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Radiation Protection in Interventional Radiology

Article in The Indian journal of radiology and imaging · January 2022

DOI: 10.1055/s-0041-1741049

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THIEME
Review Article

Radiation Protection in Interventional

Radiology
Tushar Garg1 Apurva Shrigiriwar1

1 Department of Interventional Radiology, Seth GS Medical College & Address for correspondence Tushar Garg, Department of
KEM Hospital, Mumbai, Maharashtra, India Interventional Radiology, Seth GS Medical College & KEM Hospital,
Acharya Donde Marg, Mumbai, Maharashtra 400012, India
Indian J Radiol Imaging (e-mail: [email protected]).

Abstract There has been a rapid development in the field of interventional radiology over recent
years, and this has led to a rapid increase in the number of interventional radiology
Keywords procedures being performed. There is, however, a growing concern regarding radiation
► ALARA exposure to the patients and the operators during these procedures. In this article, we
► interventional review the basics of radiation exposure, radiation protection techniques, radiation
radiology protection tools available to interventional radiologists, and radiation protection
► radiation protection during pregnancy.

Introduction above a threshold. The threshold is different for different

individuals and is subject to biological variation. Examples of
There has been a rapid increase in the number of interven- deterministic effects include skin injury, hair loss, and cat-
tional radiology (IR) procedures performed in the last de- aracts. According to the reports to U.S. Food and Drug
cade. As the number and complexity of IR procedures being Administration (FDA) and literature, the frequency of injury
performed increase, this leads to increase in radiation expo- is between 1:10,000 to 1:100,000 procedures.6
sure to both patients and staff. This high radiation exposure The skin is the tissue of major concern in interventional
can lead to the occurrence of deterministic effects in both fluoroscopy procedures as the skin is the site where the
patients and staff, and these vary from transient erythema to radiation enters the body; thus, it receives the highest
skin necrosis.1–3 Also, all irradiated patients are at risk of an radiation dose out of any body tissue. The Center of Disease
increased incidence of stochastic injuries. Although IR differs Control and Prevention has classified the deterministic
from diagnostic imaging in the sense that IR procedures are effects of single-delivery radiation dose to the skin of the
usually therapeutic and, in most cases, the risk associated neck, torso, pelvis, buttocks, and arms into five bands (A1, A2,
with radiation exposure is less than the therapeutic effect.4 B, C, D) based on skin dose range, national cancer institute
The radiation exposure to the staff and patients should be skin reaction grade, and approximate time after the onset of
minimized by using the ALARA principles—as the radiation effect.7
protection is optimized when exposure is “as low as reason-
ably achievable, economic, and societal factors are being
Stochastic Effect
taken into account.5”
It is a type of radiation effect in which the severity of the
effect is independent of the total dose, but its probability
Deterministic Effect
increases with the dose increase. An example of this effect is
Deterministic health effects are those in which the severity of radiation-induced cancer, although the probability of radia-
the effect is directly proportional to the dose of radiation tion-induced malignancy caused by an invasive procedure is

DOI https://doi.org/ © 2022. Indian Radiological Association. All rights reserved.

10.1055/s-0041-1741049. This is an open access article published by Thieme under the terms of the
ISSN 0971-3026. Creative Commons Attribution-NonDerivative-NonCommercial-License,
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Radiation Protection in Interventional Radiology Garg, Shrigiriwar

Table 1 Guidelines for patient radiation dose reduction

Preprocedure planning Individual training: All operators should be trained according to the institutional requirements for
fluoroscopy use
All staff members should receive an initial training course in patient radiation management before
they start working in the IR suite with refresher training courses at least annually
Equipment: Only rooms with proper radiation measuring equipment should be used for procedures
that have high radiation exposure
Patient consent: Radiation risks associated with IR procedures should be discussed with the patient
while obtaining procedural consent when the risk radiation exposure associated with a procedure is
high, and the patient is in a high-risk category
Procedure planning: Evaluation of patients should be done with non-invasive cross-sectional imaging
modalities that do not require ionizing radiation use whenever possible. If ionizing radiation
producing modalities are used, dose reduction should be made to decrease total-patient radiation
dose
Procedural planning Procedural radiation monitoring: This should be done throughout the procedure, and the operator
should be notified when the pre-defined radiation dose threshold is crossed
Dose minimization techniques: Pulse fluoroscopy should be used at the lowest pulse rate, which
yields adequate quality image, care should be taken to minimize fluoroscopy time and fluoroscopic
images captured, and appropriate collimation should be used
Postprocedural care Dose documentation: Radiation dose should be recorded in the medical record according to SIR
guidelines.11
Patient follow-up: If the patient receives significant radiation during the procedure, they should be
followed up after the procedure

Abbreviation: IR, interventional radiology.

small compared with the natural frequency of malignancies.8 equivalent in soft tissues 10 mm below the surface of the
When treating pediatric and young adult patients or per- body at the location of the dosimeter, from both the body and
forming procedures which involve substantial absorbed dose collar dosimeters:
to radiosensitive organs, it is crucial to consider the effects of
stochastic effect in the risk–benefit analysis. E(estimate) ¼ 0.5 Hw þ 0.025 HN

HW¼ Reading from dosimeter at waist or chest under the

Patient Dose
apron
In the 1990s, the FDA reported various radiation-induced HN¼ Reading from dosimeter at the neck outside the
skin injuries, which promoted the development of guidelines apron
to document radiation use.9 In 2008, the American College of Occupational Dosimetry in the Interventional Radiology
Radiology (ACR) published its recommendations on patient Suite
radiation exposure in medicine, which included diagnostic The dosimeter has to be used by IR staff during the
imaging procedures and interventional procedures.10 procedure, and the radiation dose is monitored monthly,
Management of radiation dose requires a holistic ap- to allow identification of practices leading to high
proach, which includes pre-procedure planning, intraproce- personal dose and implementation of work habit
dural management, postprocedural care, and periodic changes.
quality assessment. Complete guidelines are available at The International Commission of Radiological Protection
https://www.jvir.org/article/S1051-0443(09)00344-3/pdf; recommends using two dosimeters by IR staff, one under the
however, a summary is present in ►Table 1. apron and one at the collar above the lead apron.12 In
pregnant workers, the fetal dose is estimated by the use of
a dosimeter placed at the mother’s abdomen, under the
Measurement of Occupational Exposure
radiation protection garments.
Dose limits to workers are expressed in the form of equiva-
lent dose in an organ or tissue (HT) for exposure of part of the
Dose Limits
body, and effective dose (E) for exposure of the whole body,
both of them use the SI unit sievert (Sv). The dose limits are maximum values of radiation exposure,
Equivalent dose is measured by multiplying the radiation which ideally should not be reached. Two types of occupa-
weighting factor by mean absorbed dose in a tissue or organ, tional dose limits have been defined: those that establish an
T, which is measured with the personal help dosimeters, and acceptable risk level for stochastic effects and those
effective dose (E) is the weighted sum of all equivalent doses intended to protect specific organs or tissues.5,13 The
in all specified tissues and organs of the body. dose limit recommendations by U.S. National Council on
In the United States, the estimate effective dose is calcu- Radiation Protection and Measurements are given
lated by combining the Hp,10 which represents the dose in ►Table 2.

Indian Journal of Radiology and Imaging © 2022. Indian Radiological Association. All rights reserved.
 Radiation Protection in Interventional Radiology Garg, Shrigiriwar

Table 2 NCRP recommended dose limits for occupational exposure (adapted from Report No. 116—Limitation of Exposure to
Ionizing Radiation)

Dose quantity Effective dose Effective dose Equivalent dose to Equivalent Equivalent
(annual) (cumulative) lens of the eye dose to skin dose to extremities
NCRP maximum 50 mSv/y 10 mSv x age (y) 150 mSv/ y 500 mSv/y 500 mSv/y
permissible dose

Abbreviation: NCRP, National Council on Radiation Protection and Measurements.

Evaluation of Personal Dosimetry Data Radiation Protection Tools

The personal dose record contains information on effective The primary source of radiation exposure to the operator and
dose E, equivalent dose to the lens of the eye from the staff is the scatter from the patient undergoing the proce-
dosimeter worn at collar level or thyroid shield and equiv- dure; this can usually be reduced by controlling the patient
alent dose to hand from a ring or bracelet dosimeter; these dose. Nevertheless, to prevent complications from chronic
readings vary based on the number, type, and location of radiation exposure, protective tools should be used to limit
personal dosimeter used. These personal dose records the occupational radiation dose to an acceptable level.
should be reviewed by the department’s radiation safety
section to ensure that the dose limits are not exceeded. If
Radiation Shields
the monthly exposure reaches 0.5 mSv for an effective dose,
5 mSv for the dose to the lens of the eye, or 15 mSv to the Architectural Shields
hands or extremities a radiation safety officer or a medical Architectural shielding primarily denotes the lead shield,
physicist should investigate to determine the cause of which is built into the walls of IR suites. Rolling and station-
unusual dose and should make suggestions to keep the ary shields rest on the floor of the suite; they are constructed
worker’s dose low. by using transparent-leaded plastic and are useful for pro-
These investigations include checking the validity of the viding additional shielding to both operators and staff. These
dosimeter reading and evaluating changes in the operator’s shields are particularly very useful for nurses and anesthesia
work habits if there is a temporary increase. If the increase is personnel working in the IR room.17
not temporary, the working habits of the individual should
be observed over a series of representative procedures. After
Mobile and Fixed Shielding
the cause(s) of high personal dose levels are identified, then
recommended changes to work practice should be imple- A variety of shields are available in a fluoroscopy suite for
mented, which are then checked with a real-time dosimeter, radiation protection. These include table skirts, ceiling-sus-
which can provide immediate feedback about the radiation pended shielding, and mobile shields on wheels. The shields
dose levels. work by decreasing the scatter radiation from the patient to
the operator and the staff, which is the main mechanism of
radiation exposure. Equipment-mounted shielding includes
Radiation Protection
the protective drapes that are suspended from the tables and
Three basic principles are at play, time, distance, and the ceilings. Protective lead curtains are detachable devices
shielding are at play to achieve radiation protection. In that can be placed on either side of the table where the
fluoroscopy-guided interventions, the time spent checking operator is working; they help prevent the radiation expo-
the C-arm fluoroscopy is directly related to radiation expo- sure to lower extremities of the operator, which are other-
sure. Time exposure of the staff should be ALARA as wise not protected with the help of a lead apron.18 In a study
generally less exposure time correlates to less radiation published by Shortt et al, the use of protective lead curtains
dose.14 The fluoroscopy time is often used as an indicator of under the table showed statistically significant dose reduc-
procedural dose, but the actual correlation is very poor, and tion in lower extremities as compared with control (Siemens
therefore fluoroscopy time individually should not be used Angioskop C-Arm undercouch fluoroscopy systems [Siemens
as the dose indicator.15 Total fluoroscopy time during an IR Medical Solutions, Forchheim, Germany]).19
procedure can be reduced by optimizing the number of Ceiling suspended shields are generally made out of
fluoroscopic images captured, the number of x-pulses gen- transparent leaded plastic and should always be used in
erated per image, number of runs, and their duration and lengthy procedures. They are most useful when they are
frame rate. positioned close to the patient’s skin; they work by reducing
A greater distance from the source of radiation can also the scatter radiation to the operator. When placed at an
reduce radiation exposure, as the amount of radiation appropriate location and angle, they can reduce the radiation
exposure is inversely proportional to the square of the exposure to the lens of the eye significantly.20,21 The
distance.16

Indian Journal of Radiology and Imaging © 2022. Indian Radiological Association. All rights reserved.
Radiation Protection in Interventional Radiology Garg, Shrigiriwar

reduction in the radiation can be as much as 90 to 98% monitor readings over 4 mSv and are below 40 years of age
depending on the location of the X-ray source and the due to the risk of radiation-induced thyroid cancer.27,28
shield.22
Ceiling-Suspended Personal Protective Garments
Ceiling suspected personal protection apron (Zero Gravity,
Radiation Shielding Placed on Patients
CFI Medical Solutions) has been developed to reduce fatigue
Disposable protective drapes or shields, which can be placed and prevent orthopaedic injuries in operators, which occur
directly on patients, drastically decrease the scatter radia- from wearing heavy protective apparel.29 They utilize a
tion. RADPAD (Worldwide innovations & technologies, Inc., suspended 1.0 mm lead body shield, which engages magnet-
Kansas City, Kansas) is one such shield; it is available as a ically to a vest worn by the operator, which allows it to move
sterile surgical drape and contains bismuth and barium as in sync with the operator; also, it employs a 0.5 mm lead
radiation protection materials. It should be placed appropri- equivalent acrylic face shield that protects the head, eyes,
ately on the patient between the image intensifier and the and neck of the operator. These ceiling-suspended aprons
operator to reduce scatter radiation. Proper positioning of provide superior operator protection as compared with
RADPAD is critical; if it is placed in the path of the primary conventional lead aprons with under table shield or ceiling
beam, it can increase the radiation to the patient drastically. mount shields. They have an added advantage of being more
Various types of RADPAD are available in the market based flexible, which allows clinicians freedom of movement dur-
on the procedure being performed, and these include RAD- ing challenging procedures.
PAD peripheral shield with absorbent, RADPAD biopsy shield
with absorbent, RADPAD Jugular Access/TIPS shield with
Eye Protection
absorbent, RADPAD biliary shield with absorbent, RADPAD
fenestrated radial entry shield with absorbent, and RADPAD Radiation exposure to the eye lens can lead to the formation
infant collimation shield. of cataracts until recently maximum permissible dose for the
In IR suites instead of standard surgical drapes, sterile lens is 150 mSv per year, but now new data has shown that
lead-free disposable drapes can be used, which are made of the threshold might be significantly lower or even zero.30,31
lightweight disposable cloth with a 0.1mm lead equivalency. Operators can minimize radiation dose to the lens by paying
These drapes are simple to position and do lead to a signifi- attention to imaging-chain geometry, beam projection, po-
cant reduction in radiation exposure, varying from 14% up to sition and head orientation of the operator, leaded eyewear,
94%.23–25 and ceiling-suspended shields. Lead glasses with different
styles and fit provide different lens protection, although
glasses with lead equivalences of 0.35 and 0.5 mm and higher
Personal Radiation Protection Garments
provide similar protection.32,33 Large-sized lens glasses (at
Leaded Aprons and Thyroid Shields least 27 cm2 per glass) and those with large side panels are
Lead aprons and thyroid shields are the principal radiation preferred.34,35 There are various types of eyeglasses; these
protection tool for interventional radiologists, and they include fit-over glasses, wraparound, rectangular with a side
should be worn at all times during the procedure. The shield, sports wrap, and newer lightweight models.
radiation protection provided by these lead aprons is similar Typically, during fluoroscopy, the operator’s head is
to a 0.25 to 1 mm thick lead. Ninety percent or more reduc- placed at an angle to the scatter volume because of which
tion of scatter radiation is observed when lead aprons with the operator’s eyes are exposed to radiation from the side;
0.5 mm thickness are used. therefore, they should use glasses designed to block side
The selection of aprons and thyroid shields from a wide exposure. All eyewear styles are found to be less effective as
variety of styles, sizes, and materials depends on radiation the exposure is changed from the front so side, but the
protection efficacy, fit, comfort, weight, durability, and ease sportswear model has the lowest profile side panel and
of maintenance. Different designs of lead aprons are avail- therefore offers the least protection. The newer lightweight
able in the market. These include aprons with only front models are comfortable to wear on a regular basis as they are
covers, aprons that wrap around the body, and two-piece not heavy, they also provide equal frontal and lateral protec-
garments with vest and kilt. Styles with front closures tion due to the wide area of the frame, but the overall
provide a double barrier of thickness to the chest, abdomen, protection is inferior to the classic models. Finally, to attain
and pelvis in the front as the fabric overlaps her;, this may be proper radiation protection, lead glasses should have a
desirable to operators of reproductive age. The aprons that good fit.
cover the back are heavier than others, but they protect the
back when the operators turn away from the patient during
Radiation Protection for the Head and Hands
fluoroscopy. Any of these designs can be used, but the apron
that is selected must fit properly and give adequate coverage For cranial protection disposable, lightweight, surgical caps
at the neckline and armholes.26 containing two layers of barium sulfate-bismuth oxide com-
Thyroid shields are also available in various styles, but all posite can be used.36 Hands are the closest body part of the
of them wrap around the neck. They are especially recom- operator to the patient and the primary beam, so they can
mended for personnel who receive monthly collar radiation potentially be exposed to a very high radiation dose. Most

Indian Journal of Radiology and Imaging © 2022. Indian Radiological Association. All rights reserved.
 Radiation Protection in Interventional Radiology Garg, Shrigiriwar

operators believe that instead of using hand radiation shield- exposure to a monthly equivalent dose of 0.5 mSV once the
ing, using collimation, oblique views, and intermittent fluo- pregnancy is identified.39 The Nuclear Regulatory Commis-
roscopy to avoid hand placement in the beam results in more sion has declared a regulatory limit of 5 mSV for the entire
radiation protection to the patient and operator. duration of pregnancy.38 The dose of exposure to the con-
A variety of hand protective products are still available in ceptus can be approximated as one half of the personal
the market for operators to choose from. Some products that equivalent dose at 1 cm, Hp (10), for the dosimeter placed
are most commonly used include attenuation gloves, and on the waist/abdomen.40 The employer must evaluate and
radiation protection creams containing bismuth oxide. ensure that the conceptus dose is kept below the recom-
mended threshold throughout the gestation period.
For monitoring radiation exposure, the use of a single
Quality Control
personal dosimeter worn under any protective apron at the
It is an essential part of radiation protection in any IR level of the waist is recommended. An additional dosimeter
department. Qualified personnel with medical physicists can also be placed on the mother’s abdomen. These readings
help perform acceptance tests like image quality, radiation should be monitored monthly. Any worker contemplating
output, and visual inspection of protective devices on all pregnancy can also request a waist/abdominal badge.
image systems and personal protective devices. These quali- Workplace Injury Illness Prevention Programs are man-
ty control tests have to be performed annually under the datory in 15 states in the United States to provide hazard
medical physicist. awareness training to the employees upon initial hire and
subsequently annually. Counseling on the potential risks of
radiation exposure to pregnant workers and their partners, if
Good Radiation Safety Practices
possible, is an integral part of radiation protection
The Society of Interventional Radiology and Cardiovascular programs.38
and Interventional Radiology Society of Europe published Following work modifications are recommended when-
occupational radiation protection in IR guidelines in 2010. ever possible:
These guidelines provide some techniques that can be imple-
1. Minimizing fluoroscopy time (prohibiting less-experi-
mented by all IR departments to decrease the patient dose,
enced workers from operating the fluoroscopy controls).
scatter dose, and occupational dose. Key points are men-
2. Substituting ultrasound for fluoroscopy guidance if it does
tioned below37:
not affect patient outcome.
1. Minimize fluoroscopy time 3. Carefully planning the intervention may reduce unneces-
2. Minimize the number of fluoroscopic images sary fluoroscopy.
3. Use available patient dose reduction technologies 4. Stepping into the control room during imaging runs.
4. Use good image chain geometry 5. Standing behind a full-length leaded shield.41
5. Use collimation 6. Increase the distance between the operator and the
6. Use all available information to plan the interventional radiation source.
procedure 7. Placing movable lead shields between the operator and
7. Position yourself in a low-scatter area the X-ray beam when one cannot step away from the
8. Use protective shielding table.42
9. Use appropriate fluoroscopic imaging equipment 8. Redelineation of roles with the redistribution of respon-
10. Obtain appropriate training sibilities where possible.41
11. Wear your dosimeters and know your own dose
Conclusion
Radiation Protection during Pregnancy
With the exponential rise in the use of IR procedures, it is
The risk of adverse health effects to the embryo or fetus is essential to follow a holistic approach to limit radiation
extremely low or possibly nonexistent when the radiation exposure to the operators and staff and to ensure improved
exposure is lower than 100 mGy. Radiation exposure can lead patient safety. To ensure maximum radiation protection, it is
to two types of adverse health effects to the conceptus— paramount to understand the basics of radiation physics,
tissue reactions (i.e., deterministic effects—congenital dis- understand its detrimental effects—deterministic and sto-
abilities, pregnancy loss, mental retardation, growth retar- chastic effects, learn to evaluate personal dosimetry data,
dation) and stochastic effects (damage to a single cell that is and adhere to dose-limiting thresholds. Knowledge about
enough to cause a mutation which increases the risk of various radiation protection equipment and good radiation
cancer as the dose increases). The risk of these adverse health safety practice is of utmost importance.
effects depends on the gestational age during which the
exposure occurred (maximum risk during the preimplanta- Financial Support and Sponsorship
tion and organogenesis, second-trimester exposure, and the Nil.
least risk in the third trimester).38
In the United States, the National Council on Radiation Conflicts of interest
Protection and Measurements (NRCP) recommends limiting There are no conflicts of interest.

Indian Journal of Radiology and Imaging © 2022. Indian Radiological Association. All rights reserved.
Radiation Protection in Interventional Radiology Garg, Shrigiriwar

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