1. 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

2. 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

3. 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

5. Invisible Danger

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

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

8. 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:
Vaño E, Gonzalez L, Fernandez JM, et al. Occupational radiation doses in interventional cardiology: a 15-year follow-up. Br J Radiol. 2006;79:

9. 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:
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:
Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol. 2013;111:

10. Why be concerned?
In a large prospective trial of 90,957 radiographers ( ), 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, Am J Roentgenol. 2016;206:

11. 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:
Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol. 2013;111:

12. 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.

14. “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.”

15. “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. “

16. Dr. Edward Dietrich

17. 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

18. 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

19. 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

20. 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

21. Protecting Your Head

22. 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

23. 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