The Real Risk of Fluoroscopic Radiation Kenneth A. Gorski, BSN, RN, RCIS, FSICP Manager: Pediatric and Congenital Cardiac Catheterization Cleveland Clinic Children’s Cleveland, Ohio

Kenneth A. Gorski, BSN, RN, RCIS, FSICP   I have no relevant financial relationships to dislose Examples of relationships are: Advisory Board/Board Member, Consultant, Honoraria, Research Support, Speaker’s Bureau, Stockholder

FLUOROSCOPY What is the risk of ionizing radiation to physicians and the cath lab team Common sense methods to reduce risk Technology to reduce risk

Invisible Danger

Vulnerability Head Eyes Neck/thyroid Arms/hands (particularly Left) Legs

Vulnerability Legs, arms, and head least protected Left side of operator typically exposed to higher radiation dose than right side

Why be concerned? Trials have confirmed that the Left side of the brain of operators is exposed to higher radiation doses during fluoroscopic guided procedures Reeves RR, Ang L, Bahadorani J, et al. Invasive cardiologists are exposed to greater left sided cranial radiation: the BRAIN study (brain radiation exposure and attenuation during invasive cardiology procedures). JACC Cardiovasc Interv. 2015;8:1197-1206. Vaño E, Gonzalez L, Fernandez JM, et al. Occupational radiation doses in interventional cardiology: a 15-year follow-up. Br J Radiol. 2006;79:383-388.

Why be concerned? A series of articles in recent years have been published highlighting left-sided brain tumors (Glioblastoma Multiform – GBM) Finkelstein MM. Is brain cancer an occupational disease of cardiologists? Can J Cardiol. 1998;14:1385-1388. Roguin A, Goldstein J, Bar O. Brain tumours among interventional cardiologists: a cause for alarm? Report of four new cases from two cities and a review of the literature. EuroIntervention. 2012;7:1081-1086. Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol. 2013;111:1368-1372.

Why be concerned? In a large prospective trial of 90,957 radiographers (1994-2008), those performing fluoroscopic guided interventions showed elevated risks of: Brain cancer(> 2x) Breast cancer Melanomas Rajaraman P, Doody MM, Yu CL, et al. Cancer risks in US radiologic technologists working with fluoroscopically guided interventional procedures, 1994-2008. Am J Roentgenol. 2016;206:1101-1108.

Sounding the Alarm: 43 patients 33 Interventional Cardiologists 6 Interventional Radiologists, 2 Electrophysiologists 2 RNs All worked for many years in active fluoroscopic interventional procedure practices 12–32 years; mean 23.5 ± 5.9 years 24 GBMs (57%), 2 astrocytomas (5%), 5 meningiomas (12%) Roguin A, Goldstein J, Bar O. Brain tumours among interventional cardiologists: a cause for alarm? Report of four new cases from two cities and a review of the literature. EuroIntervention. 2012;7:1081-1086. Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol. 2013;111:1368-1372.

Sounding the Alarm: “In the general population, the side involved in these tumors is distributed equally (left, 50%; right, 50%). What was interesting in this series of self-reported cases was that the tumor was on the left side in 85% of cases The left side has higher radiation exposure; even with these small numbers, there is a statistical difference than the expected 1:1 side involvement ratio.” Roguin A, Bartal, G. Radiation and your brain. Endovasc Today. 2016;15:63-65.

www.orsif.org

“Ionizing radiation exposure in the United States (U. S “Ionizing radiation exposure in the United States (U.S.) rose 74%, on a per-capita basis, from the early 1980s to 2006, with nearly half of the exposure related to medical imaging. While there has been an increasing focus on reducing patient exposure to radiation, less attention has been paid to lowering the risk for medical professionals who have cumulative exposure that is significantly higher than that for patients. There have been reports of malignant brain tumors in the left hemisphere for interventional cardiologists who are subjected to radiation exposure rates that are two to ten times higher than those experienced by other medical specialties and correlate with the physician’s proximity to the radiation source in the cath lab. As this paper will show, sustained exposure to low-dose radiation is causing other serious adverse health consequences—including the development of several cancer types, pre-mature development of cataracts, onset of thyroid disease, and damage to reproductive organs—for interventional medical teams.”

“Regulation of occupational exposure to ionizing radiation is achieved through the establishment of maximum permissible exposure limits setting the amount of radiation to which employees may be exposed in the workplace. In the U.S., exposure to ionizing radiation in occupational settings is regulated by two separate agencies: the Nuclear Regulatory Commission (NRC) and the Occupational Safety and Health Administration (OSHA). It is OSHA that is authorized to regulate exposure to ionizing radiation generated from medical imaging devices during procedures performed in a hospital cath lab. OSHA’s exposure limits for ionizing radiation were set in 1971 (well before the invention of interventional specialties and procedures, such as PCI).The regulations were adopted from the first radioactive exposure limits set by the Atomic Energy Commission (AEC; now the NRC) in the late 1960s, and have not been updated since their implementation over 40 years ago. “

Dr. Edward Dietrich

COMMON SENSE METHODS OF RADIATION REDUCTION ALARA – As Low As Resonably Achievable Reduced acquisition frame rates Fluoro save vs. acquisition Low dose acquisition protocols Limit Beam On Time Avoiding angulations such as steep LAO/Cranial Maintaining farthest distance from source feasible Personal Protective Equipment and Physical Barriers

COMMON SENSE METHODS OF RADIATION REDUCTION Shielding Tableside Lead skirts Ceiling shields Personal Protective Equipment Lead apron with minimum .25mm pb equivalency Thyroid collar Lead sleeve Lead glasses Lead surgical cap

New Technologies System Advances New Flat Panel Detectors New X-Ray Tubes New Digital Image processing software Slower frame rates Noise reduction Automated edge enhancement Last image hold

New Technologies Remote Access / Navigation Precision wire and catheter control Operators outside procedure room Catheter manipulation through computer guidance Radiation dose reduction to operators and patients Potential for long distance procedures

Protecting Your Head

Personal Protective Advances New Material Aprons Higher Lead equivalency / lighter physical weight Track Suspended Aprons Eliminates stress and fatigue of apron weight Increases Lead equivialency to 1mm from thyroid to groin Provides protection in body areas traditional aprons cannot X-Ray attenuating hand cream Applied prior to applying gloves or double glove

Conclusions The invisible danger of low-dose ionizing radiation is real to high volume operators Common sense ALARA practices and imaging techniques minimize risks New imaging technology reduces radiation dose and increases diagnostic image quality New personal protective equipment offer increased safety and comfort