did not reduce the radiation dose further. Consequently, the use of standard personal protective equipment is a more cost-effective option for staff dose reduction. RADPAD is useful in the reduction of radiation dose to unprotected regions.
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Affiliation(s)
- Michael Lawson
- Monash Imaging, Monash Health, Clayton, VIC 3168, Australia
| | | | - Georgia Parry
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3800, Australia
| | - Mohamed Khaldoun Badawy
- Monash Imaging, Monash Health, Clayton, VIC 3168, Australia
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3800, Australia
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Lawson M, Parry G, Badawy MK. The use of patient drapes for staff dose reduction in fluoroscopically-guided interventions. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2019; 43:10.1007/s13246-019-00831-9. [PMID: 31832985 DOI: 10.1007/s13246-019-00831-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Michael Lawson
- Monash Imaging, Monash Health, Clayton, VIC, 3168, Australia.
| | - Georgia Parry
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, 3800, Australia
| | - Mohamed K Badawy
- Monash Imaging, Monash Health, Clayton, VIC, 3168, Australia
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, 3800, Australia
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Hoffmann R, Langenbrink L, Reimann D, Kastrati M, Becker M, Piatkowski M, Michaelsen J. Image noise reduction technology allows significant reduction of radiation dosage in cardiac device implantation procedures. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1374-1379. [PMID: 29052249 DOI: 10.1111/pace.13222] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 09/24/2017] [Accepted: 10/08/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Novel x-ray systems with real-time image noise reduction technology (INRT) to reduce radiation dose during fluoroscopy and cine acquisition have become available. This study evaluated the reduction of radiation dose in device implantation with INRT. METHODS Radiation dose data from 132 consecutive new device implantation procedures (102 pacemaker [PM] or implantable cardioverter defibrillator [ICD] and 30 cardiac resynchronization therapy [CRT] devices) performed between January 2015 and December 2015 on an angiography system with INRT (Allura ClarityIQ) were collected. For comparison, radiation dose data from 147 consecutive device implantation procedures (121 PM/ICDs and 26 CRT devices) performed between June 2013 and September 2014 on a C-arm system with continuous and pulsed fluoroscopy option (4 frames/second) were evaluated. Total dose area product (DAP), fluoroscopy DAP, and cine DAP were evaluated. RESULTS Patient age, gender and body weight, procedure, and fluoroscopy times were similar between systems. In PM/ICD cases, DAP of INRT and C-arm system was similar (423 ± 381 cGycm2 vs 417 ± 517 cGycm) due to pulsed fluoroscopy with the C-arm system (78% of time) and sparse use of cine. In CRT procedures requiring higher image quality (82% use of continuous fluoroscopy with C-arm system), DAP of INRT was significantly lower (1,544 ± 834 cGycm vs 7,252 ± 6,431 cGycm, P < 0.001) due to less fluoroscopy DAP (1,414 ± 757 cGycm vs 5,854 ± 6,767 cGycm) and less cine DAP (130 ± 106 cGycm vs 1,399 ± 1,342 cGycm). Considering all procedures, total DAP was reduced by 60% using INRT. CONCLUSION Novel INRT results in a substantial lowering of radiation dose in device implantation, in particular, in complex CRT implantation procedures requiring high image quality.
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Affiliation(s)
- Rainer Hoffmann
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
| | - Lukas Langenbrink
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
| | - Doris Reimann
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
| | - Mirlind Kastrati
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
| | - Michael Becker
- Department of Cardiology, Medical Clinic I, University Clinic Aachen, Aachen, Germany
| | - Michal Piatkowski
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
| | - Jochen Michaelsen
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
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Efficacy of RADPAD protective drape during coronary angiography. Herz 2017; 43:310-314. [DOI: 10.1007/s00059-017-4560-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 12/22/2022]
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Miller TR, Zhuo J, Jindal G, Shivashankar R, Beaty N, Gandhi D. The Efficacy of Shielding Systems for Reducing Operator Exposure during Neurointerventional Procedures: A Real-World Prospective Study. AJNR Am J Neuroradiol 2017; 38:450-454. [PMID: 28007766 DOI: 10.3174/ajnr.a5038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/12/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Neurointerventional surgery may expose patients and physician operators to substantial amounts of ionizing radiation. Although strategies for reducing patient exposure have been explored in the medical literature, there has been relatively little published in regards to decreasing operator exposure. The purpose of this study was to evaluate the efficacy of shielding systems in reducing physician exposure in a modern neurointerventional practice. MATERIALS AND METHODS Informed consent was obtained from operators for this Health Insurance Portability and Accountability Act-compliant, institutional review board-approved study. Operator radiation exposure was prospectively measured during 60 consecutive neurointerventional procedures from October to November 2013 using a 3-part lead shielding system. Exposure was then evaluated without lead shielding in a second 60-procedure block from April to May 2014. A radiation protection drape was randomly selected for use in half of the cases in each block. Two-way analysis of covariance was performed to test the effect of shielding systems on operator exposure while controlling for other covariates, including procedure dose-area product. RESULTS Mean operator procedure dose was 20.6 μSv for the entire cohort and 17.7 μSv when using some type of shielding. Operator exposure significantly correlated with procedure dose-area product, but not with other covariates. After we adjusted for procedure dose-area product, the use of lead shielding or a radiation protection drape significantly reduced operator exposure by 45% (F = 12.54, P < .0001) and 29% (F = 7.02, P = .009), respectively. The difference in protection afforded by these systems was not statistically significant (P = .46), and their adjunctive use did not provide additional protection. CONCLUSIONS Extensive lead shielding should be used as much as possible in neurointerventional surgery to reduce operator radiation exposure to acceptable levels. A radiation protection drape is a reasonable alternative when standard lead shielding is unavailable or impractical to use without neglecting strategies to minimize the dose.
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Affiliation(s)
- T R Miller
- From the Departments of Diagnostic Radiology, Neuroradiology (T.R.M., J.Z., G.J., R.S., D.G.)
| | - J Zhuo
- From the Departments of Diagnostic Radiology, Neuroradiology (T.R.M., J.Z., G.J., R.S., D.G.)
| | - G Jindal
- From the Departments of Diagnostic Radiology, Neuroradiology (T.R.M., J.Z., G.J., R.S., D.G.)
| | - R Shivashankar
- From the Departments of Diagnostic Radiology, Neuroradiology (T.R.M., J.Z., G.J., R.S., D.G.)
| | - N Beaty
- Neurosurgery (N.B.), University of Maryland Medical Center, Baltimore, Maryland
| | - D Gandhi
- From the Departments of Diagnostic Radiology, Neuroradiology (T.R.M., J.Z., G.J., R.S., D.G.)
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Muniraj T, Aslanian HR, Laine L, Farrell J, Ciarleglio MM, Deng Y, Ho H, Jamidar PA. A double-blind, randomized, sham-controlled trial of the effect of a radiation-attenuating drape on radiation exposure to endoscopy staff during ERCP. Am J Gastroenterol 2015; 110:690-6. [PMID: 25823765 DOI: 10.1038/ajg.2015.85] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 02/17/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography (ERCP) is associated with radiation exposure to the endoscopist and staff that may be significant in high-volume centers. We investigated whether a radiation-attenuating drape over the fluoroscopy image intensifier reduces radiation exposure during ERCP. METHODS We performed a prospective, randomized, double-blind trial of 100 therapeutic ERCPs at a tertiary-care university center. Procedures were randomly assigned to groups receiving lead-free radiation-attenuating drapes (n=50) or identical sham drapes (n=50). The drapes were suspended around the fluoroscopy image intensifier during ERCP. The primary end point was the effective dose of radiation measured at the endoscopist's eye and neck, and at the assisting nurse's neck. The cumulative annual radiation exposure was also estimated. RESULTS Fluoroscopy time, absorbed radiation dose, and dose area product were similar in the study groups. Mean effective dose for sham vs. radiation-attenuating drape was 0.21±0.27 vs. 0.02±0.02 mSv at the endoscopist's eye, 0.35±0.44 vs. 0.03±0.03 mSv at the endoscopist's neck, and 0.27±0.34 vs. 0.02±0.02 mSv at the nurse's neck (P<0.0001 for all comparisons). The relative risk reduction in radiation was 90%, 91%, and 93% at the three sites. At a high-volume center in which an endoscopist performs 500 therapeutic ERCPs per year, the estimated cumulative annual effective dose at the endoscopist's eye level is 126 mSv with conventional protection and 12 mSv with a radiation-attenuating drape, with the recommended limit being 20 mSv. CONCLUSIONS The addition of a radiation-attenuating drape around the image intensifier during ERCP significantly decreases radiation exposure to endoscopists and staff by ∼90%.
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Affiliation(s)
| | - Harry R Aslanian
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Loren Laine
- 1] Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA [2] VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - James Farrell
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Maria M Ciarleglio
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Henry Ho
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Priya A Jamidar
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
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