This document discusses radiation exposure for interventional cardiologists and strategies to reduce it. It notes that radiation is a known carcinogen and some studies have found increased cancer risks for interventionalists. While one study found a modest increase in radiation with radial access, experience level is also important. The document reviews techniques like using lead shields and skirts, lowering frame rates, and newer equipment to reduce radiation by up to 62%. Lead drapes and caps have been shown to reduce operator radiation by 75-81% in randomized trials. The conclusion is that while radiation and orthopedic injuries are major occupational hazards, strategies exist to better protect interventionalists.

1. Radiation Exposure and TRA: Is the
Access Site a Challenge or an
Opportunty?
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
0
20
40
60
80
100
120
140
160
180
Diagnostic PCI
uSv
Radial
Femoral
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
Randomized%
single%center%
study%(n=297)

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
1046
930
Overall
Air?Kerma
Radial Femoral
52.8 51.2
Overall
DAP
Radial Femoral
P=0.051
Jolly SS, et al. JACC Interv. 2013.
P=0.83

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. HOW?CAN?WE?PROTECT?
OURSELVES

13. Law: Take a Step Back
Intensity = I/d2

14. 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
contiguous with side skirt
Recommended Reading: Chambers L, et al. Radiation Safety Program
for the Cardiac Catheterization Laboratory. Cath Card Interv. 2011

15. IMPROVEMENTS%IN%
TECHNOLOGY%TO%REDUCE%DOSE

16. Randomized Trial of 15 FPS
vs. 7.5 FPS
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

17. 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.

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

19. In large patients, 7.5 FPS will not make a difference
Dose will be automatically increased to maximum allowed
Courtesy of Robert Gould

20. What do Low, Medium, High
Settings mean?
Settings refer to maximum allowable dose rate.
Explains why in large patient low setting15 fps can be lower
dose than normal 7.5 fps
Courtesy of Robert Gould

21. RADPAD: Bismuth Antimony
product

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

23. Radiation Protect Study
(Randomized trial N=230)
Alazzoni A, et al. JACC. 2014. 64(11_S). TCT-145

24. Pelvic?Lead?Drape
Developed in collaboration with Ultra-Ray Medical,
Oakville, Canada
Alazzoni A, et al. JACC. 2014. 64(11_S). TCT-145

25. Also Testing Effectiveness of
Non lead Cap (50 g)
Dosimeter both inside and outside of cap to
determine reduction in radiation dose
Worldwide
Innovations
Technology, Kansas
equivalency 0.125
mm)

26. Results
Pelvic lead drape reduced radiation dose by 76%
Primary Outcomes
0
5
10
15
20
25
Mean)Left)Chest)Radiation)Dose)(µSv)
Lead)Shield No)Lead)Shield
6.38
23.57
P<0.0001
Alazzoni A, et al. JACC. 2014. 64(11_S). TCT-145

27. Results
The cap use resulted in an 81% reduction in operator
head radiation exposure
Primary Outcomes
0
2
4
6
8
10
12
Operator)Head)Radiation)Dose)(µSv)
Inside)Cap Outside)Cap
2.99
10.75
P<0.0001
Alazzoni A, et al. JACC. 2014. 64(11_S). TCT-145

28. History of Professional
Sports
1978
2013

29. Radiation and Impact of Lead
SCAI membership survey
1/5 of interventionalists
radiation badge ever
7% of interventionalists have to limit
volume due to radiation
Klein et al. CCI. 2015. Epub.

30. Radiation and Impact of Lead
SCAI membership survey
5% incidence of Cancer
50% have experienced serious
orthopedic injury requiring time off
Klein et al. CCI. 2015. Epub.

31. 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%

32. Conclusion
Radiation and Orthopedic lead related
injury is the most important
occupational hazard
We must do more to protect ourselves
and to prevent injuries