Patient Radiation Doses in Interventional Cardiology Procedures

Interventional cardiology procedures result in substantial patient radiation doses due to prolonged fluoroscopy time and radiographic exposure. The procedures that are most frequently performed are coronary angiography, percutaneous coronary interventions, diagnostic electrophysiology studies and radiofrequency catheter ablation. Patient radiation dose in these procedures can be assessed either by measurements on a series of patients in real clinical practice or measurements using patient-equivalent phantoms. In this article we review the derived doses at non-pediatric patients from 72 relevant studies published during the last 22 years in international scientific literature. Published results indicate that patient radiation doses vary widely among the different interventional cardiology procedures but also among equivalent studies. Discrepancies of the derived results are patient-, procedure-, physician-, and fluoroscopic equipmentrelated. Nevertheless, interventional cardiology procedures can subject patients to considerable radiation doses. Efforts to minimize patient exposure should always be undertaken.

[1]  S. McFadden,et al.  X-ray dose and associated risks from radiofrequency catheter ablation procedures. , 2002, The British journal of radiology.

[2]  W J Wajszczuk,et al.  Radiation exposure to patients undergoing percutaneous transluminal coronary angioplasty. , 1987, The American journal of cardiology.

[3]  E. Vañó,et al.  Dosimetric and radiation protection considerations based on some cases of patient skin injuries in interventional cardiology. , 1998, The British journal of radiology.

[4]  T. Kahn,et al.  [Conversion coefficients for estimation of effective dose to patients from dose area product during fluoroscopy x-ray examinations]. , 2007, RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin.

[5]  F. Mettler,et al.  Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. , 2001, AJR. American journal of roentgenology.

[6]  R. Coulden,et al.  Coronary angiography: an analysis of radiographic practice in the UK. , 1993, The British journal of radiology.

[7]  J. I. Ten,et al.  Skin dose and dose-area product values for interventional cardiology procedures. , 2001, The British journal of radiology.

[8]  B. Lindsay,et al.  Radiofrequency ablation of atrioventricular nodal reentrant tachycardia using a novel magnetic guidance system compared with a conventional approach. , 2006, Heart rhythm.

[9]  E. Weiss,et al.  Clinical considerations for allied professionals: radiation safety and protection in the electrophysiology lab. , 2007, Heart rhythm.

[10]  D L Ross,et al.  Risk to patients from radiation associated with radiofrequency ablation for supraventricular tachycardia. , 1998, Circulation.

[11]  K. Faulkner,et al.  Radiation doses and somatic risk to patients during cardiac radiological procedures. , 1986, The British journal of radiology.

[12]  H. Calkins,et al.  Predictors of fluoroscopy time and estimated radiation exposure during radiofrequency catheter ablation procedures. , 1998, The American journal of cardiology.

[13]  K. Faulkner,et al.  The impact of cardiology on the collective effective dose in the North of England. , 1997, The British journal of radiology.

[14]  D. Leaman,et al.  Operator radiation exposure during percutaneous transluminal coronary angioplasty. , 1984, Journal of the American College of Cardiology.

[15]  K. Faulkner,et al.  Patient dose values in a dedicated Greek cardiac centre. , 2003, The British journal of radiology.

[16]  G. Bernardi,et al.  Patient skin dosimetry in haemodynamic and electrophysiology interventional cardiology. , 2005, Radiation protection dosimetry.

[17]  J. Lampinen,et al.  Computing patient doses of X-ray examinations using a patient size- and sex-adjustable phantom. , 1997, The British journal of radiology.

[18]  W. Rutishauser,et al.  Radiation exposure during diagnostic catheterization and single- and double-vessel percutaneous transluminal coronary angioplasty. , 1987, The American journal of cardiology.

[19]  A. Trianni,et al.  Are new technologies always reducing patient doses in cardiac procedures? , 2005, Radiation protection dosimetry.

[20]  P. Schnyder,et al.  How to set up and apply reference levels in fluoroscopy at a national level , 2007, European Radiology.

[21]  Stephen Balter,et al.  ACCF/AHA/HRS/SCAI clinical competence statement on physician knowledge to optimize patient safety and image quality in fluoroscopically guided invasive cardiovascular procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task , 2005, Circulation.

[22]  R. Geise Efficacy and Radiation Safety in Interventional Radiology , 2002 .

[23]  E. Vañó,et al.  Patient dose values in interventional radiology. , 1995, The British journal of radiology.

[24]  O. Gefeller,et al.  Short communication: time of day influences patient radiation exposure from percutaneous cardiac interventions. , 2003, The British journal of radiology.

[25]  A. Dibié,et al.  Comparison of transradial vs. transfemoral approach in the treatment of acute myocardial infarction with primary angioplasty and abciximab , 2004, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[26]  V. Štísová Effective dose to patient during cardiac interventional procedures (Prague workplaces). , 2004, Radiation protection dosimetry.

[27]  Peter Wilde,et al.  Comparison of radiation doses from multislice computed tomography coronary angiography and conventional diagnostic angiography. , 2006, Journal of the American College of Cardiology.

[28]  G Panayiotakis,et al.  Patient radiation doses during cardiac catheterization procedures. , 1998, The British journal of radiology.

[29]  C. Martin,et al.  Effective doses for coronary angiography. , 1996, The British journal of radiology.

[30]  E. Efstathopoulos,et al.  Medical personnel and patient dosimetry during coronary angiography and intervention. , 2003, Physics in medicine and biology.

[31]  T. Kahn,et al.  Konversionsfaktoren zur Ermittlung der effektiven Dosis für Patienten aus dem Dosisflächenprodukt bei Röntgendurchleuchtungsuntersuchungen , 2007 .

[32]  E. Picano,et al.  Radiation dose exposure during cardiac and peripheral arteries catheterisation. , 2006, International journal of cardiology.

[33]  J. Paul,et al.  Strategies for reduction of radiation dose in cardiac multislice CT , 2007, European Radiology.

[34]  P. Karaiskos,et al.  Level of patient and operator dose in the largest cardiac centre in Greece. , 2008, Radiation protection dosimetry.

[35]  R. Padovani,et al.  Patient dosimetry approaches in interventional cardiology and literature dose data review. , 2005, Radiation protection dosimetry.

[36]  O. Gefeller,et al.  Standardization of Occupational Dose to Patient DAP Enables Reliable Assessment of Radiation-Protection Devices in Invasive Cardiology , 2003, RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin.

[37]  K. Faulkner,et al.  Patient and staff radiation dosimetry during cardiac electrophysiology studies and catheter ablation procedures: a comprehensive analysis. , 2006, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[38]  M. de Belder,et al.  Cardiac catheterisation: radiation doses and lifetime risk of malignancy , 2007, Heart.

[39]  T. Slovis,et al.  The ALARA concept in pediatric CR and DR: dose reduction in pediatric radiographic exams--a white paper conference. , 2005, AJR. American journal of roentgenology.

[40]  N. Adorante,et al.  Use of GAFCHROMIC XR type R films for skin-dose measurements in interventional radiology: Validation of a dosimetric procedure on a sample of patients undergone interventional cardiology. , 2006, Physica medica : PM : an international journal devoted to the applications of physics to medicine and biology : official journal of the Italian Association of Biomedical Physics.

[41]  E. Efstathopoulos,et al.  Patient dosimetry during coronary interventions: a comprehensive analysis. , 2004, American heart journal.

[42]  M. Kohzuki,et al.  Patient skin dose in cardiac interventional procedures: Conventional fluoroscopy versus pulsed fluoroscopy , 2007, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[43]  M. Zorzetto,et al.  Radiation exposure to patients and operators during diagnostic catheterization and coronary angioplasty. , 1997, Catheterization and cardiovascular diagnosis.

[44]  J. Persliden,et al.  Patient radiation exposure during coronary angiography and intervention. , 2000, Acta radiologica.

[45]  I H Kerr,et al.  Patient dose reduction in diagnostic radiology. , 1991, Clinical radiology.

[46]  E. Vañó,et al.  Comparison of a conventional and a flat-panel digital system in interventional cardiology procedures. , 2004, The British journal of radiology.

[47]  V. Tsapaki,et al.  Effective dose to a patient undergoing coronary angiography. , 2001, Radiation protection dosimetry.

[48]  M A Wondrow,et al.  Effect of pulsed progressive fluoroscopy on reduction of radiation dose in the cardiac catheterization laboratory. , 1990, Journal of the American College of Cardiology.

[49]  P J Eifel,et al.  Potential biological effects following high X-ray dose interventional procedures. , 1994, Journal of vascular and interventional radiology : JVIR.

[50]  W. Kübler,et al.  External beam radiation after stent implantation increases neointimal hyperplasia by augmenting smooth muscle cell proliferation and extracellular matrix accumulation. , 1999, Journal of the American College of Cardiology.

[51]  K. Bailey,et al.  Effect of external beam irradiation on neointimal hyperplasia after experimental coronary artery injury. , 1992, Journal of the American College of Cardiology.

[52]  J. Dahm,et al.  Significant reduction of radiation exposure to operator and staff during cardiac interventions by analysis of radiation leakage and improved lead shielding. , 2002, The American journal of cardiology.

[53]  M. Ricciardello,et al.  Evaluation of radiation dose and risk to the patient from coronary angiography. , 1998, Australian and New Zealand journal of medicine.

[54]  D. Trifunović,et al.  Patient dosimetry in interventional cardiology at the University Hospital of Osijek. , 2007, Radiation protection dosimetry.

[55]  岩崎 民子 SOURCES AND EFFECTS OF IONIZING RADIATION : United Nations Scientific Committee on the Effects of Atomic Radiation UNSCEAR 2000 Report to the General Assembly, with Scientific Annexes , 2002 .

[56]  R. Nowotny,et al.  A pilot study exploring the possibility of establishing guidance levels in x-ray directed interventional procedures. , 2008, Medical physics.

[57]  H Thierens,et al.  A large-scale multicentre study in Belgium of dose area product values and effective doses in interventional cardiology using contemporary X-ray equipment. , 2007, Radiation protection dosimetry.

[58]  J. Dahm,et al.  RADIATION DOSE REDUCTION IN INVASIVE CARDIOLOGY BY RESTRICTION TO ADEQUATE INSTEAD OF OPTIMIZED PICTURE QUALITY , 2003, Health physics.

[59]  M A Wondrow,et al.  Real-time measurement of radiation exposure to patients during diagnostic coronary angiography and percutaneous interventional procedures. , 1999, Journal of the American College of Cardiology.

[60]  M. Bell,et al.  Does the use of new intracoronary interventional devices prolong radiation exposure in the cardiac catheterization laboratory? , 1994, Journal of the American College of Cardiology.

[61]  G. Panayiotakis,et al.  Radiation exposure of patients and coronary arteries in the stent era: A prospective study , 2000, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[62]  K. Empen,et al.  Radiation Exposure to Patients Undergoing Percutaneous Coronary Interventions , 2004, Herz.

[63]  M. Walsh,et al.  Radiation Safety in the Practice of Cardiology WRITING GROUP MEMBERS , 1998 .

[64]  Eugenio Picano,et al.  Informed consent and communication of risk from radiological and nuclear medicine examinations: how to escape from a communication inferno , 2004, BMJ : British Medical Journal.

[65]  J. Dahm,et al.  Effective techniques for reduction of radiation dosage to patients undergoing invasive cardiac procedures. , 2003, The British journal of radiology.

[66]  J. Dahm,et al.  Radiation exposure benefit of a lead cap in invasive cardiology , 2003, Heart.

[67]  P. Tornvall,et al.  Skin dose alarm levels in cardiac angiography procedures: is a single DAP value sufficient? , 2005, The British journal of radiology.

[68]  S. Achenbach,et al.  Current Role of Cardiac Computed Tomography , 2007, Herz Kardiovaskuläre Erkrankungen.

[69]  Stephen Balter,et al.  Methods for measuring fluoroscopic skin dose , 2006, Pediatric Radiology.

[70]  N. Theocharopoulos,et al.  Accurate Assessment of Patient Effective Radiation Dose and Associated Detriment Risk From Radiofrequency Catheter Ablation Procedures , 2001, Circulation.

[71]  E. Vañó,et al.  Clinical and technical determinants of the complexity of percutaneous transluminal coronary angioplasty procedures: Analysis in relation to radiation exposure parameters , 2000, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[72]  R D Safian,et al.  Radiation exposure to patients undergoing diagnostic and interventional cardiac catheterization procedures. , 1997, Catheterization and cardiovascular diagnosis.

[73]  J. Debatin,et al.  Radiation exposure during cardiac CT: effective doses at multi-detector row CT and electron-beam CT. , 2003, Radiology.

[74]  Masayuki Zuguchi,et al.  Relationship between fluoroscopic time, dose-area product, body weight, and maximum radiation skin dose in cardiac interventional procedures. , 2006, AJR. American journal of roentgenology.

[75]  C. Hamm,et al.  Radiation dose exposure in multislice computed tomography of the coronaries in comparison with conventional coronary angiography. , 2008, International journal of cardiology.

[76]  E Vañó,et al.  Patient dose related to the complexity of interventional cardiology procedures. , 2001, Radiation protection dosimetry.

[77]  Virginia Tsapaki,et al.  Dose performance evaluation of a charge coupled device and a flat-panel digital fluoroscopy system recently installed in an interventional cardiology laboratory. , 2004, Radiation protection dosimetry.

[78]  Randall C. Thompson,et al.  Radiation Dose to Patients From Cardiac Diagnostic Imaging , 2007, Circulation.

[80]  G. Giannoglou,et al.  Radiation doses to patients undergoing coronary angiography and percutaneous transluminal coronary angioplasty. , 2003, Radiation protection dosimetry.

[81]  R. Sievert,et al.  Book Reviews : Recommendations of the International Commission on Radiological Protection (as amended 1959 and revised 1962). I.C.R.P. Publication 6. 70 pp. PERGAMON PRESS. Oxford, London and New York, 1964. £1 5s. 0d. [TB/54] , 1964 .

[82]  A. Yue,et al.  Radiation Peak Skin Dose to Risk Stratify Electrophysiological Procedures for Deterministic Skin Damage , 2004, The International Journal of Cardiovascular Imaging.

[83]  J. Langberg,et al.  Radiation Exposure During Radiofrequency Catheter Ablation of Accessory Atrioventricular Connections , 1991, Circulation.

[84]  F Verhaegen,et al.  Correlation of patient skin doses in cardiac interventional radiology with dose-area product. , 2000, The British journal of radiology.

[85]  B. Lindsay,et al.  Radiation exposure to patients and medical personnel during radiofrequency catheter ablation for supraventricular tachycardia. , 1992, The American journal of cardiology.

[86]  J. Wade Estimation of effective dose in diagnostic radiology from entrance surface dose and dose-area product measurements. , 1998, The British journal of radiology.

[87]  M. Bell,et al.  Balloon angioplasty of chronic total coronary artery occlusions: what does it cost in radiation exposure, time, and materials? , 1992, Catheterization and cardiovascular diagnosis.

[88]  A. G. Brennan,et al.  Factors affecting patient radiation exposure during routine coronary angiography in a tertiary referral centre. , 2000, The British journal of radiology.

[89]  Amy Berrington de González,et al.  Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries , 2004, The Lancet.

[90]  E. Picano,et al.  Sustainability in the cardiac cath lab , 2007, The International Journal of Cardiovascular Imaging.

[91]  P. C. Johns,et al.  Radiation risk to patients from percutaneous transluminal coronary angioplasty. , 1993, Journal of the American College of Cardiology.

[92]  R. Jabara,et al.  Comparison of multidetector 64-slice computed tomographic angiography to coronary angiography to assess the patency of coronary artery bypass grafts. , 2007, The American journal of cardiology.

[93]  A. Cowen,et al.  X‐Ray Dose Reduction in Fluoroscopically Guided Electrophysiology Procedures , 2006, Pacing and clinical electrophysiology : PACE.

[94]  E Gaxiola,et al.  Real-time measurement of skin radiation during cardiac catheterization. , 1998, Catheterization and cardiovascular diagnosis.

[95]  E. Vañó,et al.  Maximum skin dose assessment in interventional cardiology: Results in three different European hospitals , 2003 .

[96]  M. Walsh,et al.  ACC expert consensus document. Radiation safety in the practice of cardiology. American College of Cardiology. , 1998, Journal of the American College of Cardiology.