1

Fluoroscopy

M Ishaq Khan.
Lecturer.
UIRSMIT, FAHS,
The University of Lahore.
Radiation Safety
& Protection in
Interventional
Fluoroscopy
 Learning Outcomes:
•Introduction to Radiation safety in fluoroscopy
•Negative Effects of ionizing radiations:
Stochastic effect
Determinstic effect

•Risks and benefits of fluoroscopy

•Management/safety protection for fluoroscopy
 Introduction to Radiation
Safety in Fluoroscopy:-
•Over the last 25 years, fluoroscopically guided interventional procedures
have revolutionized medical care. Percutaneous stunt placement has
replaced surgical bypass for arterial revascularization.

•Hysterectomy for symptomatic fibroids is becoming less common as a result

of the wide availability of uterine artery embolization. These developments
have benefited thousands upon thousands of people because of less
morbidity than in the surgical procedures they have replaced.
•Fluoroscopy does, however, come with a price: exposure to
ionizing radiation. It is the responsibility of each
interventionist to use fluoroscopy judiciously and in such a
way that its immediate medical benefits outweigh its
potential future risks.

•Todo so, the practitioner must understand the bio-effects of

ionizing radiation, provide meticulous pre-procedural and
post-procedural patient care, and develop optimal work
habits in the fluoroscopic suite. A well-rounded radiation
management program is important not only to minimize
exposure to the patient but also to minimize occupational
doses incurred by the interventional radiology team.
 Negative Effects of Ionizing
Radiation:-
Effects of radiation can be divided into two basic categories:
1. Stochastic effects.

2. Deterministic effects.
i)- Stochastic Effects:
•Stochastic effects are those in which no clear relationship
exists between the magnitude of the radiation dose and the
severity of the effect.
•Stochastic effects include genetic mutation and induction of
cancer.
•These assumptions are not universally accepted. However,
because of this uncertainty, the current approach is that
stochastic effects have no threshold dose. Therefore, no
radiation dose can be considered absolutely safe. It is
imperative that fluoroscopically guided diagnostic and
therapeutic procedures be performed under the safest
ii)- Deterministic Effects:
•Deterministic effects are those in which the likelihood & severity of the effect
are related to the magnitude of the radiation dose: the higher the dose, the
more severe the effect. Deterministic effects have a minimum dose threshold
below which no effect will occur. Examples of deterministic effects are
radiation-induced skin injury (including epilation, acute burns, and delayed
ulcers) and radiation-induced cataracts.
•The threshold dose for temporary epilation is about 3-Gy, whereas that for
development of a cataract is about 2-Gy for a single exposure. Thresholds are
higher for doses fractionated over time. Cataracts and epilation have occurred
in patients as a consequence of complex intracranial neuro-interventional
procedures such as embolization of arteriovenous malformations (AVMs).
•Since the mid-1980s, skin injuries have been reported in patients as a direct
result of complex fluoroscopically guided interventional procedures,
including arterial embolization, arterial revascularization, cardiac
radiofrequency ablation, and TIPS.

•The rise in reporting these adverse events resulted in U.S. Food and Drug
Administration (FDA) action in 1994 and in U.S. federal regulations limiting
the x-ray tube output of interventional fluoroscopic equipment. Similar
actions have taken place throughout the world.

•The threshold dose for acute skin erythema is about 2-Gy, and that for
delayed deep skin ulcers is about 12 to 15-Gy.
•The risk for deterministic injury rises if multiple sequential procedures are
performed at the same anatomic location i.e TIPS procedure and TIPS
revision 3 months apart).

•Other risk factors for skin injury include obesity, diabetes mellitus, and
connective tissue disease. Minimizing the risk of deterministic patient
injury is a major focus of current radiation safety initiatives.
 Benefits of Fluoroscopy:-
Fluoroscopy is used in a wide variety of examinations and procedures to
diagnose or treat patients. Some examples are:
•Barium X-rays and enemas (to view the gastrointestinal tract)
•Catheter insertion and manipulation (to direct the movement of a catheter
through blood vessels, bile ducts or the urinary system).
•Placement of devices within the body, such as stents (to open narrowed or
blocked blood vessels)
•Angiograms (to visualize blood vessels and organs)
•Orthopedic surgery (to guide joint replacements and treatment of fractures).
 Risks of Fluoroscopy:-
•Fluoroscopy carries some risks, as do other X-ray procedures. The radiation
dose the patient receives varies depending on the individual procedure.
Fluoroscopy can result in relatively high radiation doses, especially for
complex interventional procedures (such as placing stents or other devices
inside the body) which require fluoroscopy be administered for a long
period of time.
•Radiation-related risks associated with fluoroscopy include:

i. Radiation-induced injuries to the skin and underlying tissues (“burns”),

which occur shortly after the exposure, and
ii. Radiation-induced cancers, which may occur some time later in life.
•The probability that a person will experience these effects from a
fluoroscopic procedure is statistically very small. Therefore, if the
procedure is medically needed, the radiation risks are outweighed by the
benefit to the patient.

•In fact, the radiation risk is usually far less than other risks not associated
with radiation, such as anesthesia or sedation, or risks from the treatment
itself. To minimize the radiation risk, fluoroscopy should always be
performed with the lowest acceptable exposure for the shortest time
necessary.
 Management of Patient
Exposure during Fluoroscopy:-
•Equipment Maintenance.

•Pre-procedural Patient Care.

•Intra-procedural Patient Care.

i)- Equipment Maintenance:-
•Optimal radiation exposure management begins with equipment purchase
and room design. The interventionist must be involved in both processes
and must insist that radiation safety be a major factor in decision making.
For an existing interventional radiology suite, adherence to a preventive
maintenance schedule ensures that equipment will operate properly.

•Preventive maintenance also allows early replacement of parts before their

deterioration contributes to unnecessarily high radiation exposure.
ii)- Pre-procedural Patient Care:-
•The interventional procedure must be medically necessary to justify
exposure to ionizing radiation. This is particularly important for procedures
known to be associated with high exposure: TIPS, visceral stent placement,
visceral embolization, and neuroembolization. For these interventions in
particular, the risk for radiation-induced skin injury should be specifically
discussed in the consent process.

•In addition, history taking should include questions about previous

radiation exposure and factors that increase a person’s susceptibility to
radiation-related skin injury (e.g., diabetes). The physical examination
should include inspection of the skin at previous x-ray beam entry sites.
•Discussion of radiation-induced cancer risk is not typically included in the
consent process because the immediate benefit of a medically necessary
procedure far outweighs the risk for development of cancer in the distant
future. However, the interventionist should be prepared for patient
questions regarding this issue.

•Patient pregnancy is a contraindication to fluoroscopically guided

procedures because of the risk of genetic mutation during early gestation
and the risk of mental retardation and leukemia during late gestation.
Because the life of the fetus depends on the life of the mother, however,
occasional exceptions to this rule exist.
•It is key for the interventionist to collaborate closely with an obstetrician
and a physicist during and after the procedure. In instances in which the
woman and fetus survive the acute threat to life, formal fetal dose
calculation may contribute to a recommendation that the pregnancy be
terminated. Same collaboration should take place if found that a fetus was
exposed unintentionally.
iii)- Intra-procedural Patient Care:-
•For most interventional procedures, fluoroscopy time is the single most
important determinant of patient radiation exposure that is under control
of the operator. It correlates poorly with patient dose, however, because so
many other variables, such as body habitus, affect the absorbed dose. It is
possible to reach a skin dose of 2 Gy with a fluoroscopy time of 15 to 20
minutes in an obese abdomen.
•The operator should strive to keep the fluoroscopy time as brief as possible
and should maintain awareness of the elapsed fluoroscopy time during the
course of a procedure. New interventional rooms display the elapsed
fluoroscopy time on an in-room monitor, whereas older equipment uses an
audible signal at 5-minute intervals to note the elapsed fluoroscopy time.
•Work habits of the interventionist have a profound effect on patient
radiation exposure. Optimal work habits require knowledge of radiation
physics, familiarity with tableside controls of the x-ray equipment, practice
using these controls, and a commitment to radiation safety as a patient care
priority.

•Factors affecting fluoroscopy time include complexity of the procedure,

operator experience, patient anatomy, image quality, inventory of
disposables, and luck. One learned skill that can help lower fluoroscopy
time is to make use of last image hold.
C-Arm
• It is a good and very important question.
• Fortunately, there are techniques that can reduce the risk for all
concerned. And there are federal regulations in place to limit the
maximum output for C-Arms.

i)- Talk to your patient about the radiation risks:

•They need to be informed about and understand that the radiation dose
may be high, and what the risks are, including damage to DNA. It’s
important to share this information in a way that is easy to understand.
Remember, much of the terminology and language that you use day in and
day out is foreign to them.
ii)- Try to reduce the amount of radiation exposure:
•Obviously, you can’t shield your patients entirely. However, you can reduce
their exposure to radiation by limiting or adjusting the time of exposure to
radiation.

iii)- Adjust distance:

•Your patient’s exposure to radiation increases exponentially by how close
the patient is to the x-ray tube. Try to position your patient as far as
possible from the tube. Ideally, your patient should be 12-15 inches away.
In addition, your patient should be as close as possible to the image
intensifier.
iv)- Shorten the fluoro times:
•If you use intermittent fluoroscopy in combination with the image hold
capacity, you can reduce the amount of radiation. You can also use pulsed
fluro, single pulse, manual mode, image hold and the timer warning
settings.

v)- Unauthorized personnel should not be in the room during

the fluoroscopy:
Only the personnel trained and required for the procedure should be in
attendance.
vi)- Analyze original radiographs before performing the
fluoroscopic examination:
•This can reduce the repeat rate for the time required for the procedure.

vii)- Stand on the image intensifier side of the C-Arm when

performing the procedure:
•This will avoid radiation leakage from the x-ray tube.

viii)- Be sure to step away from the patient during the

fluoroscopy:
•Placing yourself one foot further (or more) from the patient will reduce
the amount of radiation you are exposed to.
ix)- Shield yourself as much as possible:
•Leaded eyewear with side shields can protect the lens or your eyes.
Without side shields, your eyes are not protected if you look sideways
from the C-Arm x-ray tube to see the image on the monitor. You should
also wear leaded gloves and wear a wrap-around apron which will keep
the lead between you and the x-ray tube.

x)- Install structural shielding to reduce radiation:

•This could be a lead acrylic shield that is under the table or even mounted
on the ceiling.
 References:-
•https://
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RVIEW_OF_CONTEMPORARY_INTERVENTIONAL.21.aspx
•https://pubs.rsna.org/doi/abs/10.1148/radiographics.16.5.8
888398
•https://pubs.rsna.org/doi/abs/10.1148/radiology.219.2.r01
ma41515
•https://www.sciencedirect.com/science/article/pii/S105104
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