Occupational Radiation Exposure During Endovascular Aortic Repair

Sailer, Anna M.; Schurink, Geert Willem H.; Bol, Martine E.; Haan, Michiel W. de; Zwam, Willem H. van; Wildberger, Joachim E.; Jeukens, Cécile R. L. P. N.

doi:10.1007/s00270-014-1025-8

Cited by 37 publications

(50 citation statements)

References 25 publications

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“…These principles include wearing a dosimeter at all times, with cumulative doses monitored regularly and leveraged use of real-time dosimetery where possible. 44,45 Other principles include lowering the rate of fluoroscopy where applicable, minimizing the use of cinefluorography (which produces 10 times more radiation compared with standard fluoroscopy), using collimation, and maximizing the distance between the operator and x-ray source, remembering that as distance doubles exposure is reduced by a factor of 4. 46 Finally, closely monitoring the orientation and angulation of the x-ray source, particularly avoiding left anterior oblique projection, which exposes the operating team to the highest amount of scatter radiation, is key for minimizing the absorbed dose.…”

mentioning

confidence: 99%

Radiation Induced DNA Damage in Operators Performing Endovascular Aortic Repair

El-Sayed¹,

Patel²,

Cho³

et al. 2018

Journal of Vascular Surgery

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BACKGROUND:Radiation exposure during fluoroscopically guided interventions such as endovascular aortic repair (EVAR) is a growing concern for operators. This study aimed to measure DNA damage/repair markers in operators perfoming EVAR. METHODS:Expression of the DNA damage/repair marker, γ-H2AX and DNA damage response marker, phosphorylated ataxia telangiectasia mutated (pATM), were quantified in circulating lymphocytes in operators during the peri-operative period of endovascular (infrarenal, branched, and fenestrated) and open aortic repair using flow cytometry. These markers were separately measured in the same operators but this time wearing leg lead shielding in addition to upper body protection and compared with those operating with unprotected legs. Susceptibility to radiation damage was determined by irradiating operators' blood in vitro.RESULTS: γ-H2AX and pATM levels increased significantly in operators immediately after branched endovascular aortic repair/fenestrated endovascular aortic repair (P<0.0003 for both). Only pATM levels increased after infrarenal endovascular aortic repair (P<0.04). Expression of both markers fell to baseline in operators after 24 hours (P<0.003 for both). There was no change in γ-H2AX or pATM expression after open repair. Leg protection abrogated γ-H2AX and pATM response after branched endovascular aortic repair/fenestrated endovascular aortic repair. The expression of γ-H2AX varied significantly when operators' blood was exposed to the same radiation dose in vitro (P<0.0001).CONCLUSIONS: This is the first study to detect an acute DNA damage response in operators performing fluoroscopically guided aortic procedures and highlights the protective effect of leg shielding. Defining the relationship between this response and cancer risk may better inform safe levels of chronic low-dose radiation exposure. 1,2 The growing number and complexity of procedures means that interventionists are exposed to higher amounts of radiation, a subject that is becoming increasingly topical. Radiation-Induced3-7 A recently published 15-year follow-up study of the EVAR trial, comparing endovascular and open aortic repair, reported an increased incidence of malignancy in patients treated by EVAR. 8 There is, rightly so, a significant focus currently on reducing the patients' exposure to radiation, but mounting evidence suggests that recurrent lowdose exposure to the practitioner is equally as important. Robust data collection to assess the risks posed to the interventionist is in its infancy, but a number of studies suggest a link to adverse health effects, including a higher risk of posterior subcapsular lens changes and malignancy.9-11 One recent study found a higher incidence of malignancy, including brain cancer, breast cancer, and melanoma, in interventionists who performed fluoroscopically guided procedures compared with those who had never performed these.12 A better understanding of the hazards of occupational radiation exposure requires sensitive tools to measure exposure at an individu...

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mentioning

confidence: 99%

Radiation Induced DNA Damage in Operators Performing Endovascular Aortic Repair

El-Sayed¹,

Patel²,

Cho³

et al. 2018

Journal of Vascular Surgery

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“…Although the DR AK is the most reliable and is independent of the collimation for DR analysis, DAP better correlates with the operator radiation dose and the total absorbed by the patients. 13 …”

Section: Discussionmentioning

confidence: 99%

“…Thus, the current DRs were not corrected for tissue radiosensitivity, age, or sex and do not represent the actual stochastic parameter Sieverts, and both DAP and AK are direct outputs and do not include the backscatter factor. 13 However, understanding the multifactorial effect of different radiation predictors on the direct measured DR can provide an insight as to how the final cumulative radiation dose for each patient and C-arm configuration is created.…”

Section: Discussionmentioning

confidence: 99%

Radiation Awareness for Endovascular Abdominal Aortic Aneurysm Repair in the Hybrid Operating Room. An Instant Patient Risk Chart for Daily Practice

et al. 2017

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Purpose: To determine which patient and C-arm characteristics are the strongest predictors of intraoperative patient radiation dose rates (DRs) during endovascular aneurysm repair (EVAR) procedures and create a patient risk chart. Methods: A retrospective analysis was performed of 74 EVAR procedures, including 16,889 X-ray runs using fixed C-arm imaging equipment. Four multivariate log-linear mixed models (with patient as a random effect) were constructed. Mean air kerma DR (DRAK, mGy/s) and the mean dose area product DR (DRDAP, mGycm2/s) were the outcome variables utilized for fluoroscopy as differentiated from digital subtraction angiography (DSA). These models were used to predict the maximum radiation duration allowed before a 2-Gy skin threshold (for DRAK) or a 500-Gycm2 threshold (for DRDAP) was reached. Results: The strongest predictor of DRAK and DRDAP for fluoroscopy imaging was the radiation protocol, with an increase of 200% when changing from “low” to “medium” and 410% from “low” to “normal.” The strongest predictors of DRAK and DRDAP for DSA were C-arm angulation, with an increase of 47% per 30° of angulation, and body mass index (BMI), with an increase of 58% for every 5-point increase in BMI. Based on these models, a patient with a BMI of 30 kg/m2, combined with 45° of rotation and a field size of 800 cm2 in the medium fluoroscopy protocol has a predicted DRAK of 0.39 mGy/s (or 85.5 minutes until the 2-Gy skin threshold is reached). While using comparable settings but switching the acquisition to a DSA with a “2 frames per second” protocol, the predicted DRAK will be 6.6 mGy/s (or 5.0 minutes until the 2-Gy threshold is reached). Conclusion: X-ray radiation DRs are constantly fluctuating during and between patients based on BMI, the protocols, C-arm position, and the image acquisitions that are used. An instant patient risk chart visualizes these radiation dose fluctuations and provides an overview of the expected duration of X-ray radiation, which can be used to predict when follow-up dose thresholds are reached during abdominal endovascular procedures.

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“…The authors also identified that personal behavior within the fluoroscopic suite alters dose considerably. Depending on their responsibilities during the procedure nurses may have greater opportunity of deliberately increasing their distance from the patient resulting in a decrease in dose …”

Section: Methodsmentioning

confidence: 99%

“…There has been increasing concern over recent epidemiological evidence suggesting that radiation‐induced cataracts can occur at much lower doses than previously assumed . Staff involved in fluoroscopic CV procedures have demonstrated an elevated incidence of radiation‐associated lens changes . In response, in 2011 the ICRP recommended reducing the occupational dose limit for the eye from 150 mSv (millisievert) to 20 mSv per year .…”

Section: Introductionmentioning

confidence: 99%

Occupational radiation exposure to nursing staff during cardiovascular fluoroscopic procedures: A review of the literature

Wilson‐Stewart

Shanahan

Fontanarosa

et al. 2018

J Applied Clin Med Phys

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Fluoroscopy is a method used to provide real time x‐ray imaging of the body during medical procedures to assist with medical diagnosis and treatment. Recent technological advances have seen an increase in the number of fluoroscopic examinations being performed. Nurses are an integral part of the team conducting fluoroscopic investigations and are often located close to the patient resulting in an occupational exposure to radiation. The purpose of this review was to examine recent literature which investigates occupational exposure received by nursing staff during cardiovascular fluoroscopic procedures. Articles published between 2011 and 2017 have been searched and comprehensively reviewed on the referenced medical search engines. Twenty‐four relevant studies were identified among which seventeen investigated nursing dose comparative to operator dose. Seven researched the effectiveness of interventions in reducing occupational exposure to nursing staff. While doctors remain at the highest risk of exposure during procedures, evidence suggests that nursing staff may be at risk of exceeding recommended dose limits in some circumstances. There is also evidence of inconsistent use of personal protection such as lead glasses and skull caps by nursing staff to minimize radiation exposure. Conclusions: The review has highlighted a lack of published literature focussing on dose to nurses. There is a need for future research in this area to inform nursing staff of factors which may contribute to high occupational doses and of methods for minimizing the risk of exposure, particularly regarding the importance of utilizing radiation protective equipment.

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Occupational Radiation Exposure During Endovascular Aortic Repair

Abstract: Average FO dose was a factor four higher than SO dose. Predictors for high personal doses are procedural DAP, iodinated contrast volume, and left-anterior C-arm projections greater than 60°.

Cited by 37 publications

References 25 publications

Radiation Induced DNA Damage in Operators Performing Endovascular Aortic Repair

Radiation Induced DNA Damage in Operators Performing Endovascular Aortic Repair

Radiation Awareness for Endovascular Abdominal Aortic Aneurysm Repair in the Hybrid Operating Room. An Instant Patient Risk Chart for Daily Practice

Occupational radiation exposure to nursing staff during cardiovascular fluoroscopic procedures: A review of the literature

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