Valuckiene Z, et al. Ionizing Radiation Exposure In Interventional Cardiology: Current Radiation Protection Practice Of Invasive Cardiology Operators In Lithuania. J Radiol Prot. 2016 Sep;36(3):695-708.

Our purpose was to assess the utilization and effectiveness of radiation protection and optimization techniques among interventional cardiologists in Lithuania. Thirty one (68.9%) out of 45 Lithuanian interventional cardiologists participated in the survey. Protective aprons were universally used, but not the thyroid collars; 35.5% (n  =  11) operators use protective eyewear and 12.9% (n  =  4) wear radio-protective caps; 83.9% (n  =  26) use overhanging shields, 58.1% (n  =  18)—portable barriers; 12.9% (n  =  4)—abdominal patient’s shielding; 35.5% (n  =  11) work at a high table position; 87.1% (n  =  27) keep an image intensifier/receiver close to the patient; 58.1% (n  =  18) reduce the fluoroscopy FR; 6.5% (n  =  2) reduce the fluoro image detail resolution; 83.9% (n  =  26) use a ‘store fluoro’ option; 41.9% (N  =  13) reduce magnification for catheter transit; 51.6% (n  =  16) limit image magnification; and 35.5% (n  =  11) use image collimation. Median effective patient doses were significantly lower with x-ray optimization techniques in both diagnostic and therapeutic interventions.

Uthoff H, Benenati MJ, Katzen BT, et al. Lightweight Bilayer Barium Sulfate–Bismuth Oxide Composite Thyroid Collars For Superior Radiation Protection In Fluoroscopy-Guided Interventions: A Prospective Randomized Controlled Trial. Radiology. 2014 Feb;270(2): 601-606.

To test whether newer bilayer barium sulfate–bismuth oxide composite (XPF) thyroid collars (TCs) provide superior radiation protection and comfort during fluoroscopy-guided interventions compared with standard 0.5-mm lead-equivalent TCs. Patient (height, weight, and body mass index) and procedure (type and duration of intervention, operator, fluoroscopy time, dose-area product, and air kerma) data did not differ between the XPF and standard groups. Comfort was assessed in all 256 measurements. On average, the XPF TCs were 47.6% lighter than the standard TCs (mean weight ± standard deviation, 133 g ± 14 vs 254 g ± 44; P < .001) and had a significantly higher likelihood of a high level of comfort (visual analog scale >90; odds ratio, 7.6; 95% confidence interval: 3.0, 19.2; P < .001). Radiation dose reduction provided by the TCs was analyzed in 117 data sets (60 in the XPF group, 57 in the standard group). The mean radiation dose reductions (ie, radiation protection) provided by XPF and standard TCs were 90.7% and 72.4%, with an adjusted mean difference of 17.9% (95% confidence interval: 7.7%, 28.1%; P < .001) favoring XPF.

Üreyen CM, Cosansu K, Vural MG, et al. Is trans-radial approach related to an increased risk of radiation exposure in patients who underwent diagnostic coronary angiography or percutaneous coronary intervention? (The SAKARYA study). Anatol J Cardiol. 2019 Jun;22(1):5-12.

It is still debatable whether diagnostic coronary angiography (CA) or percutaneous coronary interventions (PCIs) increase radiation exposure when performed via radial approach as compared to femoral approach. This question was investigated in this study by comparison of dose-area product (DAP), reference air kerma (RAK), and fluoroscopy time (FT) among radial and femoral approaches. After adjusting these clinical confounders, there was no significant difference with regard to DAP, RAK, and FT between femoral and radial access in Group I. In contrast, PCI via radial access was significantly associated with increased DAP, RAK, and FT in Groups II and III.

Ubeda C, Vano E, Miranda P, et al. Patient And Staff Doses In Paediatric Interventional Cardiology Derived From Experimental Measurements With Phantoms. Phys Med. 2016 Jan;32(1):176-81.

The aim of this paper was to determine experimentally the entrance surface air kerma (ESAK) and kerma-area product (KAP) levels to patients and scatter doses at the cardiologist’s eyes during paediatric interventional cardiology (IC) procedures for Chile, on the basis of measurements taken from X-ray systems characterization for different thicknesses of polymethyl methacrylate, together with the average values of fluoroscopy time and number of cine frames for ten paediatric IC procedures.

Tenorio ER, Oderich GS, Sandri GA, et al. Impact Of Onlay Fusion And Cone Beam Computed Tomography On Radiation Exposure And Technical Assessment Of Fenestrated-Branched Endovascular Aortic Repair. J Vasc Surg. 2019 Apr;69(4):1045-1058.e3.

The objective of this study was to analyze the impact of advanced imaging applications and cone beam computed tomography (CBCT) on radiation exposure of the patient and operator and detection of technical problems during fenestrated-branched endovascular aortic repair (F-BEVAR) for treatment of pararenal aneurysms and thoracoabdominal aortic aneurysms (TAAAs). Procedures performed with onlay fusion/CBCT had significantly (P < .05) higher technical success (99.4% vs 98.8%) and lower contrast material volume (155 ± 58 mL vs 172 ± 80 mL), fluoroscopy time (83 ± 34 minutes vs 94 ± 49 minutes), and cumulative air kerma (2561 ± 1920 mGy vs 3767 ± 2307 mGy). Despite higher case volume and increasing complexity during the experience, operator effective dose decreased to 9 ± 4 × 10−2 mSv/case with system 3 compared with 26 ± 3 × 10−2 mSv/case with system 1 and 20 ± 2 × 10−2 mSv/case with system 2 (P = .001).


The present study aimed to determine doses delivered to the eye lenses of surgeons while using the inverted-C-arm technique and the protective effect of leaded spectacles during orthopedic surgery. The kerma in air was measured at five positions on leaded glasses positioned near the eye lens and on the neck using small optically stimulated luminescence (OSL) dosemeters. The lens equivalent dose was also measured at the neck using an OSL dosemeter. The maximum equivalent dose to the eye lens and the maximum kerma were 0.8 mSv/month and 0.66 mGy/month, respectively. The leaded glasses reduced the exposure by ~60%. Even if the surgeons are exposed to the maximum dose of X-ray radiation for 5 years, the equivalent doses to the eye lens will not exceed the present limit recommended by the ICRP.

Sun Z, AbAziz A, Yusof AKM. Radiation-Induced Noncancer Risks In Interventional Cardiology: Optimisation Of Procedures And Staff And Patient Dose Reduction. Biomed Res Int. 2013;2013:976962.

Concerns about ionizing radiation during interventional cardiology have been increased in recent years as a result of rapid growth in interventional procedure volumes and the high radiation doses associated with some procedures. Noncancer radiation risks to cardiologists and medical staff in terms of radiation-induced cataracts and skin injuries for patients appear clear potential consequences of interventional cardiology procedures, while radiation-induced potential risk of developing cardiovascular effects remains less clear. This paper provides an overview of the evidence-based reviews of concerns about noncancer risks of radiation exposure in interventional cardiology. Strategies commonly undertaken to reduce radiation doses to both medical staff and patients during interventional cardiology procedures are discussed; optimisation of interventional cardiology procedures is highlighted.

Stewart FA, Akleyev AV, Hauer-Jensen M, et al. ICRP PUBLICATION 118: ICRP Statement on Tissue Reactions and Early and Late Effects of Radiation in Normal Tissues and Organs — Threshold Doses for Tissue Reactions in a Radiation Protection Context. Ann ICRP. 2012 Feb;41(1-2):1–322.

This report provides a review of early and late effects in normal tissue and organs with respect to radiation protection. The organ systems comprise the haematopoietic, immune, reproductive, circulatory, respiratory, musculoskeletal, endocrine, and nervous systems; the digestive and urinary tracts; the skin;and the eye.

Stangenberg L, Shuja F, van der Bom IMJ, et al. Modern Fixed Imaging Systems Reduce Radiation Exposure To Patients And Providers. Vasc Endovasc Surg. 2018 Jan;52(1):52-58.

The present study explores another approach to reduce radiation exposure. Advanced imaging technology, which includes both hardware and software modifications aimed at noise reduction, can reduce the patient entrance dose and subsequently scatter radiation without compromising image quality.11 In this study, we evaluate 1 such technology (Philips ClarityIQ; Philips Healthcare, Best, the Netherlands) before and after an upgrade of the fixed cardiovascular imaging system at our institution and compared its effect on radiation exposure during EVAR or superficial femoral artery (SFA) interventions for patients and providers.

Smilowitz NR, Balter S, Weisz G. Occupational hazards of interventional cardiology. Cardiovasc Revasc Med. 2013 Jul-Aug;14(4):223-8.

Complex catheter-based interventions and rising case volumes confer occupational risks to interventional cardiologists. Despite advances in technology, modern interventional procedures are performed in a manner remarkably similar to the techniques pioneered decades ago. Percutaneous interventions are associated with operator orthopedic injuries, exposures to blood borne pathogens, and the effects of chronic radiation exposure from fluoroscopy. This review highlights the occupational hazards of interventional procedures and provides a glimpse at the technologies and techniques that may reduce risks to operators in the catheterization laboratory.