ORAMED: Extremity and Eye lens dosimetry in

interventional procedures (Work Package 1)

Practical guidelines to reduce extremity and eye lens

doses in interventional cardiology and radiology
procedures

Carinou Eleftheria, WP1 leader, Greek Atomic Energy Commission (GAEC), Greece
Domienik Joanna, Nofer Institute of Occupational Medicine (NIOM), Poland
Donadille Laurent, Institut de Radioprotection et de Sret Nuclaire (IRSN), France
Ferrari Paolo, Radiation Protection Institute (ENEA), Italy
Jankowski Jerzy, Nofer Institute of Occupational Medicine (NIOM), Poland
Koukorava Christina, Greek Atomic Energy Commission (GAEC), Greece
Krim Sabah, Belgian Nuclear Research Centre (SCKCEN), Belgium
Nikodemova Denisa, Slovak Medical University Faculty (SMU), Slovakia
Ruiz-Lopez Natacha, University Hospital Centre and University of Lausanne (CHUV), Switzerland
Sans Merce Marta, University Hospital Centre and University of Lausanne (CHUV), Switzerland
Struelens Lara, Belgian Nuclear Research Centre (SCKCEN), Belgium
Vanhavere Filip, ORAMED coordinator, Belgian Nuclear Research Centre (SCKCEN), Belgium

ORAMED contract grant agreement n211361 January 2011

 GUIDELINES FOR REDUCING EXTREMITY
AND EYE LENS DOSE IN INTERVENTIONAL
PROCEDURES
These guidelines were established in the framework the ORAMED project (2008-2011), a Collaborative Project
supported by the European Commission within its 7th Framework Program.

General problematic

During interventional radiology and cardiology procedures the

medical staff can receive relatively high doses. The operator and
assisting personnel is required to remain close to the patient and
thus they are exposed to the scattered field. Despite the fact that
the body and neck areas can be individually shielded by a protective
lead apron and a thyroid collar, the hands, legs and the eye lenses
often remain practically unshielded.

Description of the work

A coordinated measurement program was performed in different hospitals in Europe. Eyes
(Left or Right,
and Middle)
Moreover, simulations of the most representative workplaces/procedures in
interventional cardiology and radiology (IC/IR) were performed to determine the
main parameters that influence the extremity and eye lens doses.
A measurement protocol was established, according to which several parameters
related to the angiographic system, the type and complexity of the procedure, the Wrists
(Left and Right)
position of the physician and the protective equipment, some field parameters (kV Rings

values, filtration, projections, etc.) and finally the air kerma area product (KAP) (Left and Right)

values were recorded. For the measurements in the various positions

thermoluminescent dosemeters (TLDs) were used, sealed in small plastic bags and Legs
taped on the parts of the body to be monitored. (Left and Right)

Numerical simulations were performed using the MCNP-X

Monte Carlo code. The input file contains 2
anthropomorphic phantoms, representing the patient and
the operator. Some modifications were performed on the
Figure 1. Location of
operator's phantom: eyes, arms and hands were added, as the measuring points
well as a lead apron and a thyroid collar. An X-ray source
Figure 2. and an image intensifier were also included in the
The anthropomorphic
phantoms used for the
geometry.
simulations

MEASUREMENT CAMPAIGN

The list of procedures includes 3 cardiac and 5 general

interventional diagnostic and therapeutic examinations. The aim was to evaluate extremity and eye
The list is composed of cardiac angiographies (CA) and lens doses of medical staff.
angioplasties (PTCA), radiofrequency ablations (RFA), Data are derived from:
pacemaker implantations (PM), angiographies (DSA) and 42 hospitals/rooms across Europe
angioplasties (PTA) of the lower limbs (LL), the carotids 6 different European countries
(C), the reins (R) and the brain (B), embolisations and 1329 procedures
endoscopic retrograde cholangiopancreatographies
(ERCP).
SIMULATION CAMPAIGN

The parameters examined are:

beam quality, beam projection, field size, irradiated The aim was to evaluate the influence of
part of the patient, position of the operator and different parameters on eye, hand, wrist
protective equipment (table and ceiling shields and and leg doses.
lead glasses).
1/3
 Conclusions
The various parameters which can influence the doses were studied and analyzed and the following conclusions
were drawn:
The ceiling suspended shield can reduce the eye dose from 2 to 7 times.
Protective glasses with large lens and side shield should be used (90% dose reduction) especially when a ceiling
suspended shield is not available and/or the X ray tube is above the operating table.
The proper use of table shield can reduce the doses to the legs from 2 to 5 times.
The tube should be placed below the operating table when it is possible. This configuration is associated with
doses 2-77 times and 2-50 times smaller to the eyes and to the hands, respectively when compared to above
table and biplane configurations. However, the doses to the legs are larger, effect which can be compensated
by the use of properly positioned table shield.
If the biplane configuration is used the proper use of an additional shield covering covering the scattered
radiation due to the lateral beam is very important.
The femoral artery access should be preferred, if it is possible from the medical point of view, than the radial
one. If the shields are properly used the doses are lower for the femoral access, 2 to 7 times (CA/PTCA results.
The use of automatic contrast injection system makes possible to the operator to leave the room during the
image acquisition is a practice which can reduce the doses significantly (by 4 to 7 times), especially to the
hand ones.
Recommendations
Only dedicated interventional equipment and room (properly
shielded) should be used.
Personal protective equipment should be used (at least collar
and lead aprons). Lead glasses with side shield should be
preferred.
The room protective equipment should be used and positioned
properly.
The ceiling suspended shield should be placed as close to the
patient as possible. The combination of transparent ceiling
shield and lead drapes that touch the patient is very efficient
for the protection of the eyes and hands.
If biplane systems are used the proper use of lateral shield is
very important for the protection of the eyes.
The tube should be placed below the operating table. The
higher doses at the legs in this setup can be reduced by a
properly positioned table shield.
Care should be taken for the table shield when the operators
needs to move around the table for medical reasons.
Mobile floor shield should be used for the assisting personnel
that needs to be in the irradiation room
The femoral access should be preferred whenever it is
possible from the medical point of view.
Going outside the operating room during the image
acquisition is a practice which can reduce the doses
significantly.
Avoid direct exposure of hands to primary radiation.
Monitoring of doses to fingers or wrists and eyes should be
performed on routine basis. The dosemeters should be worn
on the side of the operator which is closest to the X ray tube.
The dosemeter should be placed on the dorsal or palmar side
of the hand when the X ray tube is placed above or below the
operating table respectively.

This study has received funding from the European Atomic Energy Community's 7th
Framework Program (FP7/2007-2011 - grant agreement n211361).
 APPENDIX - Main results of WP1
AVERAGE DOSES FOR THE DIFFERENT PROCEDURES

IR procedures IC procedures
0.45 DSA/PTA LL 0.45
0.40 0.40 CA/PTCA
DSA/PTA C/B
0.35 0.35 RFA
DSA/PTA Renal

Average Hp(0.07) (mSv)

Average Hp(0.07) (mSv)

0.30 0.30 PM/ICD

Embolisations
0.25 0.25
0.20 0.20
0.15 0.15
0.10 0.10
0.05 0.05
0.00 0.00

ERCP Among the cardiac procedures studied, the doses to the

operators are higher during PM and ICD implantations, even
0.45
though the KAP values are relatively low. During these
0.40 ERCP procedures the operators work very close to the irradiating field
0.35 and most of the time without any protective shield.
Average Hp(0.07) (mSv)

0.30
0.25
For the IR procedures special attention should be given to the
0.20
embolisations, especially to the doses to the eye lenses.
Operators are also significantly exposed during therapeutic
0.15
procedures such as angioplasties of the lower limbs and the renal
0.10
arteries.
0.05
0.00 For ERCP procedures the doses are generally low. Special care
should be taken regarding the use of a ceiling suspended shield,
for the protection of the eyes, especially when over couch
systems are used.

MAXIMUM DOSES

Position of the maximum dose in Position of the maximum dose/annual dose limit in
all IR procedures all IR procedures
R Leg
L Leg
M Eye The maximum doses were recorded 2%
9%
L Leg
15% 10% most frequently on the left finger and L Wrist
R Leg on the left wrist. R Wrist 7% M Eye
L/R Eye 2% 30%
7% 10% However, taking into account the
respective annual limits for all
R Finger L Finger
positions (150 mSv for the eyes and 13%
4%
500 mSv for the extremities) the eye
L Wrist
lens exposure seems to become more
22% R Finger
important. 2%
L Finger L/R Eye
R Wrist 35%
24%
8%

EXTRAPOLATION TO ANNUAL DOSES

0%
4% In many cases the 3/10th of
9% 7%
the extremity and eye lens <15 mSv
limits were exceeded.
11% <50 mSv 18%
50 mSv<Hp<100 mSv For the hands there were 15 mSv<Hp<50 mSv
cases exceeding the limit.
100 mSv<Hp<500 mSv
>500 mSv Monitoring of the hands and 50 mSv<Hp<150 mSv
eye lens should be performed
75%
77% in routine basis in all
>150 mSv
procedures except ERCPs.

Frequency distribution of how many times the annual Frequency distribution of how many times the annual
dose for hands exceed a certain dose level dose for eyes exceed a certain dose level