Reducing radiation dose: Equipment, procedure, and operator Perfecting the Trifecta

Abstract

This article illustrates the positive impact of fluoroscopic imaging equipment on radiation dose reduction in CTO PCI.• The reader should recognize the importance of purchasing and maintaining the best equipment, understanding procedure/patient complexity, and assuring operator training in radiation dose reduction.• Future efforts/studies should focus upon all three areas of dose reduction for best results.Radiation safety in the cardiac catheterization laboratory has been an important aspect of patient care from its inception. The founders of SCAI, Mason Sones and Melvin Judkins, worked closely with experts in X-ray imaging creating an imaging service to assist laboratories in providing the highest quality images at the lowest dose. With time, (performed) most documentations on fluoroscopy, only short cine runs, no extreme angles, and optimal table (collimation) settings".Operator and staff must maximize their distance from the X-ray tube (The Inverse Square Law), utilize all available shielding, and keep all appendages, operator and patient, out of the imaging field. Societies have published guidelines summarizing these best practices. 5As invasive cardiology expanded from diagnostic to intervention to peripheral to structural, the interventional cardiologist have been inundated by technology requiring the mastering of many skills. This is returning the invasive cardiologists primarily to the cath lab and potentially even specializing in certain areas of interventional practice.Due to the complexity of the equipment, patient/procedure, and operator training, CTOs personify this specialization. The interventional operator must appreciate best practices in radiation safety that includes high quality imaging equipment, a thorough understanding of the patient/procedure, and appropriate operator (and staff ) training in radiation safety. As the professional "gambler" at a race track seldom gambles without full knowledge of the entire race, the interventional cardiologist similarly must understand the total environment. Whether it be the track, horse, and expertise in the betting of the gambler, or the equipment, procedure, and training of the interventionalist, perfecting the trifecta is essential to achieve the best results.

Radiation dose optimization in diagnostic and interventional radiology: Current issues and future perspectives

“…Many publications focus on radiation protection issues in fluoroscopy and specially in interventional procedures [1,[57][58][59][60][61][62][63][64][65][66]. The common feature of all studies is that patient dose optimization in interventional procedures occurs by a combination of equipment protocol modification and operator behaviour, and not simply by changing the protocol characteristics.…”

“…The active use of digital processing, customization of exam protocols, removal of antiscatter grid in specific clinical cases (such as spinal digital subtraction angiography), reduction of pulse rate and frame rate, default use of the fluoroscopy mode at low level, as well as continuous dose monitoring and patient follow-up, are suggested. The new technology features that currently accompany state-of-the art X-ray angiography machines provide potential for dose optimization but their use and their effect on radiation dose must be clearly understood [62,63]. A recent study by Tsalafoutas et al has shown that protocol setting has a large impact on image characteristics and radiation exposure, and that these protocols do not always perform as expected [23].…”