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International Radiation Protection Association11th International Congress
Madrid, Spain - May 23-28, 2004
Refresher Course
Radiation Protection in Cardiac and Interventional Procedures
C. Reek
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IRPA 11 Refresher Course 2
Overview
• Introduction and Background• Regulations• Dose• Patient Dose Reduction-Factors• Special Cases• Limitation of Staff Dose• Good Practice• Recommendations
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IRPA 11 Refresher Course 3
Sources of Radiation
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IRPA 11 Refresher Course 4
November 8th 1895
Wilhelm Conrad Röntgen
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IRPA 11 Refresher Course 5
• 23rd January 1896• Public lecture on X rays• Hand of von Kolliker
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IRPA 11 Refresher Course 6
First British Radiographs
• 25th January 1896• BMJ Alan Campbell Swinton
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IRPA 11 Refresher Course 7
British Medical Journal 18th April 1896
• First published report of the dangers of X rays
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IRPA 11 Refresher Course 8
1921
• Deaths attributed to X rays
• No regulations prior to 1928
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IRPA 11 Refresher Course 9
Stochastic (Random) Effects
1 in 83,333Majority of NHS staff (<0.3mSv/yr)
1 in 25,000Cancer from radiation exposure of 1 mSv
1 in 43,500Accidents at work
1 in 9500Accidents on road
1 in 850Natural causes (40 yr old)
1 in 200Smoking 10 cigarettes/day
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IRPA 11 Refresher Course 10
Deterministic Effects
>25 to eye>250 to eye>5Cataract5050010Telangiectasia
9090018Dermal necrosis
7070014Dry desquamation
353507Permanent epilation
<<11002Transient erythema
Mins fluoro0.2Gy/min
Mins fluoro0.02Gy/min
Threshold Dose to Skin
Injury
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IRPA 11 Refresher Course 11
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IRPA 11 Refresher Course 12
Development of Interventional Cardiology
1929First documented human
cardiac catheterisationEberswald, GermanyDr Werner Forssman
1958Diagnostic coronary
angiogramDr Mason Sones
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IRPA 11 Refresher Course 13
Development of Interventional Radiology
1964Transluminal angioplastyDr Charles Dotter
1967Judkins techniqueDr. Melvin Judkins
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IRPA 11 Refresher Course 14
Development of Interventional Cardiology
1974
First peripheral balloon angioplasty
Dr Andreas Gruentzig
1977
First cath lab PTCA on awake patient
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IRPA 11 Refresher Course 15
Development of Interventional Cardiology
1980Use of angioplasty in
evolving myocardial infarct
Dr Geoffrey Hartzler
1987First use of coronary stents
in human
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IRPA 11 Refresher Course 16
• Transplant post-biopsy
9.9 x 24.6 mm det. balloon
Embolisation: detachable balloon occlusion
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IRPA 11 Refresher Course 17
Regulations
• Ionising Radiation Regulations 1999-relate to public and staff safety
• Ionising Radiation (Medical Exposure) Regulations IR(ME)R 2000
-govern the fate of patients undergoing a medical exposure
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IRPA 11 Refresher Course 18
Regulations
• Duties of all bodies- employer, practitioner, operator and referrer
• ALARA/ ALARP principle• Training• Diagnostic Reference Levels (DRLs)• Local Rules-policies, procedures, protocols• Other Bodies eg NRPB, ICRP, ACC, BCIS,
European Commission’s Radiation Protection Research Program
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IRPA 11 Refresher Course 19
Dose Definitions
• Gray - energy absorbed per unit mass(in diagnostic = KERMA, energy transferred)
• Sievert - equivalent dose=absorbed dose x radiation weighting factor
• Effective dose – equivalent dose in each organ and tissue x tissue weighting factor and summed over whole body
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IRPA 11 Refresher Course 20
Dose Definitions
• DAP - dose area product (Gycm²)incident dose x area of X ray field
• Entrance skin dose – absorbed dose in the skin at a given location on the patient (Gy)
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IRPA 11 Refresher Course 21
Annual Dose Limits
1 mSv1 mSvFetus50 mSv150 mSv500 mSvOrgans
15 mSv50 mSv150 mSvEyes
1 mSV6 mSv20 mSvWhole body
PublicUnclassified / trainees
Classified Staff
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IRPA 11 Refresher Course 22
Monitoring
Ensure
• Film badges and TLDs are easily available
• Results of monitoring are available to all
• Reminders to wear them are in appropriate places
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IRPA 11 Refresher Course 23
Dose to patient
13.07070CA + ad hoc PTCA + stent
9.04920PTCA + stent
9.35060CA + ad hoc PTCA
6.93760PTCA
5.63040Coronary angiography
ED mSVDAP cGycm²Procedure
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IRPA 11 Refresher Course 24
Diagnostic Reference Levels
• Set for categories of procedures – 20/annum• At least 100 cases• DAP (dose area product) or screening time and
mAs• Level set - 90th percentile• No national DRLs for coronary angiography• NRPB – proposed 36 Gcm²• European DIMOND – proposed 45 Gcm²
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IRPA 11 Refresher Course 25
Dose Reduction - Equipment
• Frame rate selection• Pulsed fluoroscopy• Fluoroscopy and image
acquisition dose rate selection
• Last image hold• ‘Replay fluoro’• Electronic magnification• Image processing• Flat panel detectors
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IRPA 11 Refresher Course 26
Dose reduction -Equipment
• Road map• Reload facility• Virtual collimation• Intelligent filtration• Dose display
BUT• Most dose reduction
features optional• Improved imaging allows
more complex cases
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IRPA 11 Refresher Course 27
Dose Reduction - Equipment
• Modification of existing equipment• Equipment maintenance • Quality assurance
regular IQ and dose checksmanufacturermedical physicists
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IRPA 11 Refresher Course 28
Factors affecting exposure
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IRPA 11 Refresher Course 29
Inspiration
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IRPA 11 Refresher Course 30
Operational Factors
• Arterial access• Oblique views
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IRPA 11 Refresher Course 31
Operational Factors
• Suitable kV and mA
• Centring
• Diaphragms-ROI
• Field size -panning
• Magnification
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IRPA 11 Refresher Course 32
Appropriate Views
Views should not be prescriptive-depend on patient
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IRPA 11 Refresher Course 33
Lateral View
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IRPA 11 Refresher Course 34
Operational
• Stenting strategy
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IRPA 11 Refresher Course 35
Behavioural
• Table and detector in correct position before screening
• Screening time• Image acquisition –operator / radiographer?• Use of equipment features-dose reduction
programmes etc• Prolonged procedures – reduce skin dose• Operator fatigue
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IRPA 11 Refresher Course 36
Radiation Awareness
• Regular audit• Feedback on dose information
patientsstaff
• High standards of equipment maintenance and quality assurance
• Appropriate theoretical training with annual updates
• Practical training and regular re-assessment
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IRPA 11 Refresher Course 37
Audit - Operator key
0
1
2
3
4
5
6
7
8
9
Ave . scr. Tim e
Operator Key
1 2
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31 32 33 34 35
36 37 38 39 40 41 42
TOTAL - REG TOTAL - ALL
3 4 5 6 7
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IRPA 11 Refresher Course 38
Audit
1513
0 0
23
323740
15
24
46
37
27
0
32
9
1
434342
030 0
47
0
25
40
79
3 2
21
2927
6 5
55
4
0
10
20
30
40
50
60
70
80
No.
No. of cases
Left Heart Catheters - January - March 2001 (No. of Cases)
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IRPA 11 Refresher Course 39
Audit
0
500
1000
1500
2000
2500
3000
3500
CGycm2
Ave dose
Left Heart Catheters - January - M arch 2001 (Ave Dose)
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IRPA 11 Refresher Course 40
Audit
0 0
13
6
1110
7
4
2 3
19
25
11
0
7
16
19
0
2
4
2524
0
24
17
22
0 0
13
0
15
12
0
5
10
15
20
25
%
% above DRL
Left Heart Catheters - January - March 2001 (% Above DRL)
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IRPA 11 Refresher Course 41
Special Cases-Cardiology
• EPS/RFA• Brachytherapy• CT angiography• Radio-isotopes• Echocardiography• Magnetic Resonance Imaging
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IRPA 11 Refresher Course 42
Electrophysiology
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IRPA 11 Refresher Course 43
Brachytherapy
60mm seed delivery catheter Catheter in diagonal 6 month follow up result
in LAD
Bifurcation in-stent restenosis Two wires Cutting balloon final result
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IRPA 11 Refresher Course 44
CT Angiography
• Anomalous right coronary artery arising from LC sinus
• Occlusion of RCA
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IRPA 11 Refresher Course 45
Magnetic ResonanceImaging
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IRPA 11 Refresher Course 46
Special Cases-Radiology
Per-operative arterial rupture
Covered stent deployment
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IRPA 11 Refresher Course 47
Radiology
• Dose ranges depend on type and site of intervention
• Dose reduction to patient -principles as cardiology
• Tube movements less• Position of operator more variable• Use ultrasound guidance where possible• CT fluoroscopy-decreased operation times
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IRPA 11 Refresher Course 48
Risk
0.00
0.04
0.08
0.12
0.16
0.20
0 15 30 45 60 75 90
Age at Exposure
Death per Sievert
(Sv)
FemaleMale
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IRPA 11 Refresher Course 49
Doses
3.8450Closure of persistent ductusarteriosus
8.4670Tetralogy of Fallot
ED mSvDAP cGcm²
Dose from common paediatric procedures
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IRPA 11 Refresher Course 50
Paediatric Intervention
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IRPA 11 Refresher Course 51
Limitation of Staff Exposure
• Reduce patient exposure - reduce staff exposure
• Radiation awareness and education• Dedicated interventional equipment• Reduce time of exposure• Use inverse square law• Use shielding by barrier
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IRPA 11 Refresher Course 52
Limitation of Staff Dose
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IRPA 11 Refresher Course 53
Use lead shields
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IRPA 11 Refresher Course 54
Wear appropriate lead protection
• Lead glasses• Thyroid shield• Lead apron – 3.5 - 5mm
lead equivalent• Monitoring
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IRPA 11 Refresher Course 55
Use mobile barriers
• Lead shield for operator
• Mobile barrier for radiographer
• Other staff appropriately positioned
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• Position monitors so that operator looks away from beam
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Paediatrics-always a special case
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Good Practice 1
• Follow Local Rules, procedures and protocols• Have all available information about patient
eg. previous grafts, echo data etc• Check patient identity, exposure justification,
consent• Position patient• Ensure all appropriate staff in room are
protected and wearing monitors• Use all lead shielding
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Good Practice 2
• Position table before screening• Keep mA low-kV high (60-90kV for coronaries)• X ray tube at max and II at min distance from
patient• Check staff position• Use dose reduction programmes if possible• Acquire images on full inspiration where
possible• Collimate to area of interest and choose views
carefully
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Good Practice 3
• Prolonged procedure-change beam angulation• Minimise fluoroscopy, high dose rate time,
number of acquisitions• Remember software features to reduce dose eg
replay fluoro• Don’t over use magnification• Remove grid for small patients• Check and record screening time and DAP cf
DRL
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Recommendations
• Dedicated interventional equipment• Radiation dose reduction packages should be mandatory• Radiation dose should be displayed on monitors• Radiation awareness should be promoted by audit and
regular feedback• Local standards-regular review and improvement• Continuing education-including practical training with
annual updates and testing• Research continued-to develop international standards