Radiation exposure and its reduction in the fluoroscopic examination and fluoroscopy-guided interventional radiology

Article information

J Korean Med Assoc. 2011;54(12):1269-1276

Publication date (electronic) : 2011 December 13

doi : https://doi.org/10.5124/jkma.2011.54.12.1269

Woo Kyoung Jeong, MD

Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea.

Corresponding author: Woo Kyoung Jeong, jeongwk@hanyang.ac.kr

Received 2011 September 06; Accepted 2011 September 20.

Abstract

Radiation exposure during fluoroscopy has been of consistent interest because fluoroscopy is used not only for diagnostic purposes such as upper gastrointestinal series but for many minimally-invasive treatments in various clinical fields. In 2000, the International Commission on Radiological Protection published the important report about the avoidance of radiation injuries from medical interventional procedures, and this report defined harm during fluoroscopic-guided interventional procedure and how to reduce the radiation dose of patients and staff. Two aspects of fluoroscopy exposure differ from other types of medical radiation exposure, including computed tomography. One is that the entrance surface dose during an interventional procedure may be very high, so the deterministic effects of radiation such as skin or corneal injury should be emphasized more than stochastic effects such as cancer risk. The other is that the variation in radiation exposure is great for the same kind of procedure, so it is very difficult to generate a reference level for the radiation dose. Therefore, it is necessary to develop a guideline for the use of fluoroscopy through a nationwide survey about irradiation during fluoroscopic examinations and fluoroscopy-guided intervention procedures. In conclusion, radiation exposure by fluoroscopic guided intervention is not negligible, and the practitioner should always aim to reduce radiation exposure during interventional procedures.

Keywords: Radiation dosage; Fluoroscopy; Interventional radiography; Radiation monitoring; Radiation skin injury

References

1. Schauer DA, Linton OW. NCRP report no. 160. Ionizing radiation exposure of the population of the United States, medical exposure: are we doing less with more, and is there a role for health physicists? Health Phys 2009. 971–5.

2. Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ. Fluoroscopically guided interventional procedures: a review of radiation effects on patients' skin and hair. Radiology 2010. 254326–341.

3. Koenig TR, Wolff D, Mettler FA, Wagner LK. Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. AJR Am J Roentgenol 2001. 1773–11.

4. Koenig TR, Mettler FA, Wagner LK. Skin injuries from fluoroscopically guided procedures: part 2, review of 73 cases and recommendations for minimizing dose delivered to patient. AJR Am J Roentgenol 2001. 17713–20.

5. Valentin J. Avoidance of radiation injuries from medical interventional procedures. Ann ICRP 2000. 307–67.

6. Mettler FA Jr, Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology 2008. 248254–263.

7. Jaco JW, Miller DL. Measuring and monitoring radiation dose during fluoroscopically guided procedures. Tech Vasc Interv Radiol 2010. 13188–193.

8. Bor D, Sancak T, Olgar T, Elcim Y, Adanali A, Sanlidilek U, Akyar S. Comparison of effective doses obtained from dose-area product and air kerma measurements in interventional radiology. Br J Radiol 2004. 77315–322.

9. Ruiz Cruces R, Garcia-Granados J, Diaz Romero FJ, Hernandez Armas J. Estimation of effective dose in some digital angiographic and interventional procedures. Br J Radiol 1998. 7142–47.

10. McParland BJ. A study of patient radiation doses in interventional radiological procedures. Br J Radiol 1998. 71175–185.

11. Vano E, Gonzalez L, Fernandez JM, Guibelalde E. Patient dose values in interventional radiology. Br J Radiol 1995. 681215–1220.

12. Marshall NW, Noble J, Faulkner K. Patient and staff dosimetry in neuroradiological procedures. Br J Radiol 1995. 68495–501.

13. Balter S, Schueler BA, Miller DL, Cole PE, Lu HT, Berenstein A, Albert R, Georgia JD, Noonan PT, Russell EJ, Malisch TW, Vogelzang RL, Geisinger M, Cardella JF, St George J, Miller GL 3rd, Anderson J. Radiation doses in interventional radiology procedures: the RAD-IR Study. Part III: Dosimetric performance of the interventional fluoroscopy units. J Vasc Interv Radiol 2004. 15919–926.

14. Miller DL, Balter S, Cole PE, Lu HT, Schueler BA, Geisinger M, Berenstein A, Albert R, Georgia JD, Noonan PT, Cardella JF, St George J, Russell EJ, Malisch TW, Vogelzang RL, Miller GL 3rd, Anderson J. RAD-IR study. Radiation doses in interventional radiology procedures: the RAD-IR study: part I: overall measures of dose. J Vasc Interv Radiol 2003. 14711–727.

15. Miller DL, Balter S, Cole PE, Lu HT, Berenstein A, Albert R, Schueler BA, Georgia JD, Noonan PT, Russell EJ, Malisch TW, Vogelzang RL, Geisinger M, Cardella JF, George JS, Miller GL 3rd, Anderson J. Radiation doses in interventional radiology procedures: the RAD-IR study: part II: skin dose. J Vasc Interv Radiol 2003. 14977–990.

16. Miller DL, Kwon D, Bonavia GH. Reference levels for patient radiation doses in interventional radiology: proposed initial values for U.S. practice. Radiology 2009. 253753–764.

17. Chung JW. Korea Food & Drug Administration. Evaluation of patient dose in interventional radiology 2007. Seoul: Korea Food & Drug Asministration;

18. Schueler BA. Operator shielding: how and why. Tech Vasc Interv Radiol 2010. 13167–171.

19. National Council on Radiation Protection and Managements. Limitation of exposure to ionizaing radiation: NCRP report no. 116 1993. Bethesda: National Council on Radiation Protection and Measurements;

20. Klein LW, Miller DL, Balter S, Laskey W, Haines D, Norbash A, Mauro MA, Goldstein JA. Occupational health hazards in the interventional laboratory: time for a safer environment. Radiology 2009. 250538–544.

21. Finkelstein MM. Is brain cancer an occupational disease of cardiologists? Can J Cardiol 1998. 141385–1388.

22. Matanoski GM, Seltser R, Sartwell PE, Diamond EL, Elliott EA. The current mortality rates of radiologists and other physician specialists: specific causes of death. Am J Epidemiol 1975. 101199–210.

23. 10 Pearls: radiation protection of patients in fluoroscopy [Internet]. International Atomic Energy Agency Radiation Protection of Patients cited 2011 Nov 18. Vienna: International Atomic Energy Agency; Available from: https://rpop.iaea.org/RPOP/RPoP/Content/Documents/Whitepapers/posterpatient-radiation-protection.pdf.

24. 10 Pearls: radiation protection of staff in fluoroscopy [Internet]. International Atomic Energy Agency Radiation Protection of Patients cited 2011 Nov 18. Vienna: International Atomic Energy Agency; Available from: https://rpop.iaea.org/RPOP/RPoP/Content/Documents/Whitepapers/poster-staff-radiationprotection.pdf.

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Figure 1

Fixed reference point. DAP, dose-area product.

Figure 2

Kerma (dose)-area product. DAP₁, dose-area product at the upper position; d₁, radiation dose at the upper position; a₁, irradiated area at the upper position; DAP₂, dose-area product at the lower position; d₂, radiation dose at the lower position; a₂, irradiated area at the lower position.

Table 1

Comparison of radiation dose metrics between the USA and Korea surveys

DAP, dose-area product; TACE, transcatheter arterial chemoembolization; TIPS, transjugular intrahepatic portosystemic shunt; AVF, arteriovenous fistula; PTBD, percutaneous transhepatic biliary drainage; GDC, Guglielmi detachable coils.

From Miller DL, et al. J Vasc Interv Radiol 2003;14:711-727, with permission from Elsevier [13] and Chung JW; Korea Food & Drug Administration. Evaluation of patient dose in interventional radiology. Seoul: Korea Food & Drug Administration; 2007 [16]

Table 2

Maximum, minimum, and mean values of entrance skin doses and their standard deviations during the interventional procedures in Korea

From Chung JW; Korea Food & Drug Administration. Evaluation of patient dose in interventional radiology. Seoul: Korea Food & Drug Administration; 2007 [16].

TACE, transcatheter arterial chemoembolization; AVF, arteriovenous fistula; PTBD, percutaneous transhepatic biliary drainage; GDC, Guglielmi detachable coils

^a)Entrance skin dose on occipital area