Not all lightweight lead aprons and thyroid shields

are alike
Elias Fakhoury, DO,a Jo-Ann Provencher, MS,b Raja Subramaniam, PhD,b and David J. Finlay, MD, FACS, RPVI,c
Paterson, NJ; and New York, NY

ABSTRACT
Objective: With the explosion of minimally invasive surgery, the use of fluoroscopy has significantly increased.
Concurrently, there has been a demand for lighter weight aprons. The industry answered this call with the development
of lightweight aprons. Our goal was to see whether lighter weight garments provide reduced protection.
Methods: Dry laboratory testing was performed in a standard X-ray room, using a standard fluoroscopy table and
standard acrylic blocks. A commercial-grade pressurized ion chamber survey meter (Ludlum Model 9DP; Ludlum
Measurements, Inc, Sweetwater, Tex) was used to detect gamma rays and X-rays above 25 keV. Nonlead aprons from
several manufacturers were tested for scatter radiation penetration above the table at a fixed distance (3 feet) and
compared with two standard 0.5-mm lead aprons of different manufacturers.
Results: Scatter measurements were made at 60 kVp and 70 kVp for pure lead (0.5 mm), mixed, and nonlead protective
garments. Scatter penetration for the nonlead blends and barium aprons was 292% and 258%, respectively, at 60 kVp
compared with the pure lead apron. At the higher beam quality of 70 kVp, the scatter penetration was 214% and 233% for
the blend and barium aprons, respectively, compared with the pure lead apron. Our measurements demonstrate a
noticeable difference in scatter reduction between pure lead and nonlead garments. Pure barium aprons and nonlead
aprons from certain companies demonstrated scatter penetration that is inconsistent with the 0.5 mm of lead equiva-
lence as claimed on the label. In addition, there was an incidental finding of a handful of lightweight aprons with
significant tears along the seams, leaving large gaps in protection. Our study also demonstrates that several companies
rate their lightweight garments as 0.5 mm lead equivalent, when actually only a small area on the chest and abdomen
where the garment overlapped was 0.5 mm, leaving the rest of the garment with half the protection at 0.25 mm.
Conclusions: Our reliance on protective lead garments to shield us from the biologic effects of radiation exposure and
the inferiority of some lightweight garments necessitate a streamlining of the testing methods and transparency in data
reporting by manufacturers. (J Vasc Surg 2018;-:1-5.)
Clinical Relevance: However ergonomically efficient, some nonlead lightweight aprons do not offer the same radiation
protection as standard 0.5-mm lead aprons. The authors suggest streamlining of testing methods and transparency in
data reporting by the manufacturers of radiation protective garments so the end user has a clear understanding while
making a purchase decision.
Keywords: Radiation; Safety; Apron; Exposure; Endovascular

With the explosion of minimally invasive surgery, the
use of fluoroscopy has significantly increased over the
years. At the same time, there has been a demand for
lighter weight aprons because of an increased number
of neck and back issues associated with wearing of
heavier lead garments for long periods. The industry
From the New York Medical College at St. Joseph’s University Medical Center,
Patersona; the Icahn School of Medicine at Mount Sinai Medical Center,b
and the Metropolitan Hospital, New York Medical College, Icahn School of
Medicine at Mount Sinai Medical Center,c New York.
Author conflict of interest: none.
Presented in the Associate Faculty Global Podium Presentations at the
Forty-fourth Veith Symposium, New York, NY, November 14-18, 2017.
Correspondence: Elias Fakhoury, DO, New York Medical College at St. Joseph’s
University Medical Center, 703 Main St, Paterson, NJ 07503 (e-mail: fakhoury.
elias@gmail.com).
The editors and reviewers of this article have no relevant financial relationships to
disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
0741-5214
Copyright Ó 2018 by the Society for Vascular Surgery. Published by Elsevier Inc.
https://doi.org/10.1016/j.jvs.2018.07.055
has answered this call with the development of aprons
and thyroid shields made with lighter materials.
Radiation protective clothing is a Food and Drug Admin-
istration class I device, a category with the least stringent
requirement for classification.1 Regulators reserve the
right to audit manufacturers’ claims, but manufacturers
are essentially self-policing.2 This has allowed companies
to test nonlead garments using criteria meant to
evaluate lead garments and thus falsely claim they are
lead equivalent.1 Although there are some nonlead
garments that come close to the protection provided
by lead, there are also nonlead garments that provide
reduced protection, especially in the lower, more biolog-
ically harmful kilovoltage peaks, which make up the
majority of scatter radiation to which staff is exposed.2,3
METHODS
All testing was performed in a standard X-ray room, with
a standard fluoroscopy table. Dry laboratory testing using
standard acrylic blocks to simulate a patient was used. A
commercial-grade pressurized ion chamber survey
meter (Ludlum Model 9DP; Ludlum Measurements, Inc,

1
2 Fakhoury et al
Sweetwater, Tex) was used to detect gamma rays and
X-rays above 25 keV (Model 9DP energy response: 625%
from 60 keV to 1.25 MeV). Nonlead aprons from several
manufacturers were tested for scatter radiation penetra-
tion above the table at a fixed distance (3 feet) and
compared with two standard 0.5-mm lead aprons of
different manufacturers. Other than replacing different
garments, all other factors in the experiment were held
constant. Measurements were repeated three times to
ensure reproducibility of the data. Pure lead aprons tested
were 20 years old. All other aprons were <1 year old.
Demographics included the C-arm (Philips Model BV
300; Philips Healthcare, Best, The Netherlands), average
kilovolt potential and milliamperes during testing, and
total above-table ambient scatter in milliroentgens on
each side of the aprons. Because our measurements simu-
lated a typical clinical setting, scatter measurement data
likely have an insignificant contribution from stray radia-
tion. However, results from the data follow the trend
reported in previous studies.2
RESULTS
Scatter measurements were made at 60 kVp and 70
kVp for pure lead (0.5 mm), mixed (containing some
lead), nonlead blends, and pure barium protective gar-
ments. The lead-equivalent thickness was marked as
0.5 mm in the label for all the garments. Scatter penetra-
tion for the nonlead-containing blend and barium
aprons was 292% and 258%, respectively, at 60 kVp
compared with the pure lead aprons. At the higher
beam quality of 70 kVp, the scatter penetration was
214% and 233% for the blend and barium aprons, respec-
tively, compared with the pure lead apron (Table). Our
measurements demonstrate a roughly 2:1 difference in
scatter reduction between standard pure lead garments
and the nonlead garments that we tested. Clinical rele-
vance of this finding can be explained by considering,
for example, a procedure with a reference air kerma of
2 Gy. Assuming that the operator’s position is at 3 feet
from the entrance skin, the scatter at the location is
approximately 2 mGy. Using the penetration data for
lead and nonlead garments from the Table, this results
in an operator’s exposure of 5 mGy and 20 mGy at 60
kVp and 10 mGy and 40 mGy at 70 kVp, respectively.
Thus, there is a potential for an operator’s exposure to
be fourfold higher by using a nonlead garment. Pure
barium aprons and the blend apron chosen for this study
showed scatter penetration (Fig 1)4,5 that is inconsistent
with the 0.5 mm of lead equivalence radiation protection
as claimed on the label. However, there was one com-
pany with a mixed apron (Mixed A; Burlington Medical,
Newport News, Va) that had the same attenuation char-
acteristics of the 0.5-mm pure lead apron. This same
company’s nonlead apron had a higher penetration but
significantly less than that of their competitors. An inci-
dental finding was that a handful of lightweight aprons
Journal of Vascular Surgery
--- 2018
ARTICLE HIGHLIGHTS
d
Type of Research: Experimental study of lead and
nonlead protection garments
d
Take Home Message: Some nonlead lightweight
aprons did not offer the same radiation protection
as standard 0.5-mm lead aprons.
d
Recommendation: Radiation protection garments
need standard measurements and accurate and
transparent data reporting to allow easy understand-
ing of their safety and efficacy data.
had significant tears along the seams. This finding
demonstrated large gaps in protection (Fig 2). We found
a total of 30 different pieces of lightweight protective
garments with significant tears of 300 tested. No such
tears were found in pure lead aprons.
DISCUSSION
The use of fluoroscopy has significantly increased over
the years. Because of this growing demand, >50% of
vascular procedures are now performed in operating
rooms that lack above- and below-the-table shielding,
which is standard in dedicated interventional and cardi-
ology suites. In addition, as minimally invasive proced-
ures become more common in orthopedics and
neurosurgery, exposure times have increased signifi-
cantly in nonshielded operating rooms. Without this
additional shielding found in dedicated interventional
suites, C-arm guidance relies solely on protective
clothing to protect the user from ambient low-energy
scatter radiation. It is this low-energy scatter that is the
source of the majority of the staff’s whole body dose.6
Concurrently, there has been a demand for lighter
weight aprons because of an increased number of
musculoskeletal issues associated with wearing of
heavier lead garments for long periods. The industry
has answered this call with the development of aprons
and thyroid shields made with lighter materials. Radia-
tion protective clothing is a Food and Drug Administra-
tion class I device, a category with the least stringent
requirements for classification.1 Regulators reserve the
right to audit manufacturers’ claims, but manufacturers
are essentially self-policing.1,6 This has allowed com-
panies to test nonlead garments using criteria meant
to evaluate pure lead garments and ultimately claiming
that they are lead equivalent.1 Although there are some
nonlead garments that come close to the protection
provided by lead, there are also nonlead garments that
provide reduced protection, especially in the lower range
kilovoltage peaks, which makes up the majority of
scatter radiation to which staff is exposed.7
Lightweight protective garments often contain a mix of
light metals with varying protection to different wave-
lengths of radiation. Manufacturers do not make a full
Journal of Vascular Surgery
Volume -, Number -
Table. Penetration of scattered radiation through different protective garments
Scatter
Lead type At 60 kVp/1.5 mA, %
Pure lead, 0.5 mm 0.24
Mixed A,0.5 mm 0.23
Nonlead A, 0.5 mm 0.42
Nonlead B, 0.5 mm 0.94
Pure barium, top 0.86
Pure barium, skirt 1 1.85
Fig 1. Scatter penetration at 60 kVp and 70 kVp for various protective garments.
disclosure of the exact proportions of each lightweight
element in the apron because of proprietary reasons.2
What makes lead so protective against radiation is its
high atomic number (Z) and density. High density in
lead is due to a combination of its high atomic mass
and the relatively small size of its bond lengths and
atomic radius. The high atomic number and density
make lead a more favorable material for photoelectric
absorption. Thus, scattered photons encountered in diag-
nostic X-ray imaging can be effectively absorbed using
0.5 mm of lead. Besides being a soft metal, lead is easily
molded to various shapes to be used in protective
garments. Because the average energy of clinically used
X-ray spectra is below the K-shell binding energy for
lead, the secondary fluorescence emission from photon
absorption in lead is insignificant. However, materials
such as tungsten, iron, aluminum, barium, and antimony
used in lightweight aprons can be activated to produce
secondary fluorescence radiation.2,3,5,8-13 Because the
probability for photoelectric absorption is proportional
Fakhoury et al 3
Penetration compared with pure lead
At 70 kVp/2.6 mA, % At 60 kVp, % At 70 kVp, %
0.58
0.47
0.77
1.82 292 214
1.93 258 233
317 219
to Z4, the lower atomic number materials used in light-
weight aprons lack the stopping power of lead. Thus,
the photon attenuation of pure lead is superior to that
of the lightweight material.14,15
Manufacturers often claim that their aprons are
“certified to the exacting standards of [the various gov-
erning bodies (International Electrotechnical Commis-
sion, Association of Surgical Technologists, or German
Institute for Standardization)], leading to the mispercep-
tion that these organizations require certain results to be
achieved in order to grant a ‘certification.’ In reality, the
standards do not certify anything, they are simply guide-
lines for testers on how to test and report results.”1
Moreover, the standards do not require any minimum
standards to be achieved in protective barrier attenua-
tion. Other criticisms of the Standard Test Method for
Determining Attenuation Properties (ASTM designation
F2547-06) are described: the energy range is not broad
enough (should include lower and higher kilovoltage
peaks); a direct beam is used, whereas operators are
4 Fakhoury et al
Fig 2. Nonlead lightweight aprons demonstrating significant tears along the seams, an incidental finding of this
study. The tear originates at the seams and rips through the fabric because of the sheer weight of the garment.
Fig 3. Although the label may claim 0.5-mm lead equiv-
alence, the thickness applies only to the overlap region as
demonstrated in this apron.
exposed to scatter of a different quality; and the use of
narrow-beam geometry is permitted, which can grossly
underestimate exposure.1,8
Companies frequently perform narrow-beam (single-
beam) testing, including only the higher kilovoltage
peaks (120 and 150 kVp). The lighter nonlead metals
have similar results to lead in these ranges (Table;
Fig 1).11 However, broad- or wide-beam testing should
be mandatory, with transmission values at all beam qual-
ities (30, 60, 90, 120, and 150 kVp) because lighter weight
materials do poorly in the lower energies (below 80 kVp)
that make up the majority of scatter to which the staff is
exposed.2,3,8-10,16 A difference in attenuation from 99% to
94% may not seem significant, but it would mean that
the user would receive six times as much transmitted
radiation.
Journal of Vascular Surgery
--- 2018
In addition, lead equivalence protection values should
not apply only to the overlap zones, unless the overlap
zones are complete from neck to bottom and from the
posterior axillary line on one side to the other for the
largest person who might wear that size of apron. Our
study demonstrates that several companies rate their
lightweight garments as 0.5 mm lead equivalent, when
actually only a small area on the chest and abdomen
where the garment overlapped was 0.5 mm, leaving
the rest of the garment with half of the protection at
0.25 mm2 (Fig 3).
Manufacturers often use the overlap aprons to meet the
minimum lead equivalent protection of 0.5 mm. Except
for a small frontal strip in the center of the chest and
abdomen, most of the coverage is only half at
0.25 mm, which provides an exponential reduction in
coverage.
CONCLUSIONS
Our reliance on protective lead garments to shield us
from exposure to scatter radiation and thereby minimize
risk of biologic effects from the exposure is well
documented. With the advent of nonlead protective
garments, manufacturers have been allowed to
self-regulate. Selectively chosen guidelines out of specifi-
cations for testing pure lead garments are used to incor-
rectly certify nonlead garments as having the required
lead equivalence (commonly 0.5 mm of lead). Although
hospital radiation safety programs are required to check
the aprons for integrity under fluoroscope at least once a
year, seldom is a quantitative evaluation of the lead
equivalence of the aprons performed. Thus, industry-
reported data are relied on for lead equivalence informa-
tion for protective garments. Our experience, like that of
others,2 shows that protection offered by nonlead
garments may not be the same as that of pure lead
garments (we found one exception) across the spectrum
Journal of Vascular Surgery
Volume -, Number -
of photon energy encountered clinically. With the
proliferation of nonlead garments in clinical practice, a
streamlining of the testing methods and transparency
in data reporting by the manufacturers are needed.
This will enable the end user to have a clear understand-
ing while making a purchase decision for protective
garments. Furthermore, it will be worthwhile for inter-
ventionalists to assess the lead equivalence protection
offered by the light aprons as well as their structural
integrity before deployment for clinical use.
AUTHOR CONTRIBUTIONS
Conception and design: DF
Analysis and interpretation: EF, RS
Data collection: JP
Writing the article: JP, RS
Critical revision of the article: EF, DF
Final approval of the article: EF, JP, RS, DF
Statistical analysis: Not applicable
Obtained funding: Not applicable
Overall responsibility: DF
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Submitted Mar 9, 2018; accepted Jul 5, 2018.