This document discusses radiation protection for operators performing cardiac procedures. It finds that half of brain tumors in interventional cardiologists were glioblastomas located in the left temporal region, suggesting an association with occupational radiation exposure. A randomized controlled trial found that using a pelvic lead drape reduced operator left chest radiation dose by 76%, and a novel lead-free surgical cap reduced operator head radiation exposure by 81%. Adopting measures like new equipment, lowering frames per second, lead drapes and caps can significantly reduce radiation exposure for operators.

1. Radiation Protection for Operators
performing Coronary Angiography or
Intervention
Sanjit Jolly MD, FRCP
Interventional Cardiologist, Hamilton Health
Sciences, McMaster University,
Hamilton, Canada

2. Disclosures
 Grant Support or Honororia:
Medtronic, Astra Zeneca, St. Jude

3. Why is this important?

4. Radiation and Cancer
 36 Cases of Brain Tumours in
interventional Cardiologists
 Half Glioblastoma, 86%Left Temporal
 Mean 23 years of practice
 Case control study suggest of
radiologists working with fluoroscopy
OR 6.0 for brain tumour
Roguin, A, et al. Eurointervention. 2012;7:1081-86
Roguin, A. SOLACI, 2014.

5. Radiation
 Class I Carcinogen
– Known causal agent for malignancy

6. DOES RADIAL ACCESS INSTEAD OF
FEMORAL INCREASE RADIATION
DOSE?

7. RCT of Radial vs. Femoral
64
166
32
110
180
160
140
120
100
80
60
40
20
0
Diagnostic PCI
uSv
Radial
Femoral
Randomized
single center
study (n=297)
• 100% increase in radiation dose for diagnostic and 50% increase
in radiation dose for PCI for cardiologist
Lange HW, et al. Cath Cardiovasc Int. 2006;67:12-16

8. Limitations
 Side shield NOT used in radial cases
 Single operator

9. R I V A L
RIVAL Radiation Substudy:
Trend for increase in Air Kerma with no
difference in DAP
Air Kerma
Radial Femoral
1046
930
Overall
DAP
P=0.83
Radial Femoral
52.8 51.2
Overall
P=0.051
Jolly SS, et al. JACC Interv. 2013.

10. Radial Center Volume and Air
Kerma (mGy)
P=0.002
P=0.597
P=0.403
Difference only present in low volume Radial
Centers
Jolly SS, et al. JACC Interv. 2013.

11. Summary of Radial vs.
Femoral for Radiation
 Modest difference only in low volume
radial operators
 Experience and how you practice more
important than radial vs. femoral

12. RADIATION PROTECT Trial
A Randomized Controlled Trial of
RADIATION PROTECTion with a Patient Lead Shield and a
Novel, Non-Lead Surgical Cap for Operators Performing
Coronary Angiography or Intervention
Co-principal investigators:
Ashraf Alazzoni, MD, FRCPC
Sanjit Jolly, MD, FRCPC
McMaster University
Hamilton, Ontario, Canada

13. Disclosure Statement of Financial Interest
• Lead drape was designed in collaboration
and provided by UltraRay Medical
(Oakville, Canada)
• Lead free Cap was provided by Worldwide
Innovations & Technologies Inc (Kansas
City, USA)

14. Pelvic Lead Drape
Produced by UltraRay Medical, Oakville, Canada

15. A novel surgical cap (No Brainer, RADPAD)
•Light (53 grams in
weight)
•Lead Free
•It contains bismuth
and barium
Provided by Worldwide Innovations & Technologies Inc,
Kansas City, USA

16. Results 230 Patients with high likelihood of
undergoing same sitting percutaneous
coronary intervention (PCI) were enrolled
and underwent randomization
Randomization was stratified by chronic
total occlusion PCI cases in a 1:1 ratio
1 patient was missed
since procedure was
done without putting the
dosimeters on operator
1 patient operator’s left
chest dosimeter was
severed before starting
procedure
115 Patients were
assigned to the lead
shield group
115 Patients were
assigned to the
control group
113 Patients were
included in the lead
shield group
115 Patients were
included in the
control group
229 were included in the surgical cap analysis

17. Results Procedural Data
Characteristic*
Lead Shield
(N=113)
Control
(N=115)
Median contrast
volume used – mL
(IQR)
130.00 (92.00-
184.00)
126.00 (90.00-
190.00)
Median fluoroscopy
time – minutes
(IQR)
9.52 (5.43-
15.48)
9.98 (5.42-
15.48)
Median air kerma –
mGy (IQR)
857.94 (512.00-
1324.0)
942.49 (552.68-
1485.0)
*No significant difference between both groups

18. Results
Primary Outcomes
Pelvic lead drape reduced radiation dose by 76%
14
12
10
8
6
4
2
0
3.07
12.57
Mean Left Chest Radiation Dose (μSv)
Lead Shield No Lead Shield
P<0.001

19. Results Sub-Group Analysis
Sub-Group Lead Shield Control
Percentage
of Reduction
(%)
P Value
CTO 10.34 ±10.38 56.50 ± 57.74 80 0.002
non CTO 6.04 ± 7.20 20.77 ± 22.06 75 <0.0001
PCI including
7.91 ± 8.44 18.73 ± 9.89 76 <0.0001
rotablation
Coronary
angiography only
3.40 ± 3.21 8.44 ± 5.89 72 <0.0001
Femoral 4.62 ± 7.49 38.28 ± 37.11 91 <0.0001
Radial 6.88 ± 7.51 18.14 ± 21.36 67 <0.0001
BMI tertile 1 3.33 ± 2.61 18.62 ± 21.16 78 <0.0001
BMI tertile 2 6.06 ± 6.62 31.94 ± 39.01 81 <0.0001
BMI tertile 3 9.77 ± 10.09 20.57 ± 18.25 66 <0.0001
Fellow 6.58 ± 7.93 21.67 ± 22.86 74 <0.0001
Staff 6.12 ± 7.05 26.41 ± 34.06 78 <0.0001

20. Results
Primary Outcomes
The cap use resulted in an 81% reduction in operator
head radiation exposure
7
6
5
4
3
2
1
0
1.25
6.47
Operator Head Radiation Dose (μSv)
Inside Cap Outside Cap
P<0.001

21. Conclusion
•Lead shield and the No Brainer cap reduced operator
radiation exposure by >75%
•These simple protective measures can be easily
incorporated into clinical practice and increase
operators safety
Perspective: These interventions can reduce the
operator dose of complex retrograde CTO to a
diagnostic cath

22. History of Professional
Sports
1978
2013

23. OTHER WAYS TO PROTECT
YOURSELF FROM RADIATION

24. Newton’s Inverse Square
Law: Take a Step Back
Intensity = I/d2

25. Measures to reduce
Radiation exposure
 Arm should be brought in beside body
after access obtained
 Lead Side skirt should be used
 Minimize magnification
 Ceiling Lead shield should be as close
to operator as possible
Recommended Reading: Chambers L, et al. Radiation Safety Program
for the Cardiac Catheterization Laboratory. Cath Card Interv. 2011

26. IMPROVEMENTS IN
TECHNOLOGY TO REDUCE DOSE

27. Randomized Trial of
15 FPS vs. 7.5 FPS for
Fluoro
48
34
15 FPS 7.5 FPS
Abdelaal E, et al. JACC interv. 2014;7:567-74.
N=363
Operator dose
(uSv)
30% Relative
Reduction

28. New Equipment can reduce
Dose
 Before and after study, Phillips ECO
Allura (n=605)
 Algorithms to reduce dose include:
 Reduces Detector dose rate
 Increased thickness of filters
 Automatically uses lowest dose possible based on
patient (peak tube voltage, cathode current, etc)
 Reduce FPS from 15 to 7.5 FPS
Wassef AW, et al. JACC Interv. 2014;7:550-7.

29. Pre and Post Phillips ECO
Air Kerma Gy
Pre Post
48% Reduction
P<0.0001
62% Reduction
P<0.0001
1.07 1.07 1.07
0.56
35% Reduction
P<0.0001
0.7
0.41
Pre vs. Post Pre vs. 15 FPS Pre vs. 7.5 FPS
Wassef AW, et al. JACC Interv. 2014;7:550-7.

30. RADPAD: Bismuth Antimony
product

31. Radpad RCT in Transradial
PCI
23% Reduction in Operator dose with Radpad
P<0.001
Politi, L ,et al. Cath Card Int 2012. 79(1):97-102

32. Summary
 Reducing FPS 15 to 7.5 reduces dose
by about 30%
 New protocols (equipment) can reduce
dose by 30%
 Lead drapes and Novel Cap can
reduce dose by 75%

33. Conclusion
 Radiation is the most important
occupational hazard of interventional
cardiologists
 We must do more to protect ourselves