university of north carolina - aapm hqamos3.aapm.org/abstracts/pdf/68-19749-234349-90002.pdf ·...
TRANSCRIPT
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Optimizing Dose in the Interventional Suite:
Do you really need that image quality?
Robert G, Dixon, MDUniversity of North Carolina
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Financial Disclosure
Educational Consultant for Bard Access Systems
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Personal Disclosure
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What can I teach a room full of physicists?
http://theinvisibleagent.wordpress.com/tag/physics/
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Two Perspectives
PhysicistInterventional
Radiologist
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Two Perspectives
PhysicistInterventional
Radiologist
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Learning Objectives
• Appreciation of the clinical perspective• Need for operator education
• Simple techniques to optimize dose
• Discuss the question: “Do I really need all that image quality?”
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Wide Range of Dose
Mettler et al. Radiology 2008
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What should we teach them?
1. Basic, simple techniques
2. Target the young physicians
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Things you know
• Increase table height
• Add Barriers
• Exit the room for DSA runs
• Limit magnification
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Increase the Table Height
Why?
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Source to Skin Distance
• SSD: determined by table heightthe operator’s height
• Skin dose decreases as SSD increases
• Therefore, maximize SSD within reason700 mm (27.6 inches)600 mm (23.6 inches): increase dose 17-29%Simple 10 cm (4 inch) maneuver
Wagner LK, Archer BR Cohen Am.JVIR 2000;11:25-33
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20% Savings
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Vary the technique
• Operator is in control• Vary:
Frame RatesGantry PositionProtocol UsedCollimation
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Optimize
• Prior to the case
• During the case
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Prior to the case
• Review old studiesCTMRIUS
• Review prior Interventional Procedures
• Have a clear plan
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During the case
• Ask: do I need great quality to…• Gain access to the celiac artery• Demonstrate IVC Filter Position• Insert a port• Drain an abscess• Perform cerebral angiography• Embolize a bleeding visceral artery
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Use it if you need it
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Use it if you need it
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Consider alternatives if you don’t
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Save Fluoro
• LIH
• Fluoro Video Clips
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Last Image Hold
Last Image Hold Spot Radiograph
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Slow the Frame Rate
• Fluoroscopic Frame Rate
• DSA acquisition Frame Rate
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Pulsed Fluoroscopy15 – 30 pps for critical procedures where precision
required
7.5 pps used for many casesUp to 70% dose savings compared with
continuous fluoro *
3 pulses per secondUsed when dose savings are paramount or for
simple procedures
* Miller DL et al. Radiology 2002;225:329-336
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75 yo male ESRD
Left Arm Fistula
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Following Angioplasty
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High Dose Procedures
• Embolization
• TIPS
• Renal/Visceral stent placements
• Cardiac RFA
• Coronary angioplasty/stent
• Biliary procedures
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TIPS
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Protocols
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Eyes: Protect Them!
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Cataracts
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Ocular Guidelines
• Previously - Deterministic Effect: • 2 – 5 Gy for protracted exposure
• Early Studies• Short follow up• Lacked sufficient sensitivity• Few subjects with dose < few Gy
NCRP 168
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Worse Case Scenario
• Source above table
• No Barrier Protection
• Dose to the eye 450 – 900 mSv/yr
Vano Br J Radiol1998Schueler et al. Radiographics 2006
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Eye Protection
Typical workloads: dose to eye may exceed the threshold for cataracts after several years of work if radiation protection tools are not used.
Vano et al. Radiology 2008;248:945-953
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Newer Data
• Opacification of the lens at lower doses
• Based on • Patients: CT scans, radiation therapy• Atomic-bomb survivors• Residents of contaminated buildings• Chernobyl accident liquidators• Radiologic technologists
NCRP 168
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Newer Data
• Chernobyl workers: < 1 Gy
• Rad Techs: risk increases linearly with no apparent threshold
• These challenge prior recommendations
NCRP 168Worgul et al; Radiat Res 2007
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ICRP
• Lens of the eye: threshold for tissue reaction in absorbed dose is now considered to be 0.5 Gy
• Occupational exposure:• Now recommend an equivalent dose
limit of 20 mSv/yr (avg over 5 yrs)• Previously 150 mSv/yr• No single year > 50 mSv
www.ICRP.org – statement on tissue reaction.2011
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Lens Exposure Cardiology
• Retrospective cumulative lens dose
• Avg: 22 years working/ 51 years old
• 25 mSv – 1600 mSv
• New Annual dose limit 20 mSv/yr• Exceeded by 60% of cardiologists
Jacob et al. Radiat Prot Dosimetry 2012
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Lens Exposure Cardiology
• Several years + no protection may exceed ICRP lifetime dose threshold of 500 mSv
• Risk for developing radiation-induced cataracts
Jacob et al. Radiat Prot Dosimetry 2012
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Eye Protection
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21%
Cousins et al. Radiol 1987;22:688-692
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Operator Eye Protection
Thornton, Dauer et al.JVIR 2010
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Comparing Strategies
Thornton, Dauer et al.JVIR 2010
• Leaded Glasses: reduced by a factor of 5 - 10
• Scatter Shielding Drapes:reduced by a factor of 5 - 25
• Both Together:reduced by a factor of > 25
• Suspended Shielded:Undetectable
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CT Suite
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15 yo with post-op abscess
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CT Abdomen and Pelvis
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CT Suite
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Lung Cancer
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Lung Cancer
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Lung Cancer
![Page 67: University of North Carolina - AAPM HQamos3.aapm.org/abstracts/pdf/68-19749-234349-90002.pdf · 2012. 7. 28. · Do you really need that image quality? Robert G, Dixon, MD. University](https://reader033.vdocuments.mx/reader033/viewer/2022060903/609f1674ae643276a07e1e18/html5/thumbnails/67.jpg)
Lung Cancer
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Summary
• Appreciation of the clinical perspective• Need for operator education• Target the young physicians
• Simple techniques to optimize dose
• Discuss the question: “Do I really need all that image quality?”