Radiation Protection Dosimetry (2022), Vol. 197, No. 3–4, pp. 230–236 https://doi.org/10.

1093/rpd/ncab182
Advance Access publication 4 January 2022

RADIATION DOSE FOR PATIENTS WITH KAWASAKI DISEASE

UNDERGOING FLUOROSCOPICALLY GUIDED CARDIAC
CATHETERIZATION

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Patricia Miranda1 , Eliseo Vano2 , Carlos Ubeda3, *, Ximena Figueroa3 , Paulina Doggenweiller1 ,
Marcus Oliveira 4 and Dandaro Dalmazzo5
1
Hemodynamic Department, Cardiovascular Service, Luis Calvo Mackenna Hospital, Antonio Varas 360,
Santiago, Chile
2
Radiology Department, Faculty of Medicine, Complutense University and IdIS, San Carlos Hospital, Calle
del Prof Martín Lagos, 28040 Madrid, Spain
3
Medical Technology Department, Health Sciences Faculty, Tarapaca University, 18 de septiembre 2222,
Arica, Chile
4
Department of Health Technology and Biology, Federal Institute of Bahia, R. Emídio dos Santos,
s/n - Barbalho, Salvador, Brazil
5
Faculty of Health and Odontology, Universidad Diego Portales, Santiago, Vergara 210, Chile
*Corresponding author: cubeda@uta.cl

Received 25 May 2021; revised 14 November 2021; editorial decision 8 December 2021; accepted 8 December
2021
The goal of the present study was to estimate the radiation dose for a group of 45 Kawasaki disease (KD) patients undergoing
fluoroscopically guided cardiac catheterization. The sample of procedures corresponds to a single hospital and was collected in
10 years. Anthropometric characteristics and the quantities of air kerma-area product (PKA ) among others were recorded for
each procedure. Monte Carlo PCXMC 2.0 software was used to estimate organ and effective doses. The PKA value of 7.2 Gy cm2
was proposed as the local Diagnostic Reference Level for KD. For organ absorbed doses, median values for thyroid, heart, lungs,
esophagus, skin, active bone and breast were 1.2; 2.2; 4.6; 2.7; 1.1; 1.2 and 2.7 mGy, respectively. For effective dose, the mean
value was 2.7 ± 2.5 mSv. This paper presents the first patient dose values for the KD using catheterization techniques, in Latin
America and the Caribbean Region.

reliable as children grow and the chest wall thickens.

INTRODUCTION
Kawasaki disease (KD) is an acute and self-limiting
medium-vessel vasculitis of unknown etiology that
especially affects infants and children (80% under
5 years of age) but can also occur in older children
and adolescents(1, 2) . KD targets the coronary arteries
and other cardiovascular structures(3, 4) .
The long-term prognosis is determined by the ini-
tial and current level of coronary artery involvement.
Patients with giant coronary aneurism are at risk
for myocardial ischemia from coronary artery throm-
bosis and stenosis. Medical management of these
patients is important, and is based on judicious use
of thromboprophylaxis and monitoring to identify
evolving stenosis. Invasive revascularization proce-
dures might be required for selected patients(1–3) .
KD is now the most common cause of acquired
heart disease in children in developed countries(2) . In
Chile, the incidence of KD was 10.4 per 100 000 chil-
dren under 5 years of age in 2011(5) , similar to other
countries except Japan, Korea and the remainder of
Asian countries.
With regard to cardiovascular testing during long-
term follow-up, echocardiographic measurements of
the coronary artery lumen become progressively less
Echocardiography is also less reliable for detection of
vascular stenosis or thrombosis than for dilatation.
The ‘gold standard’ for coronary artery assessment
is fluoroscopically guided cardiac catheterization
(FGCC). This procedure provides a detailed image
of the coronary artery lumen and is very useful in
defining regional flow-limiting stenosis and assessing
these conditions for potential intervention(1, 2, 6) .
The FGCC is a minimally invasive and vital tech-
nique, aiming to diagnose and/or possibly treat heart
disease, such as coronary artery stenosis or coronary
aneurysms, among others(7) . However, FGCC and
electrophysiological procedures are the most signifi-
cant contributors to radiation dose in children with
heart disease(8, 9) . In Chile, the number of FGCC pro-
cedures carried out among the pediatric population
ranged between 40 and 80 per 1 000 000 inhabitants
per year(10) .
Children patients undergoing FGCC procedures
are known to be at potentially greater risk of
radiation-induced stochastic effects (i.e. cancer) and
mortality, compared with adult patients, due to the
higher radiation sensitivity of children’s tissues and
to their longer lifespan for the possible development
of neoplasms(11, 12) . According to the International

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 RADIATION DOSE FOR PATIENTS WITH KAWASAKI DISEASE
Commission on Radiological Protection (ICRP),
the first step in managing the risks from ionizing
radiation should be to know the dose values imparted
to the patients during the imaging procedures(11) .
The modern X-ray systems used for interventional
cardiology produce patient radiation dose reports at
the end of the procedures. If dose reports are not avail-
able automatically, dose values should be recorded on
the patient’s clinical record chart, together with the
procedure and patient identification. Interventional
systems show different dose metrics, such as: air
kerma-area product (PKA )(13) , air kerma at the
patient entrance reference point (Ka,r ), fluoroscopy
time and the number of cine series (and/or cine
images) according to the international standard for
interventional fluoroscopy systems(14) .
The ICRP has recommended that the appropriate
dosimetric indicator for the probability of stochastic
radiation effects is the average organ absorbed
dose. The radiation quantity ‘effective dose’ is used
in radiation protection to specify exposure limits
for workers and members of the public, to ensure
that the occurrence of stochastic health effects
is kept below unacceptable levels but it is also
used in imaging for comparison purposes between
different imaging modalities (e.g. interventional, CT
or radiopharmaceuticals)(11) .
The goals of this study were: (a) to report the
PKA and Ka,r in a sample of patients with KD; (b)
to establish local Diagnostic Reference Levels (DRLs)
and (c) to estimate organ absorbed dose and effective
dose for a this group of patients undergoing FGCC in
Chile. The results of this paper were obtained as part
of the International Atomic Energy Agency (IAEA)
regional project in Latin America and the Caribbean
for the optimization of radiation protection in inter-
ventions guided by X-ray imaging(15, 16) .
MATERIALS AND METHODS
When referring to radiation dose values for patients,
we used the quantity of PKA, proposed by the
International Commission on Radiological Units
(ICRU)(13) .The quantity Ka,r , referred to in the
standard IEC 60601-2-43(14) , is the incident air
kerma without backscatter(13) at the patient entrance
reference point. This point is intended to be rep-
resentative of the position of the patient’s skin (in
adult patients) at the entrance site of the X-ray beam
during an interventional procedure. For pediatrics,
some corrections are needed to estimate the skin
doses(17) . For fluoroscopic systems with an isocentre,
the interventional reference point is located along
the central ray of the X-ray beam at a distance of
15 cm from the isocentre in the direction of the focal
spot(14) . Organ absorbed doses and effective doses
cannot be measured directly in patients undergoing
interventional cardiac procedures. Nonetheless, they
231
can be estimated to a reasonable approximation using
the Monte Carlo calculation methods, provided that
sufficient technical and geometrical data are available
on the X-ray examination technique(12) .
The study was conducted at the pediatric car-
diovascular service at Luis Calvo Mackenna Hospi-
tal (Santiago, Chile). For several years, this service
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had a biplane X-ray system (Siemens Axiom Artis
BC, Siemens Inc., Erlangen, Germany) equipped with
image intensifiers, which was installed in 2006 and
decommissioned in 2018. This system had specific
imaging protocols for pediatric procedures and with
a properly calibrated ionization transmission cham-
ber integrated into the collimator housing to mea-
sure PKA , and Ka,r . This equipment was periodically
submitted to the quality control program during its
12 years of operational life, using the protocols agreed
to during the European DIMOND and SENTINEL
programs(17–19) . This service has been involved in
three technical cooperation projects since 2008 (RLA
9057, RLA 9067 and RLA 9075), with the support
of the IAEA(15, 16) . The totality of the dosimetric
data used in this study corresponded to the previous
Siemens X-ray system.
The study design was prospective case series(20) .
All pediatric patients with diagnosis of KD, who had
undergone FGCC from January 2008 to July 2018,
were screened for inclusion.
For each patient, and from the patient dose reports
produced by the X-ray system, we recorded the fol-
lowing data: procedure identification, patient age,
gender, weight, height, PKA , Ka,r , number of cine
series, total number of cine frames, fluoroscopy time,
projection angle, patient number, X-ray tube voltage,
filtration (mm Al) and additional filter (mm Cu). PKA
values were corrected with the appropriate calibration
factor (0.81 in this system) for the frontal C-arm
(derived from the table and mattress attenuation mea-
sured for the X-ray beam qualities in the system used).
No correction factor was necessary for the lateral C-
arm. DRLs will be set by calculating the third quartile
of the full database of patient dose values for the PKA
quantity, as recommended by the ICRP(21) .
Organ absorbed doses and effective doses were
calculated using the Monte Carlo PCXMC 2.0
software(22) . The calculation was performed exam-
ining for each cine series extracted from patient
dose report the parameters of projection: field size;
projection angle; patient number; patient height;
patient weight; patient age (0, 1, 5, 10, 15); X-ray
tube voltage (kV); filtration (mm Al); additional
filter (mm Cu); focus-reference point distance
(FRD) (cm); X-ray beam width (cm at FRD);
X-ray beam height (cm at FRD); coordinates of
a point inside the phantom, through which the
central axis of the X-ray beam is directed (Xref,
Yref and Zref); arms in phantom (1 or 0); and
input dose value (in our case the PKA was used).
 P. MIRANDA ET AL.
Table 1. Total frequency by gender [male (M) and female (F)]. Median, minimum (min) and maximum (max) values for age,
weight, height and body mass index grouped by gender.

Gender Frequency Age (years) Weight (kg) Height (m) Body mass index
(kg/m2 )
Median(Min–max) Median (Min–max) Median (Min–max) Median (Min–max)

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F 13 5.6 (0.6–12.6) 27 (5.8–54.9) 1.27 (0.6–1.6) 16.7 (14.6–23.4)
M 32 10.8 (2.0–14.2) 41 (9.3–80.0) 1.44 (0.7–1.8) 19.1 (13.6–27.7)
Total 45 8.9 (0.6–14.2) 32.4 (5.8–80.0) 1.37 (0.6–1.8) 18.6 (13.6–27.7)

Table 2. Results for PKA (Qxx are quartiles; SD are the standard deviations) by gender [male (M) and female (F)].

Gender Q25 PKA (Gy cm2 ) Q50 PKA (Gy cm2 ) Q75 PKA (Gy cm2 ) Mean PKA (Gy cm2 ) SD PKA (Gy cm2 )

F 1.1 2.2 3.9 3.2 2.9

M 1.7 3.1 9.9 6.7 7.5
Total 1.5 2.9 7.2 5.7 6.7

Table 3. Results for Ka,r (Qxx are quartiles; SD are the standard deviations) by gender [male (M) and female (F)].

Gender Q25 Ka,r (mGy) Q50 Ka,r (mGy) Q75 Ka,r (mGy) Mean Ka,r (mGy) SD Ka,r (mGy)

F 13.6 29.6 47.6 39.9 40.7

M 23.2 34.1 80.9 62.9 65.1
Total 22.1 32.4 72.0 56.3 59.6

To incorporate the contribution of the fluoroscopy DISCUSSION

series in the doses calculated using the PCXMC
software, the PKA contribution of the fluoroscopy
series was distributed proportionally to the contri-
bution of the cine series, as validated in one of our
previous papers(10) . Absorbed doses were calculated
and analyzed for the seven heavily irradiated organs.
All dosimetric data collected were tabulated
and statistically analyzed with SPSS software IBM,
2018(23) . The proposed analysis has been exclusively
descriptive for all the variables studied.
RESULTS
Table 1 shows the anthropometric characteristics of
the 45 subjects. Table 2 summarizes the quartiles,
means and standard deviations (SDs) for the PKA
values for all procedures. Table 3 summarizes the
quartiles, means and SDs for the Ka,r values for all
procedures. Table 4 shows mean, SD and median
values for organ absorbed doses to active bone
marrow, heart, lungs, thyroid, esophagus, skin and
breast for all procedures. Table 5 summarizes the
quartiles, means and SDs for the effective dose values
for all procedures.
The FGCC are typically divided into two groups
for patient dose evaluation, diagnostic (normal
diagnostic and complex diagnostic) and thera-
peutic (aortic angioplasty, pulmonary angioplasty,
pulmonary angioplasty with stent, atrial septal
defect closure, aortic valvuloplasty, pulmonary
valvuloplasty, patent ductus arteriosus closure with
coil, patent)(24) . In this case, patients with KD
were undergoing only diagnostic procedures using
FGCC(10, 24) . Generally, these procedures could be
classified as complex diagnostic procedures or those
with higher doses to the patient because: (a) there are
no catheters specifically designed for children; (b) the
need to study other vessels such as the axillary and
inguinal, since they can present giant aneurysms and
(c) in small patients with high heart frequency, the
use of cine mode with higher numbers of frames per
second is required.
According to Table 1, although the sample of 45
pediatric procedures (29% girls and 71% boys) can be
considered small to support specific DRLs for PKA ,
and Ka,r , the sample sizes in pediatrics, in general,
are smaller than in adults and ICRP has recognized
the possibility of using small samples for pediatric

232
 RADIATION DOSE FOR PATIENTS WITH KAWASAKI DISEASE
Table 4. Mean, standard deviation (±SD) and median values for organ absorbed doses in active bone marrow, heart, lungs,
thyroid, esophagus, skin and breast by gender [male (M) and female (F)].

Gender Thyroid (mGy) Heart (mGy) Lungs (mGy) Esophagus (mGy) Active bone (mGy) Breasts (mGy)

Mean ± SD Median Mean ± SD Median Mean ± SD Median Mean ± SD Median Mean ± SD Median Mean ± SD Median

F 1.9 ± 1.4 1.3 4.2 ± 5.0 2.2 7.9 ± 9.4 4.0 4.4 ± 4.8 2.7 1.8 ± 1.9 1.1 5.0 ± 7.6 2.7

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M 2.0 ± 2.2 1.1 3.7 ± 3.0 2.3 7.5 ± 6.5 4.6 4.3 ± 3.6 2.6 2.1 ± 2.0 1.2 4.3 ± 3.9 2.6
Total 1.9 ± 2.0 1.2 3.9 ± 3.7 2.2 7.6 ± 7.4 4.6 4.4 ± 3.9 2.7 2.0 ± 1.9 1.2 4.5 ± 5.2 2.6

Table 5. Results for effective dose (Qxx are quartiles; SD are the standard deviations) by gender [male (M) and female (F)].

Gender Q25 (mSv) Q50 (mSv) Q75 (mSv) Mean (mSv) SD (mSv)

F 0.8 1.6 2.6 2.8 3.1

M 1.2 1.6 3.7 2.7 2.3
Total 1.1 1.6 3.7 2.7 2.5

studies(21) . Furthermore, the sample is relatively small
for presenting the values of organ absorbed dose and
effective dose as being fully representative results for
this group of patients, however, it should be taken
into consideration that it is difficult to obtain larger
samples for this pathology. This study was conducted
in the public hospital that performs ∼50% of all
pediatric FGCC procedures in Santiago (capital of
the Chile country with 7 014 702 inhabitants)(25) .
Furthermore, the population of patients with giant
aneurysms is usually small, and all efforts made in
the acute stage of the disease are focused on avoiding
these giant aneurysms in children.
Table 2 shows PKA values for all the proce-
dures. According to the IAEA Dosimetry Code
of Practice(26) , the PKA quantity was originally
introduced to determine energy imparted to patient,
since it is a quantity that can be related to the
stochastic risk of cancer induction and allows the
organ doses to be estimated. Moreover, the PKA
quantity is recommended by the ICRP 135 report,
for the purpose of establishing DRLs, which are
essential tools in the management of patient dose,
and therefore, in optimizing radiation protection by
taking into account the clinical benefits for patients.
Median values of PKA from the procedures performed
in a particular catheterization room can be compared
with local or national DRLs to identify whether the
values obtained for that particular clinical indication
with that X-ray system are higher or lower than
the existing DRLs, and thereby to decide whether
any corrective actions might be appropriate. Where
the number of facilities or X-ray rooms is small,
the median of the distribution of values of the
DRL quantity is recommended as a ‘typical value’.
This comparison of local practice data with the
existing DRLs values is the first step in optimizing
protection and can be used for patient dose audits(21) .
But for pediatrics other approaches may be used.
If nationwide only one hospital is in charge of
certain pediatric pathologies (as is the case of KD
in Chile) it is considered appropriate, to report in
addition to the median (typical) values, also the
third quartile considered (in this cases) as a local
DRL for these pathologies. This third quartile value
(considered our local DRL) may be used by other
countries in the Latin American Region. In any
case, in Table 2, we included both values: median
(as ‘typical value’ and third quartile as suggested
local DRL for KD). In addition, and as suggested
by ICRP 135, the interquartile range serves as an
indicator of dispersion of the data. It should be
noted that ICRP, in its report 135 recommends:
‘Flexibility is necessary for procedures where few
data are available (e.g. interventional procedures in
paediatric patients)’ and ‘When regional or national
DRL values are not available, local practice may
be compared with appropriate available published
data. This is especially relevant for paediatric
due to the scarcity of national or regional DRL
values’.
Since there are no DRLs published for KD and,
this paper presents the results of a patient dose evalu-
ation program spanning the last 10 years in the largest
pediatric hospital in Chile, which manages ∼50% of
all pediatric FGCC procedures carried out in the
country and where effort has already been invested
in optimization, the values we obtained could be
considered provisional local DRLs. Q75 PKA values
in our sample were 3.9 and 9.9 Gy cm2 for female and
male patients, respectively. However, DRLs should
not be grouped by sex, but rather by age and weight
of patients. Therefore, as provisional DRL for KD,
we propose the value of 7.2 Gy cm2 . This value is

233
 P. MIRANDA ET AL.
higher than those reported in one of our investiga-
tions for other procedures such as: aortic angioplasty
(1.0 Gy cm2 ), pulmonary angioplasty (2.6 Gy cm2 ),
aortic valvuloplasty (2.3 Gy cm2 ), patent ductus arte-
riosus closure with coil (1.2 Gy cm2 ), etc(24) .
For Ka,r quantity (see Table 3), median values were
29.6 and 34.1 mGy for female and male patients,
respectively. These values are obviously lower than
those shown in adult samples, and in most cases, the
threat of producing radiation-related skin injuries is
low (according to ICRP Publication 85(27) , the thresh-
old for deterministic effects on skin or transient ery-
thema is 2000 mGy), when procedures are conducted
by trained cardiologists with X-ray systems and pro-
cedures optimized as part of the quality assurance
program, as was the case in this study.
On the other hand, the results showed in Table 4,
indicate that heart doses are far from the thresh-
old of may be as low as 500 mGy recommended by
the ICRP(28) for circulatory diseases in the cardio-
vascular system during FGCC, reaching a value of
2.2 mGy for the median. The median values for thy-
roid, lungs, esophagus, skin, active bone and breasts
(only females) were 1.2, 4.6, 2.7, 1.1, 1.2 and 2.7 mGy,
respectively.
A review article published by Harbron et al.(29)
stated that effective dose values for interventional
cardiac procedures in pediatrics are generally within
the range from 3 mSv to 15 mSv, but in our case, for
KD, the range found was much lower (see Table 5).
Yakoumaskis et al. (30) , El Sayed et al. (31) and Bar-
naoui et al. (32) , reported average effective dose values
of 3.7, 3.4 and 4.8 mSv, respectively, for diagnostic
procedures using FGCC. In our study, the mean effec-
tive dose value for KD was 2.7 ± 2.5 mSv as shown
in Table 5. Uncertainties in the case of this study
are similar to the ones described in ours previous
studies(10, 25) . The real X-ray tube voltage, filtration
and additional filter were used only for the cine series
but not for fluoroscopy runs. For the PKA values, due
to the fluoroscopy runs (distributed proportionally
to the cine series), global uncertainty is estimated
as ∼10%. Besides, PCXMC software suggests 2%
statistical uncertainty. The impact of variations in
focus-to-surface distance was 2% (doing several sim-
ulations). Radiation field sizes were circular and the
square equivalent was calculated, with an estimated
uncertainty of 5% in this respect. Therefore, total
uncertainty for organ doses may hence be ∼20%.
Other sources of uncertainty such as the difference
between phantom and patient anatomy (including
size or organ positions) were not considered.
On the other hand, the development of CT
technology, has allowed the implementation of the
CT coronary angiography (CTCA) as an alternative
to imaging KD patients undergoing FGCC, although
we do not use it, since we think that FGCC keep
delivering better image quality over that CTCA.
234
According to TsujiiN et al.,(33) would show a
good correlation with results of FCGG for the
measurements of coronary artery abnormalities. Kim
et al.(34) report the application of CTCA in children
with KD and effective dose values were 2.6 ± 2.6 mSv.
Similarly, Duan et al.(35) report mean effective dose
values of 0.36 ± 0.06 mSv. In a study assessing the
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doses from various pediatric protocols in infants with
a 64-slice CT scanner using a phantom, effective
dose values were of 1.49 ± 0.10–4.66 ± 0.40 mSv.
For a 256-slice CT, this effective dose values were
1.12 ± 0.11–6.87 ± 0.56 mSv(36) . In any case, it
should be noted the large inaccuracies of the effective
dose estimations (>30%) when comparing different
imaging modalities and the impact of the patient size
in these evaluations.
CONCLUSIONS
Papers calculating the PKA and Ka,r and estimating
organ absorbed dose and effective dose are practically
nonexistent for the KD patients undergoing FGCC.
This paper presents the first patient dose values for
KD disease catheterization, in Latin America and the
Caribbean region. Can be considered small the sam-
ple size to support specific DRLs. However, the sam-
ple sizes in pediatrics, in general, are smaller than in
adults. The FGCC is the gold standard for evaluation
of coronary artery abnormalities in KD. However,
radiation doses should be measured and reported
to allow optimization, considering the relevance of
radiation risks in this population of children and
young people. FGCC is an invasive procedure that
allows information to be obtained, not only about the
coronary arteries, but also in other affected median
arteries in these patients with KD and giant coronary
aneurism.
ACKNOWLEDGMENTS
The current work has been carried out as part of the
three technical cooperation projects since 2008 (RLA
9057, RLA 9067 and RLA 9075) with the support
of the International Atomic Energy Agency (IAEA).
One of the authors (C. Ubeda) also acknowledges
the support of the Research Directorate at Tara-
paca University, through Senior Research Project
No. 7713-18.
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