Physician and Patient Radiation Exposure During Endovascular Procedures

September 18, 2017

Physician and Patient Radiation Exposure During Endovascular Procedures
There has undoubtedly been evidence of physician and patient radiation exposure during an endovascular procedure, but what exactly do the statistics look like? We break down the numbers from a study performed by physicians at the Cardiovascular Institute at Rhode Island Hospital, along with some performed by Cleveland Clinic physicians, for a look inside both the physician’s and the patient’s exposure levels during an endovascular procedure.
 
More Procedures, More Radiation
Physician and patient radiation exposure has rapidly increased over time, corresponding to an increased use of interventional endovascular procedures. As patients undergo more procedures, exposure levels and associated risks will continue to escalate. 
 
An analysis of 50 patients admitted into a cardiology ward in Pisa, Italy documented that patients underwent a median of 36 x-ray studies with a median cumulative effective dose of 60.6 mSv.
 
Physician Exposure
Physician exposure varies widely depending upon the procedure performed. For example:
  • EVAR and TEVAR for aortic aneurysms present two of the highest radiation exposures faced by vascular physicians. 
  • Peripheral vascular interventions in the extremities typically require less radiation than aortic interventions, although the duration of both types of procedures typically equates to more radiation exposure than during coronary interventions. 
A physician’s position relative to colleagues and to the x-ray source can also significantly impact exposure. 
 
In one study, Cleveland Clinic group reviewed 39 cases of fenestrated TEVAR and reported radiation doses to 218 personnel. The mean effective doses were 0.125 mSv for primary operators, 0.268 mSv for anesthesia providers, 0.026 mSv for scrub nurses, and 0.019 mSv for radiation technologists.
 
Operator doses may be 5- to 20-fold higher during procedures performed in a dedicated endovascular suite with fixed imaging equipment, compared to a conventional operating room with a mobile C-arm.
 
For physicians, the risk for radiation-associated malignancy has been estimated to increase by 0.004% per mSv of effective dose.
 
In 2013, Roguin et. al. published a landmark case series documenting 31 brain and neck tumors in interventional cardiologists and radiologists. The malignancies were left-sided in 85% of the 26 cases, corresponding to the physicians’ angle of greatest exposure, suggesting a significant connection between radiation exposure for physicians and brain malignancies.
 
Patient Exposure
In this most comprehensive study to date, vascular surgeons at the Cleveland Clinic also reviewed patient radiation doses for 2,096 consecutive endovascular procedures over a 30-month period. Mean effective doses for 9 procedure types were as follows: 
  • 15 mSv for lower extremity angiograms 
  • 47 mSv for lower extremity interventions 
  • 52 mSv for cerebrovascular angiograms 
  • 120 mSv for cerebrovascular interventions
  • 65 mSv for TEVAR
  • 109 mSv for infrarenal EVAR
  • 83 mSv for visceral interventions
  • 86 mSv for renal interventions
  • 109 mSv for atherectomy procedures
Not surprisingly, emergent procedures result in increased radiation dosage. Pre-procedural planning CTs may increase patients’ radiation exposure as well, with thoracic, abdominal, and pelvic scans imparting higher dosage than extremity scans due to the relative amounts of tissue penetration needed. For EVAR patients, postoperative CT scanning also adds significantly to patients’ radiation exposure.
 
As you can see, fluoroscopic procedures pose damaging risks to both physicians and patients during endovascular procedures. Thanks to medical device advancements, such as our IOPS device, many of these radiation risks can be vastly reduced.