VESAP4 – Radiation Safety

Notes:

- Radiation-induced cataracts
o May develop more rapidly at higher doses of exposure
o Recommendation: Not to exceed ____ mSV
 A. 50 mSv
 (20 mSv averaged over 5 years, but not to exceed 50 in a single yr)
o Classically considered a deterministic effect of radiation exposure
 > 2 Gray of radiation
o New evidence suggests cataracts may occur at lower doses
o Appears to be both deterministic and nondeterministic effect
o Appears on posterior capsule of the lens
 Different than typical cataracts
o Wearing leaded eye wear is essential in minimizing risk
- Greatest source of radiation exposure for operators
o The patient
 Scatter radiation that emanates from the patient is the main source of radiation
to operator and staff
- Bringing image intensifier closer to patient
o Decreases required dose to generate image
o Decreases radiation scatter
- Electronic vs Geometric magnification
o Geometric magnification  increases scatter radiation
- Fluorography vs Fluoroscopy
o Fluorography = digital acquisitions
 Generate much higher radiation doses vs fluoroscopy
o Utilizing fluoroscopy looping allows a fluoro run to be repeated in same way a digital
subtraction run would, But with lower doses
- Collimation
o Reduces both patient skin dose as well as scatter radiation
o Should be used whenever possible
- Pulse radiation settings  less radiation vs continuous fluoro
- Hand injection digital subtraction acquisition runs  highest radiation exposure to operator
- Maximal Radiation Protection
o Ceiling-mounted Plexiglas Shields
- The most commonly reported deterministic effect of radiation exposure as a result of
fluoroscopic procedures
o Skin injury
- Pulsed Fluoro
o Decreases exposure of radiation
o Decreases blurriness of image from patient motion
o When pulse rate is greater than 30 pulses / sec, radiation dose = continuous fluoro
- Increasing distance between operator and ______ most reduces radiation exposure
o A. Patient (not xray tube or image intensifier)
- Steep angulation will increase rather than decrease radiation dose
- Patient obesity is a risk factor for higher radiation dose and this should be mentioned during the
consent process
- Radiation threshold for severe birth defects and even pregnancy loss
o 100 mGy
 Depends on radiation dose and trimester of pregnancy
 1st weeks of pregnancy most dangerous
- Recommendation for dose limit during pregnancy is 5 mSv
o Vs annual natural radiation dose = 3 mSv

- The most effective way to reduce fetal radiation exposure during angiographic procedures is to:
o wear a monthly fetal dose badge under the lead apron and adhere to ALARA principles.
- Lead should be at least 0.5 mm and ideally 1 mm in pregnant operators.
- Pregnant operators should step 6 feet away.
- Skin injury
o In general, there is no risk of skin cancer from this type of radiation effect—it is
classified as a “tissue reaction” (formerly a “deterministic effect”) as opposed to a
stochastic effect. Stochastic effects have been associated with the development of
certain types of cancers.
- Factors that increase risk of injury from radiation exposure
o Obesity
o Meds (chemo drugs)
o Genetic Disorders (ataxia telangiectasia, Fanconi Anemia, xeroderma pigmentosum,
gardner syndrome, dysplastic nevus syndrome)
o Scleroderma, lupus, RA, hyperthyroidism, DM
o * NOT alcoholism
- Area of skin of most sensitive to radiation exposure
o Anterior surface of the neck
 Locations in decreasing sensitivity
 Anterior surface of neck
 Flexor surfaces of extremities
 Trunk
 Back
 Extensor surfaces of extremities
 Scalp
 Palm and soles of feet
- Gantry Angulation
o Known to increase the risk of radiation scatter received by operator
o Cranial angulation  increases scatter
 b/c xray source is brought higher and closer to operator (vs caudal)
o When standing on patient’s R
 LOA  increases scatter
- Physician training in the techniques to decrease patient radiation dose has been shown to:
o Decrease the patient dose index
- Fixed imaging system vs mobile system
o Which is associated with higher radiation scatter?
 A. Fixed imaging system
 (likely due to larger image receptor size and ability to run at higher
continuous and peak power levels)
- CTA w/ fluoro fusion (used in FEVAR, BEVAR)
o Associated with decrease in procedural time, and use of contrast
 Not a significant decrease in fluoro time
- Fluoroscopy time is not considered when calculating reference air kerma
- Fluoroscopy time is a poor indicatior of dose because it does not include the radiation dose that
comes from digital acquisitions
- Kerma air product is a merasure of the total output of the machine
o Readily available on monitor upon completion of the procedure
o Best metric of total radiation exposure
- Doses in excess of 200 mGy can induce cancers and the likelihood increases as the dose
increases.
- Erythema is a deterministic effect, which means that changes must occur in many cells before
the effect is seen
- Effective dose is the variable that most accurately predicts the stochastic risk and radiation dose
to which the interventionalist will be exposed
- DSA uses significantly more radiation than standard fluoroscopy.
o As such, DSA runs should be limited when possible.
- Scattered radiation exposure to the interventionalist’s body is highest:  below the
angiographic table
- The thickness of lead recommended to provide adequate shielding is:
o 0.5 mm
- The Joint Commission recommends that doses from previous procedures to the same body area
be summed over a 6 to 12 month period.
o Interventional procedures with a cumulative skin dose greater than 15 Gy to a single
skin field over a period of 6 months to 1 year is considered a sentinel event.
- Regarding radiation overdose, The Joint Commission considers a sentinel event to be prolonged
fluoroscopy with a:
o cumulative dose > 1500 Gy to a single field
- Radiation-induced effects at the cellular level include damage to both double-stranded and
single-stranded DNA.
o In general double-stranded DNA is more resistant to breaks.
o Cell death can occur in all phases of the cell cycle; the S phase is the most radio-
resistant.
o One of the most damaging effects of high levels of radiation is hydrolysis of water,
which produces free radicals.
 One of these is the hydroxyl radical.
  Hydroxyl radicals can combine to form hydrogen peroxide, which causes loss of
essential enzymes and cell death.
 Inhibition of hydrogen peroxide formation is the basis for the use of
antioxidants in cancer prevention and treatment.
o Radiation exposure can cause accumulation of p53, which inhibits the transition from
G1 to S phase, making DNA repair more difficult.

Structured Notes:

- ALARA principles
o (As Low As Reasonably Achievable)
 Time, Distance, Shielding
- Stochastic effect vs Deterministic Effect
o Deterministic Effect – occur at a specific threshold dose of exposure
 Ie skin injury is most commonly reported deterministic effect of fluoro
o Stochastic effects
 Effects that occur by chance and which may occur without a threshold level of
dose, whose probability is proportional to the dose and whose severity is
independent of the dose
 Include changes in cells that can cause neoplasm and heritable changes in
reproductive cells
 This can occur at any dose
 At low doses, likelihood is small, but probability increases with dose
- Effective Dose (unit mSv)
o It is a calculated, NOT measured dose
o Corrects for different sensitivity of various tissues
 Multiplies absorbed dose by tissue weighting factor
 Also corrects for type of radiation by multiplying by radiation weighting factor
o Should be used to assist in radiation protection planning and not in predicting cancer
risk
- Absorbed Dose
o Measure of deposited energy
 Or amount of energy that ionizing radiation imparts to a given mass of matter
o Gray (Gy) or milligray (mGy) per unit of mass
 1 Gy = energy deposition per kg of tissue (Joule/kg)
- DAP (Dose Area product)
o Absorbed dose x area irradiated (units: Gycm^2)
- Air Kerma
o = kinetic energy released in matter
o Energy released from an x-ray beam in a small volume of air that is irratidated
o Measured in Gy
- Reference Air Kerma
o = air kerma measured at a fixed point in space known as the IRP (interventional
reference point)
 o Serves as the best approximation for patient skin doise
- IRP = 15 cm from isocenter on the xray tube side of the fluoroscope
o May be used as a surrogate for the entrance skin dose
- Entrance skin dose is the measure of radiation that is absorbed by the skin at the site of the x-
ray beam and skin interface
o This is essentially the absorbed dose of the skin
- Dose area product (DAP), aka kerma area product (KAP)
o = product of the intensity of ratdiation beam and area of the beam
- Radiation-induced skin injury
o 1st sign of skin injury
 transient erythema
o Deterministic effect of x-ray exposure
o Threshold for skin injury: 2 Gy  transient erythema
 Develops several hours after exposure
o Permanent epilation: 7 Gy
 Presents several weeks after exposure
 May also lead to dyspigmentation and edema
o Dermal Atrophy: 10 Gy
o Telangiectasia Formation: 10 Gy (5-10?)
 Result from dilatation of capillaries in dermis (NOT epidermis)
 Late consequence of exposure
 Rarely develops earlier than 1 yr after exposure
 Can increase in severity for up to 10 yrs following onset
o Skin Ulceration: >10 Gy
o Desquamation and skin necrosis: >15 Gy
 May require debridement and skin grafting to repair
o Cumulative absorbed dose to skin > 2 Gy should be noted in patient’s medical record
o Patient should follow up for development of skin injury if cumulative radiation dose >
5000 mGy
- Pregnant Operators
o Recommendation for dose limit during pregnancy is 5 mSv
 Vs annual natural radiation dose = 3 mSv
o The most effective way to reduce fetal radiation exposure during angiographic
procedures is to:
 wear a monthly fetal dose badge under the lead apron and adhere to ALARA
principles.
o Lead should be at least 0.5 mm and ideally 1 mm in pregnant operators.
o Pregnant operators should step 6 feet away.
- Decreasing Radiation Scatter
o Minimize patient dose
o Fluoro looping (vs digital acquisition runs)
o Horizontal and vertical collimation
 Decreases field of view, thus narrowing radiation beam and scatter
o Detector (image intensifier) should be as low above the patient as possible
  Minimize source to detector distance
 Less energy is required to obtain an image vs when II is higher above patient
o Raising table height
 Decreases overall patient skin dose
 B/c patient’s skin is farther from the xray tube
 However, scatter radiation is increased because more xray refraction off bottom
of table
o Magnification (decreases field of view)
 Increases radiation exposure to patient
 Decreases scatter to operator
o Increase distance
o Use appropriate shielding