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OptimizationofRadiationProtectioninCardiologyL91Lecture9:OptimizationofRadiationProtectioninCardiologyEducationalObjectivesOptimizationininterventionalcardiologyWaystoimprovetheradiationprotectionaspectofprocedure(balancingdiagnosticinformationversuspatientdoses)

Asingle-centre’s(Udine,Italy)experiencewithoptimizationandflatpaneldetector2Lecture9:OptimizationofRadiationProtectioninCardiologyIsthisstatement“True”or“False”?Switchingfromoldangiographymachinewithimageintensifiertoanewmachinewithflat-paneldetectorwilldefinitelyreducepatientradiationdose.3Lecture9:OptimizationofRadiationProtectioninCardiologyInroomdosimetricindicationsHaveyoueverpaidattentiontothis?4Lecture9:OptimizationofRadiationProtectioninCardiologyDoyouknowhowtointerpretthesedata?5Lecture9:OptimizationofRadiationProtectioninCardiologyRealitycheck……

DoseInformationandDoseReportsUnderstandingthedoseinformationavailableinthecath.lab.?Doyoufollow(andarchive)patientdosereports?Understandingthedosevaluesinyouroccupationaldosereport?Canyoumakeoutifthedosevaluesasdepictedinthemonitorincath.lab.are“normal”or“toohigh”?

6Lecture9:OptimizationofRadiationProtectioninCardiologyRealitycheck……

KnowingyourXraymachineWhatisthe“cost”inradiationdoseyouare“paying”fortheimagequalityyouwant?Haveyouevaluatedwhetherfewerimageswithlowerimagequalityareacceptable?Doyouknowthedoseratevaluesanddose/imageforthedifferentoperationmodes?Doyouknowthedifferenceindoseforthedifferentfieldofview(FOV)formats(magnification)?Doyouknowhowtousethenewerdose-reducingfeatures?7Lecture9:OptimizationofRadiationProtectioninCardiologySiemensAxiomArtisCinenormalmode20cmPMMA177

Gy/fr(entrancePMMA)SiemensAxiomArtis,Fluorolowdose20cmPMMA13

Gy/fr(entrancePMMA)8Lecture9:OptimizationofRadiationProtectioninCardiologyOptimizationmeans...Toavoidacquiringmoreimagesthannecessary:Takecareofthefluoroscopytime.Takecareofthenumberofseries.Takecareofthenumberofframesperseries.

Toavoidacquiringimageswithmorequality(andmoredose)thannecessary:Itcouldbepossibletoacceptsometimessomenoisyimagesinfluoroscopyandalsoincineacquisitions.9Lecture9:OptimizationofRadiationProtectioninCardiologyOptimizationofRadiationProtectionMinimizationofdosetopatientandstaffshouldnotbethegoalMustoptimizedosetopatientandminimizedosetostaffOptimizedpatientdoserateshouldhavesufficientdoseratetoprovideadequateimagequality

Ifimagequalityisinadequate,then anyradiationdoseresultsinneedlessradiationdose!10Lecture9:OptimizationofRadiationProtectioninCardiologyOneofthecenter'sexperiencewithnewangiographicmachinehavingflatpaneldetector11Lecture9:OptimizationofRadiationProtectioninCardiologyMotorized

IrisVideo

CameraImageIntensifierDETECTORPhotonsCesiumIodide(CsI)LightAmorphousSiliconPanel(Photodiode/TransistorArray)DigitalDataElectronsReadOutElectronicsPhotonsCesiumIodide(CsI)LightPhoto-cathodeVideoSignalElectronsOutputscreenLightCCDorPUTElectronsReadoutElectronics13,000400400,0002,400Particles#ImageIntensifierFlat-panel12Lecture9:OptimizationofRadiationProtectioninCardiologyAnticipatedper-framedosereductionwithDigitalFlatPaneltechnologyis30%13Lecture9:OptimizationofRadiationProtectioninCardiologyCoronaryAngiographyandAngioplasty

Udine,

years1990-2002PhilipsOM200(1983)

PhilipsIntegris3000(1995)performedby3interventionalistsexceptin199814Lecture9:OptimizationofRadiationProtectioninCardiologyGEInnova

2000(angiographicmachinewithdigitalflatpaneltechnology)atUdineCenterActivitystarted04/12/2002Jan-Oct20031421procedures(79%oftotal)1019 diagnosticcoronaryangiography402 percutaneouscoronaryangioplasty15Lecture9:OptimizationofRadiationProtectioninCardiologyComparisonofPhilipsH3000andInnova2000inPCI

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Characteristicsofpatientsdiseasedvessels(%)

H3000:588pts,90%oftot.treatedintheyear2002

Innova:274pts,67%oftot.treatedbetweenJan-Oct200316Lecture9:OptimizationofRadiationProtectioninCardiologyComparisonofPhilipsH3000andInnova2000inPCI

--Characteristicsofprocedures&lesions(1)%17Lecture9:OptimizationofRadiationProtectioninCardiologyComparisonofPhilipsH3000andInnova2000inPCI

--Characteristicsofprocedures&lesions(2)%18Lecture9:OptimizationofRadiationProtectioninCardiology(m’)ComparisonofPhilipsH3000andInnova2000inPCI

--

Performance&complexityindex

1,3711,470,9300,20,40,60,811,21,41,61,82Comp.IndexGISEIndexr(withfluorotime)

0.300.290.340.2611,611,54048598424,121,6H3000Innova19Lecture9:OptimizationofRadiationProtectioninCardiologyComparisonofPhilipsH3000andInnova2000indiagnosticprocedures

--Characteristicsofpatients&procedures(%)

H3000:1401pts,92%oftot.studiedintheyear2002

Innova:702pt,69%oftot.studiedbetweenJan-Oct200320Lecture9:OptimizationofRadiationProtectioninCardiologym’Gy*cm2measuredComparisonofPhilipsH3000andInnova2000indiagnosticprocedures

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performanceindexesandexposureparameters

calculated4.2245415.620.3910.6731.064.4285415.827.0518.8345.8835.320102030405060FluoroTproced.Troomocc.contrast(dl)cineDAPfluoroDAPtot.DAP1,3H3000Innova21Lecture9:OptimizationofRadiationProtectioninCardiologyEntrancesurfacedose:H3000andInnova2000EntrancesurfacedoseratesinFluoroLOWforInnovais30%less22Lecture9:OptimizationofRadiationProtectioninCardiology?Whytheanticipated30%per-framedosereductionofdigitalflatpaneltechnologydoesnottranslateintoaneffectivedosereductiontopatients

23Lecture9:OptimizationofRadiationProtectioninCardiologyDifferencesinoperatingconditionsofthetwosystemsH3000fieldofview(cm)23/18/14cinemode12,5/25fpsfluoromodelow/medium/highfilterautomaticInnovafieldofview(cm)20/17/15/12cinemode15/30fpspref1/pref2(lowerdose)fluoromodelow/normalfiltermanual24Lecture9:OptimizationofRadiationProtectioninCardiology20cm23cm400cm2375cm2DetectorsareaaresimilarH3000Innova20025Lecture9:OptimizationofRadiationProtectioninCardiology17cm18cm290cm2230cm2area+26%

DAP+26%!!!!Usingsimilarnominalfieldofview(FOV)sizescorrespondstoverydifferentareaofthetwoXraybeamsH3000Innova20026Lecture9:OptimizationofRadiationProtectioninCardiologyOtherpossibilities……patientsmaynotbethesameproceduresmaynotbethesameoperators’behavior

filters/collimationuseof“difficult”projections (fluoro/cine)focus-detectormeandistances………27Lecture9:OptimizationofRadiationProtectioninCardiologyCollimatorsuseinINNOVAtoreduceexposureFOV15dosereduction25%[still]28Lecture9:OptimizationofRadiationProtectioninCardiologyFOV20CollimatorsuseinINNOVAtoreduceexposure[still]29Lecture9:OptimizationofRadiationProtectioninCardiologyproperfilteringimproperfilteringcausesimagedeteriorationH3000Filteringpreventsimagesaturationinlowabsorptionareas30Lecture9:OptimizationofRadiationProtectioninCardiologyimproperfilteringdoesnotcauseimagedeteriorationINNOVA31Lecture9:OptimizationofRadiationProtectioninCardiologySkinexposurevariationinexposurerate(DAPrate)withprojectionanthropomorphicphantom(average-sized)measurementsCusmaJACC1999ProjectionFluoroscopyentrancedoserate(mGy/min)Cineentrancedoserate(mGy/min)AP31388RAO30°19203LAO40°20216LAO40°,Cran30°80991LAO40°,Cran40°991236LAO40°,Caud20°2934132Lecture9:OptimizationofRadiationProtectioninCardiologyDistancebetweenpatientanddetector33Lecture9:OptimizationofRadiationProtectioninCardiologyd2dBecausethesameenergyisspreadoverasurface4timeslargeratadoubleddistance,thesameobjectwillreceiveonlyafourthofthedosewhenmovedawayfrom“d”to“2d”SourceDoublingthedistancefromthesourcedividesthedosebyafactorof4Theinversesquarelaw34Lecture9:OptimizationofRadiationProtectioninCardiologyTheinversesquarelaw35Lecture9:OptimizationofRadiationProtectioninCardiologyCollimation

36Lecture9:OptimizationofRadiationProtectioninCardiologyAnti-scattergrid

IncreaseDAPandskindosex2timesImproveimagequalityToberemovedforpediatricpatients!!37Lecture9:OptimizationofRadiationProtectioninCardiologyCoronaryAngiographyoptimizationDIMONDQualityCriteriaUseofthewedgefilteronbrightperipheralareas2-3sequences(exceptfordifficultanatomicdetails)12.5-15frames/s(25-30onlyifheartrateexceeds90-100bpmorinpaediatricpatients)60imagespersequenceataverage(12.5-15fr/s)exceptifcollateralshavetobeimagedorincaseofslowflowAspectsofanoptimizedangiographictechnique38Lecture9:OptimizationofRadiationProtectioninCardiologyInnova2000.

Changesinexposureparametersovertime

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diagnosticproceduresJul2003-Feb200439Lecture9:OptimizationofRadiationProtectioninCardiologyOptimizationProcess40Lecture9:OptimizationofRadiationProtectioninCardiologyOptimizationrequires……….Knowledgeoffactorscontributingtopatientandstaffradiationdosepatientfactorsproceduralfactorsequipment(machine)factorsKnowledgeofdosereductioncapabilitiesofourXraysystemPeriodicupdateofourclinicalandtechnicalworkingprotocols41Lecture9:OptimizationofRadiationProtectioninCardiologyOptimizationprocessinvolves............Datacollectionprocedures,DAP,fluorotimeDataanalysisreliabilityofdataDiscussion&processesreviewcollimators/filtersuse,FOV,projectionsImplementationofchangesmoreprecisedatacollection,collimators/filtersuse,FOV17wheneverpossible,avoidingLAOprojectionsDataverification42Lecture9:OptimizationofRadiationProtectioninCardiologyReferencelevels3rd

level“Patientrisk”2ndlevel“Clinicalprotocol”1stlevel“Equipmentperformance”Doserateanddose/image(BSS,CDRH,AAPM)Level1

+No.images+fluoroscopytimeLevel2+DAP

+MaximumSkinDose(MSD)Referencelevels:aninstrumenttohelpoperatorstoconductoptimizedprocedureswithreferencetopatientexposureRequiredbyinternational(IAEA)andnationalregulationsForcomplexproceduresreferencelevelsshouldinclude:moreparametersand,musttakeintoaccounttheprotectionfromstochasticanddeterministicrisks(Dimond)43Lecture9:OptimizationofRadiationProtectioninCardiologyModernXraysystemsdisplaydosimetricindications

directlyontheconsoleinthecontrolroomandinsidethecatheterizationlaboratory,allowingcardiologiststoknowthelevelofradiologicalriskduringtheprocedure.TypicallyDoseAreaProductandCumulativeDose(*)aredisplayed.(*)CumulativeDose(CD)istheairkermaaccumulatedforaprocedureataspecificpointinspacerelativetothefluoroscopicgantryforaprocedure(itdoesnotincludetissuebackscatter).Itcangiveanindicationoftheskindose.44Lecture9:OptimizationofRadiationProtectioninCardiologyExampleofthedataincludedinthestudyreport(Siemens)45Lecture9:OptimizationofRadiationProtectioninCardiologyTheproposedreferencelevelsforCoronaryAngiographyandPTCAwereDAP45Gy?cm2and75Gy?cm2;fluoroscopytime7.5minand17minandnumberofframes1250and1300,resp

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