A simplified model of a C-Arm fluoroscopy

unit to calculate dose distributions of

interventional cardiology procedures
1st GEANT4 Australian School and User Workshop 2011, Wollongong

Sacha Refshauge, Iwan Cornelius, Christian Langton

Discipline of Physics, Faculty of Science and Technology, QUT
Institute for Health and Biomedical Innovation, QUT
 Interventional Cardiology and C-Arm Unit
• Interventional Radiology
o Uses images from the C-Arm fluoroscopy unit to
guide minimally invasive interventional procedures.
Usually done with narrow tubes called catheters,
controlled by physician. The catheters location can be
determined from the images.
• C-Arm unit
o Used for real-time imaging of a patient. Typically used
for interventional procedures such as catheter
ablation of cardiac arrhythmias and pacemaker
implants.
o Contains an X-ray tube (source) and image intensifier,
positioned opposite. Capable of moving in to various
configurations to improve imaging and reduce
radiation scatter.
• Radiation awareness in interventional
radiology, a key issue:
o Very nature requires physician to stand beside
patient, receiving substantial doses.
o Dose up to 0.8mSv per procedure has been recorded
to the eye lense by Urboniene et al. Without proper
awareness and protection this can lead to cataracts.
o Unlike patient, medical staff are exposed to this dose
on a daily basis Typical C-Arm unit,
o Fluoroscopy-guided interventional procedures Siemens 2003.
becoming more common
“Doses to eyes and extremities of medical staff during interventional
radiology procedures”,Urboniene et al. 2011
 Radiation Protection and Awareness
Training for Physicians
• Radiation awareness training
essential:
o Without solid understanding of
radiation levels and how C-Arm
configuration affects this, physician
essentially ‘blind’
o Training is mandatory
• Radiation awareness can be
improved. Currently involves:
o Passive detectors that only reveal dose
at a single point.
o Expensive C-Arm units running to
show real-time dose in systems such
as DoseAware.
o Reading lengthy books that explain
the theory and show hypothetical
radiation maps under various
configurations.
DoseAware system: “Staff Radiation Doses in a Real-Time Display Inside the Angiography Room”, Sanchez et al.
2009
“Occupational radiation doses in interventional cardiology: a 15-year follow up”, Vano et al. 2006
 Augmented Reality
• Augmented reality allows for
virtual information to be
overlaid on to a contextual
scene.
• Medical augmented reality
solutions are becoming more
common (Samset et al).
• This technology could aid in
the training process by
immediately showing how the
changes made affect the dose
distribution in the catheter
laboratory.

“Augmented Reality in Surgical Procedures”, Samset et al. 2008

 Aim
• Improve radiation training procedures by creating a training
tool that utilises cutting-edge augmented reality
technology. A focus on being:
o Robust: to meet standards expected of a training tool
o Interactive: to increase involvement and learning
o Graphical: to aid learning
o Enthralling: to pique interest
o Realistic: to allow concentration on the core information
• Create a model of a C-Arm fluoroscopy unit (and
surrounding objects) in GEANT4 to get a 2D dose map of
the room under different configurations.
 Approach / Plan
Develop a method whereby a trainee can observe the hypothetical dose in the
room in a non-obtrusive way. As part of the training course, specific aspects of the
C-Arm configuration are altered, changing the displayed isodose lines accordingly.

An important aspect of this project is the eventual augmented reality output via a
wall-mounted display. The method in which this is done is demonstrated in the
flow-chart below.

Camera records video Sends video stream to

stream PC

PC loads dose
visualisation simulated PC detects
by GEANT4, depending marker/feature
on configuration

PC overlays
visualisation on video Result is output to
stream display
AR Training mock-up involving a
wall-mounted display
 GEANT4 C-Arm Simulation: Geometry
• Simplified model of C-Arm unit in Object Material Shape Dimensions (cm)
GEANT4.
World Air Cube 360 x 360 x 360
• Scoring volumes are at 100 cm from the Phantom Water Elliptical 174.8 (length) x 32
floor. Tube (wide) x 20 (deep)
Image Lead Cylinder 23 (length) x 11.5
Intensifier (radius)
Source Lead Cube 15 x 15 x 15
Floor Lead Rectangular 360x360x2
Shielding Cuboid

Scoring SD Cube 1x1x1

Volumes
(129600)
 Primary Beam / Cuts
Primary Beam
Parameters Value

Particle Gamma

Energy 200keV

Initial Position 60cm from patient

Initial Direction Towards image intensifier/patient (RAO, LAO, AP)

Range Cuts
Particle Cut Length Energy Threshold in Water

Gamma 100 um 1.11 keV

Electron 10 cm 23.31 MeV

Positron 1 mm 342.55 KeV

Proton 1 cm 1 MeV
Method for Dose Calculation
 Result
• Dose map generated
from 5 million
primary particles
• Physician waist of
32x20 cm oval
overlaid on to map.
 Result

Thresholds:
77% - 85%
60% - 65%
50% - 53%

Raw data with threshold levels Smoothed data with threshold levels

Smoothed for better representation on the augmented reality display. Appears as less
ambiguity.
 AR Display Result
RAO 40 LAO 40

AP
 Study of Effect of Patient Obesity on
Physician Dose
• Started with smaller cylindrical phantom. Testing showed significant changes with different sized
phantom.
• Paper by Vano et al suggests up to 14x difference in scatter from patient thickness. This led to
further testing involving changing patient height and thickness.
• Document by Ashwell et al demonstrates waist circumference to height ratio (W/Ht) and how it
can be used as a weight indicator. This led to the use of weight categories and ranges.
• Performed two tests to observe how patient geometry affects physician dose. The first considers
using the average adult height obtained from ABS and varying the waist circumference to height
ratio (W/Ht). Second considers maintaining a healthy W/Ht ratio and varying height.
Height

Waist circumference
“How Australians Measure Up”, ABS. 1995
“Influence of patient thickness and operation modes on occupational and patient radiation doses in interventional cardiology”, Vano et
al. 2005
“Ratio of waist circumference to height is strong predictor of intra-abdominal fat”, Ashwell et al. 1996
 Results
Physician Waist Dose vs Phantom Waist Circumference to Height
Ratios; Constant Height
1.2

Obese
1
Physician Waist Dose per primary (pGy)

Overweight
0.8
Male

Healthy Obese Female

0.6
Thin Overweight
Very Thin
0.4 Healthy
Thin

Very Thin
0.2

0
0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65
Waist Circumference to Height Ratio of Phantom
 Results
Dose at Physician Waist vs Phantom Height; 0.48 W/Ht
0.8

0.7
Physician Waist Dose per primary (pGy)

0.6

0.5

0.4

0.3

0.2

0.1

0
100 110 120 130 140 150 160 170 180 190 200

Height of Phantom (cm)

 Conclusion
• Seen where current training tools are lacking
and how they can be improved.
• Shown usefulness of an augmented reality
solution.
• Looked at how patient thickness affects dose.
This can be integrated in to the proposed
training tool.
 Future Plans
• More detailed C-Arm and patient
geometry for GEANT4. Allows for
more accurate results. Pending
technical drawings from Philips.
• Verify the simulation results
experimentally using DoseAware or
passive detectors (TLDs).
• Addition of a 3D camera to retrieve
depth map of scene. This will allow
visualised isodose lines to be
occluded by objects in the room.
• Multiple cameras. This will prevent
the marker or feature from being
occluded by the physician or other
people present in the room.