Radiation Protection of Patients

and Staff in Interventional

Procedures

Madan M Rehani, Ph.D.

International Atomic Energy Agency
M.Rehani@iaea.org
Open surgery Interventional Procedure
 Interventional Procedures

• Avoid open surgery

• Save lives
• Reduce morbidity
• Reduce hospital stay, even outdoor
• Reduce cost

More by other speakers in this session

 Specialists performing interventions
Besides interventional radiologists (IR),
either alone or with help of IR
• Cardiologists
• Electro-physiologists (EPs)
• Vascular surgeons
• Orthopedic surgeons
• Urologists
• Gastroenterologists
• ….many more……
 Interventional Procedures
Group I:
• Interventional Cardiologists, Electro-
physiologists, Interventional radiologists
Group II:
• Vascular surgeons
Group III:
• Orthopedic surgeons, Urologists,
Gastroenterologists, Anesthetists…..
(Unofficial classification with overlap of
functions)
 What are radiation risks?

• Are they like cancers

which are hypothetical,
pseudo-science (as per
some ….)
Cardiac Interventions

9
 Where do the injuries occur in interventional
procedures?
•Severe injuries have occurred from the neck to the buttocks
•Sometimes anteriorly &
•On the side of torso

non-cardiac procedures
10
 Woh!!!

• They must be rare but

exaggerated by
radiation protection
people!!!
 Current situation

A case of radiation induced skin

injury is filed in US courts every 4 to
6 weeks currently from
interventional procedures
≈10 cases/year

12
• US is a unique
country. We should
not be scaring people
in developing countries
Rehani & Srimahachota 2011
Malaysia
American J Roentgenology Aug. 2009
≥2000/room/yr
About 30% of participating countries have shown a 100%
increase in workload in 3 years.
 Children
The number of paediatric patients compared with
adults shows that in
• 2 countries the paediatric workload is in the
range of 40–50% of adult procedures,
• 7 countries have 5–17%, and in the remaining
• 11 countries it is less than 5%.
• Children: Effective dose and DAP
Stochastic risk in Children & Infants
 Estimates of likely skin injuries

• 3.6 billion X ray examinations globally

• 1 % interventional= 36 million
• 1 in 10,000 skin injury= 3600/year
(Conservative estimates)
 Email received by IAEA on 21st Oct.08
Requesting your help please!

I have a chronic radiation burn which has been ulcerated for months!
(Pathology report)

Causes:
• Angioplasty procedure that lasted 3.5 hours, 2 stents placed in lad which
was 100% blocked.
• Couple of weeks later the burn came out on by left lower back about the
size of a deck of cards.
• Procedure was done by cardiologist on Jan. 31, 2008
I have been suffering with this for 9 months and still it does not seem this is
going to heal. It has shrunk but is not relieving me in pain.
Issues:
• I have been to my cardiologist, 2 dermatologists none of which had ever
seen or knew how to treat this burn.
• I am now at a plastic surgeon
From: Louis K Wagner [mailto:Louis.K.Wagner@uth.tmc.edu]
Sent: Friday, 24 June 2005 15:56
To: REHANI, Madan Mohan
Subject: Vienna conference
I just received an e-mail from a patient in the US who underwent angioplasty and
developed an ulcerating injury. The patient’s physician misdiagnosed the
injury as a staph infection. When the wound worsened she went to the ER and
the ER physician diagnosed it as a burn of unknown origin. The patient then
went to the web and found reports on our meeting in Vienna last year. On the
basis of the descriptions of the injuries and their progression she was able to
diagnose the etiology as due to her angioplasty. Neither her cardiologist nor the
radiologists at the hospital were aware that such a thing could occur and were
surprised when she brought the evidence to them. This was an interesting case
report that shows that our message is slowly getting broader exposure.
Unfortunately, the patients seem to be the ones who are teaching the
physicians.
---lkw
Louis K. Wagner, Ph.D., FACR, FAAPM
The University of Texas Medical School at Houston
this situation
 Agony associated with such patients

• Topical treatment ineffective

• Exhausted insurance limits
• Cannot lie down on back
• Cannot be at work for months
• Pain
• Skin grafting
 Can one say this?

The benefit to patient was

higher than radiation risk?
Risk, but real occurrence
At least ALL
interventional procedures
are justified, so there
should be no issue of
Inappropriate procedures
CONCLUSIONS:
• In this large contemporary US cohort, nearly
all acute PCIs were classified as appropriate.
For nonacute indications, however, 12% were
classified as inappropriate, with substantial
variation across hospitals.
In a complete cohort of PCIs
performed in Washington state,
• 1% of PCIs for acute indications and
• 17% of PCIs for nonacute indications
were classified as inappropriate.
In most countries, procedures outside
radiology
 Interventional Cardiologists

Radiation Protection (RP) survey Vienna 2004

(25 countries)

Is this 1st time you are attending a

structured program on RP. Ans. Yes
88%

Any cardiologists conference you

attended where there was lecture on RP.
85%
Ans. No

Do you measure radiation dose to 96%

patient. Ans. No
 Interventional Cardiologists
Radiation Protection Vienna 2004 Singapore Ethiopia Iran Bangkok
(25 2005 2006
(RP) survey 2006 2006 (8
countries) (8 (9 countries) countries)
countries) (6 )
Is this 1st time you are
attending a structured
88% 84% 93% 100% 93%
program on RP. Ans.
Yes
Any cardiologists
conference you attended
85% 100% 100% 100% 100%
where there was lecture
on RP. Ans. No
Do you measure 96% 100% 87% 89% 71%
radiation dose to
patient. Ans. No
San Jose 2007 (11 countries of Latin-America)
Yerevan 2008 (7 countries of Eastern Europe)
Manila 2009 (8 countries)
 Urologists, Orthopedic surgeons,
Gastroenterologists, Gynecologists..

35
 Radiation Risks

• Skin injuries to patients

• In which applications have they
been demonstrated ?

• Injuries to staff-In which

applications have they been
demonstrated ?
 Radiation Risks

• Skin injuries to patients

• Demonstrated in
IC/EP/IR
• Not in other areas
• Skin injuries to staff-
also in IC/EP/IR,
• Cataract also in above
 IAEA Training Material
Free Download of power point slides
Our Cardiologists trainers in Radiation
Protection

Singapore

Thailand
Tunisia

Uruguay

They are ALL interventional cardiologists

Sessions in EP Conference
 Approved Training Package
IAEA Training Material on
Radiation Protection in Cardiology
Lessons from injured patients:

Cumulative buildup
of dose for steeply
angled high-dose
beam through large
patient not
recognized.
Lesion required grafting.

Factors affecting patient Physical factors and challenges to

radiation management
doses (I) improper filtering Thicker tissue masses absorb more
INCREASES radiation
THE USE OF PATIENT
THE ENTRANCE
ANTISCATTER DOSE BY A
GRID FACTOR OF 2
TO 6
proper filtering

In collaboration with
≈5000 downloads of training material/yr
• Training- limited outreach
• Website- Better outreach
• Something more with still
better outreach??????
FREE download from RPOP website 46
10 Pearls: Radiation protection of patients in fluoroscopy

http://rpop.iaea.org

Translation into
many languages
>6000 downloads
in last 6 months
48
 Fluoroscopy outside radiology

Group I:
• Interventional Cardiologists & Electro-
physiologists
Group II:
• Orthopedic surgeons, Urologists,
Gastroenterologists, Anesthetists…..
Group III:
• Vascular surgeons
 New Program

• Starting new training program for

Vascular surgeons, Dec 2012 in Bangkok
for Asian countries- First ever for these
specialists
 ICRP

Chairman: Madan Rehani

O. Ciraj-Bjelac, E. Vañó, D.L. Miller, S. Walsh, B.D. Giordano, J. Persliden,

51
A new way to visually convey level of dose

52
53
54
 Urological procedures (mSv) Gynaecological procedures (mSv)

Urethrography
Computed tomography pelvimetry
Cystometrography

Extracorporeal shock wave lithotripsy

Pelvimetry, digital fluorography
Cystography

Excretion urography/micturating cysto-…

Typical patient mean effective dose from
Ureteric stent placement vascular surgical procedures (mSv) Pelvimetry, conventional

Intravenous urography/intravenous pyelography

Hysterosalpingography
Percutaneous nephrolithotomy

Nephrostomy Venous Access

Uterine artery embolisation
Kidney stent insertion

0 5 10 15 20 25
EVAR 30 0 5 10 15 20 25 30

Renal/visceral
Orthopaedic angioplasty
procedures (mSv) Gastroenterology and hepato-biliary procedures (mSv)
(stent/no stent) 54 mSv
Other extremities Biopsy
Hand/wrist
ERCP (diagnostic)
Iliac angioplasty
Knee
Shoulder
(stent/no stent)
Transjugular hepatic biopsy
58 mSv
Skull
Percutaneous transhepatic cholangiography
Cervical spine
Hip
0 5 10 15 20 25 30
Bile duct stenting
Pelvis
ERCP (therapeutic)
Thoracic spine
Lumbar spine Bile duct drainage
Kyphoplasty
Transjugular intrahepatic portosystemic shunt
Vertebroplasty creation 53 mSv
55
0 5 10 15 20 25 30 0 5 10 15 20 25 30
EC
Interventional cardiologists: Nurses:
• Prevalence 52% (29/56. 95% • Prevalence 45% (5/11. 95%
CI: 35-73) CI: 15-100)
• Significance (Fisher exact • Significance (Fisher exact
test): p<0.001 test): p<0.05
• Relative risk: 5.7 (95% CI: • Relative risk: 5.0 (95% CI:
1.5-22) 1.2-21)

Rehani. Cataract RASSC Dec 2011 58

Vano, E., Kleiman, N.J., Duran, A, Rehani MM, D Echeverrie,
M Cabreraf. Radiation cataract risk in interventional
cardiology personnel. Radiat. Res. 174, 490-5 (2010). IF≈3.1
• Relative risk of psc opacities in IC was
3.2 (38% compared to 12%; p<0.005).
• 21% of nurses and technicians

Rehani. Cataract RASSC Dec 2011 59

American J Roentgenology Aug. 2009
 Occupational Protection

• Lead Apron • Usage by 100%

• Eye protection • 73%
• Personal monitoring • 30-70% using badge
• Extremely irregular
• 80% using single
• Some use outside lead apron
Occupational hazard-
use of lead apron
 FUTURE

• Staff 100% protected in particular for Eye

• Eye lens dosimetry
• Ergometric issues
• Skin injuries
• Awareness
• Avoidance, how much possible
• Protection of Children
M.Rehani@iaea.org
madan.rehani@gmail.com