FT cannot be used to estimate PSD, and CAK and KAP represent poor surrogate markers for JCAHO-defined sentinel events. Even when directly measured PSDs were used, there was a poor correlation with clinical event (no skin injuries with an average PSD >2 Gy). The effective radiation dose of an eTAAA is equivalent to two preoperative computed tomography scans. The maximal operator exposure is 50 mSv/year, thus, a single operator could perform up to 294 eTAAA procedures annually before reaching the recommended maximum operator dose.

Due to the proliferation of disciplines employing fluoroscopy as their primary imaging tool and the prolonged extensive use of fluoroscopy in interventional and cardiovascular angiography procedures, "dose-area-product" (DAP) meters were installed to monitor and record the radiation dose delivered to patients. In some cases, the radiation dose or the output value is calculated, rather than measured, using the pertinent radiological parameters and geometrical information. The AAPM Task Group 190 (TG-190) was established to evaluate the accuracy of the DAP meter in 2008. Since then, the term "DAP-meter" has been revised to air kerma-area product (KAP) meter. The charge of TG 190 (Accuracy and Calibration of Integrated Radiation Output Indicators in Diagnostic Radiology) has also been realigned to investigate the "Accuracy and Calibration of Integrated Radiation Output Indicators" which is reflected in the title of the task group, to include situations where the KAP may be acquired with or without the presence of a physical "meter." To accomplish this goal, validation test protocols were developed to compare the displayed radiation output value to an external measurement. These test protocols were applied to a number of clinical systems to collect information on the accuracy of dose display values in the field.

Modern fluoroscopes used for image‐based guidance in interventional procedures are complex X‐ray machines, with advanced image acquisition and processing systems capable of automatically controlling numerous parameters based on defined protocol settings. This study evaluated and compared approaches to technique factor modulation and air kerma rates in response to simulated patient thickness variations for four state‐of‐the‐art and one previous‐generation interventional fluoroscopes. A polymethyl methacrylate (PMMA) phantom was used as a tissue surrogate for the purposes of determining fluoroscopic reference plane air kerma rates, kVp, mA, and variable copper filter thickness over a wide range of simulated tissue thicknesses. Data were acquired for each fluoroscopic and acquisition dose curve within each vendor's default abdomen or body imaging protocol. The data obtained indicated vendor‐ and model‐specific variations in the approach to technique factor modulation and reference plane air kerma rates across a range of tissue thicknesses. However, in the imaging protocol evaluated, all of the state‐of‐the‐art systems had relatively low air kerma rates in the fluoroscopic low‐dose imaging mode as compared to the previous‐generation unit. Each of the newest‐generation systems also employ Cu filtration within the selected protocol in the acquisition mode of imaging; this is a substantial benefit, reducing the skin entrance dose to the patient in the highest dose‐rate mode of fluoroscope operation. Some vendors have also enhanced the radiation output capabilities of their fluoroscopes which, under specific conditions, may be beneficial; however, these increased output capabilities also have the potential to lead to unnecessarily high dose rates. Understanding how fluoroscopic technique factors are modulated provides insight into the vendor‐specific image acquisition approach and may provide opportunities to optimize the imaging protocols for clinical practice.PACS number: 87.59.C‐

Using the latest technology and image processing tools enables significant reduction in radiation exposure during complex liver interventional procedures.

Purpose The goal of this study was to investigate x‐ray beam profiles at various water depths to characterize the two‐dimensional x‐ray dose distribution, allowing for off‐axis and out‐of‐field radiation dose estimation for a wide range of x‐ray beam spectra commonly encountered in fluoroscopically guided interventional procedures. Methods A Siemens Artis interventional fluoroscope was operated in a service mode to generate a continuous x‐ray beam at fixed x‐ray beam spectra, defined by their kVp and the thickness of additional copper filtration. A PTW scanning water tank with a diode detector was used to measure the x‐ray beam profiles at several depths in water at various fields of view and x‐ray beam spectra, both parallel and perpendicular to the anode‐cathode axis direction. Results X‐ray beam profiles, including out‐of‐field tails, were characterized for a wide range of beam qualities. The anode heel effect was pronounced even at depth, resulting in large dose variations across the x‐ray field; this effect was even more definite at large fields of view, at higher kVps, and in the absence of additional copper filtration. Conclusions This study investigated and characterized 2D radiation dose deposition in water from x‐ray beam spectra commonly used by modern fluoroscopes in interventional procedures. This knowledge can be applied to manual dosimetry calculations or can be used to refine the accuracy of automated dose mapping tools or Monte Carlo simulations of the radiation dose to soft tissue within the x‐ray field and to tissue adjacent to the primary beam. Additionally, this study illustrates a substantial reduction of the anode heel effect by using moderate amounts of additional copper filtration to harden the x‐ray beam spectrum.

Objective: The objective of this study was to analyze radiation risk to patients during endovascular aneurysm repair (EVAR) using mobile C-arm (MA) or fixed C-arm (FA) fluoroscopes and to describe the dose distribution during the different phases of the procedure.Methods: Patients treated with EVAR using a single stent graft system between November 2009 and June 2016 were included in this study. The patients were divided into one of two groups (MA or FA) according to the type of C-arm used in the procedure. Data regarding patients' demographics and the total amount of contrast agent (CA) used, dose-area product, and fluoroscopy time for the procedures were prospectively recorded. Based on the dose report from the FA system, five standard and two optional phases of the procedure were identified to determine the dose distribution.Results: Overall, 160 patients were included (mean age, 73.30 6 8.97 years; 146 men); of these, 107 were treated with an MA system and 53 were treated with an FA system. The mean amounts of CA used were 108.55 6 42.28 mL in the MA group and 85.37 6 38.79 mL in the FA group (P ¼ .0014). The mean total dose-area product values were 49.93 6 38.06 Gy$cm 2 in the MA group and 168.34 6 146.92 Gy$cm 2 in the FA group (P < .0001). There was no significant difference in fluoroscopy time between the groups. Per-phase analysis demonstrated that identification of the proximal landing zone and main body deployment required the most radiation, accounting for 24% of the total radiation dose. Overall, 47.6% of the exposure was due to digital subtraction angiography.Conclusions: Use of an FA system can significantly reduce the amount of CA needed but may also lead to higher radiation doses in EVAR procedures. Dose monitoring remains crucial for the safety of both patients and operators. A detailed analysis of dose distribution is possible with modern systems, which may improve the quality of monitoring in the future.

Modern fluoroscopes used for image guidance have become quite complex. Adding to this complexity are the many regulatory and accreditation requirements that must be fulfilled during acceptance testing of a new unit. Further, some of these acceptance tests have pass/fail criteria, whereas others do not, making acceptance testing a subjective and time‐consuming task. The AAPM Task Group 272 Report spells out the details of tests that are required and gives visibility to some of the tests that while not yet required are recommended as good practice. The organization of the report begins with the most complicated fluoroscopes used in interventional radiology or cardiology and continues with general fluoroscopy and mobile C‐arms. Finally, the appendices of the report provide useful information, an example report form and topics that needed their own section due to the level of detail.

The first goal of this study was to investigate the accuracy of the displayed reference plane air kerma (normalKnormala,normalr) or air kerma‐area product (normalPnormalk,normala) over a broad spectrum of X‐ray beam qualities on clinically used interventional fluoroscopes incorporating air kerma‐area product meters (KAP meters) to measure X‐ray output. The second goal was to investigate the accuracy of a correction coefficient (CC) determined at a single beam quality and applied to the measured normalKnormala,normalr over a broad spectrum of beam qualities. Eleven state‐of‐the‐art interventional fluoroscopes were evaluated, consisting of eight Siemens Artis zee and Artis Q systems and three Philips Allura FD systems. A separate calibrated 60 cc ionization chamber (external chamber) was used to determine the accuracy of the KAP meter over a broad range of clinically used beam qualities. For typical adult beam qualities, applying a single CC determined at 100 kVp with copper (Cu) in the beam resulted in a deviation of <5% due to beam quality variation. This result indicates that applying a CC determined using The American Association of Physicists in Medicine Task Group 190 protocol or a similar protocol provides very good accuracy as compared to the allowed ±35% deviation of the KAP meter in this limited beam quality range. For interventional fluoroscopes dedicated to or routinely used to perform pediatric interventions, using a CC established with a low kVp (∼55−60 kVp) and large amount of Cu filtration (∼0.6−0.9 mm) may result in greater accuracy as compared to using the 100 kVp values. KAP meter responses indicate that fluoroscope vendors are likely normalizing or otherwise influencing the KAP meter output data. Although this may provide improved accuracy in some instances, there is the potential for large discrete errors to occur, and these errors may be difficult to identify.PACS number(s): 87.59.C‐, 87.59.cf, 87.53.Bn