Assessment of radiation doses received by patients during endoscopic retrograde cholangiopancreatography according to disease location.

Patient Irradiation During Endoscopic Retrograde Cholangiopancreatography (ERCP)

PF8 Expandable intramedullary nailing: a new method in the treatment of femoral periprosthetic fractures

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is a relatively new endoscopic procedure combined with fluoroscopy that is performed for multiple diagnostic and therapeutic indications. It carries a known risk of radiation exposure to patients and staff. We aimed to examine radiation administration techniques and to measure the radiation dose delivered by these techniques. Methods This was a retrospective analysis of 437 ERCP procedures performed at a tertiary care hospital between April 2015 and April 2017. Results A total of 437 ERCP procedural charts were reviewed: fluoroscopy administration was endoscopist controlled (EC, n = 187, 42.79%) or technician controlled (TC, n = 250, 57.21%). The mean (and SD) fluoroscopy time (FT) was 2.107 ± 2.0 minutes. The mean (and SD) dose–area product (DAP) was 15,227.371 ± 16,784.738 Gy·cm2. The degree of ERCP difficulty was evaluated as recommended by the American Society for Gastrointestinal Endoscopy, and graded 1–4. Level I TC procedures had a mean FT and DAP of 1.600 minutes and 12,644.72 Gy·cm2, respectively. The FT and DAP values for level I EC procedures were 1.514 minutes and 12,966.71 Gy·cm2, respectively, as compared with level IV TC procedures (mean FT, 2.539 minutes; mean DAP, 19,469.94 Gy·cm2) and level IV EC procedures (mean FT, 4.890 minutes; mean DAP, 37,921.00 Gy·cm2). Conclusion DAP and FT are increased significantly in EC ERCP in American Society for Gastrointestinal Endoscopy 4 procedures. Comparison of the different degrees of difficulty indicated that there is a linear correlation between the degree of difficulty and both FT and DAP.

491 EFFECTIVE AND ORGAN SPECIFIC DOSES FROM VIDEOURODYNAMICS IN CHILDREN

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic procedure performed for multiple diagnostic and therapeutic indications. It carries benefits and risks like all other interventions. We focused on radiation exposure to patients and staff. In the literature review, we found that radiation dose is lower when radiation administration is physician-controlled, and as the physician becomes more experienced, they utilize less radiation. The aim was to compare different operation techniques of radiation administration during ERCP. METHODS: This was a retrospective study of all 437 ERCP procedures performed at a tertiary care hospital between April 2015 and April 2017. Data were collected from the hospital electronic system and included demographics, procedure indication, fluoroscopy time (FT), dose area product (DAP), degree of difficulty as per American Society of Gastrointestinal Endoscopy (ASGE) recommendations. Median and mean FT and DAP between endoscopist- controlled (EC) compared to technician-controlled (TC). RESULTS: Of the 437 cases analyzed 45.5%males, and the mean age was 56.7. EC was 187 cases, representing 42.79%. The mean fluoroscopy time (FT) was 2.107 ± 2.0 minutes. The mean dose–area product (DAP) was 15227.371 ± 16784.738 Gy·cm2 for all procedures. The degree of ERCP difficulty was graded from 1-4 as per ASGE. Level I TC procedures had a mean FT and DAP of 1.600 minutes and 12644.72 Gy·cm2, respectively; level I EC procedures were1.514 minutes and 12966.71 Gy·cm2, respectively. For level IV, TC procedures the mean FT, 2.539 minutes, and the mean DAP was 19469.94 Gy·cm2. For level IV EC procedures, the mean FT was 4.890 minutes; the mean DAP was 37921.00 Gy·cm2. CONCLUSION: This study did not show a significant difference in radiation dose between EC and TC except in ASGE level IV, where a significant increase noticed in the EC group. The results of multiple other fluoroscopic studies in urology and cardiology showed that when the procedure is physician-controlled, radiation administered is similar or lower than TC. This difference in comparison to the other studies could be attributed to the endoscopist attention divided into multiple fronts, including doing the procedure that predisposes them to push on the pedal for longer than intended while manipulating the scope and leading the team. Although these results are inconclusive, it does shed light on the importance of further studies on radiation administration techniques for patients and staff safety.

The present work reports data of the radiation exposure to the patient in various diagnostic and therapeutic interventional radiological (IR) procedures. The study includes 260 diagnostic and 195 therapeutic exposure data in 455 IR procedures. All the IR procedures were performed on a biplane angiographic machine in a tertiary care hospital. The radiation exposure was estimated from dose-area product (DAP), fluoroscopy time (FT), number of fluoroscopic runs, number of images and cumulative dose (CD) value recorded during the procedure. The data reported in the present study show significant variability in DAP values in diagnostic and therapeutic IR procedures. In diagnostic procedures, the minimum median DAP value is 8.93 Gy cm2 for upper limb angiography with mean FT of 2.7 min and maximum DAP value is 108.8 Gy cm2 for inferior vena cava angiography with mean FT of 12.55 min. For therapeutic procedures, the median value of DAP ranges from 2.43 Gy cm2 for sclerotherapy with mean FT 0.65 min to 267.23 Gy cm2 for coiling of cerebral aneurysm with mean FT of 60.52 min. The DAP value for each procedure was also correlated with FT, number of fluoroscopic runs, number of images and CD. The reported DAP values in this study are within the range of earlier published results which suggest that our finding provides at least approximate applicability to other hospitals. The third quartile DAP values of the procedures having significant number of patient data (n ≥ 10) serves as provisional reference values for the optimization of procedure protocols.

A survey was conducted to evaluate the role of the surgeon and the patients' body size, on patient radiation dose in fluoroscopically guided lumbar discectomy and fusion (LDF) procedures. Fluoroscopy time (FT), kerma area product (KAP), cumulative dose (CD), as well as anatomical and technical data were recorded for 100 patients, who underwent single or multi-level posterior LDF, which was carried out by three senior neurosurgeons utilising a C-arm fluoroscopy system. The patients were divided into three groups based on the body mass index (BMI) values (normal, overweight, obese) and the neurosurgeon that performed each procedure (surgeon 1, surgeon 2, surgeon 3). Entrance surface dose (ESD) was estimated based on KAP values and exposure data, while the effective dose (ED) was estimated utilising the KAP values and appropriate conversion coefficients. The mean FT, KAP, CD, ESD and ED values were 11.7 s, 0.65 Gy cm2, 2.96 mGy, 11.7 mGy and 0.08 mSv for normal patients, 22.1 s, 0.94 Gy cm2, 4.27 mGy, 21.4 mGy and 0.11 mSv for overweight patients and 67.7 s, 3.59 Gy cm2, 17.79 mGy, 107.2 mGy and 0.44 mSv for obese patients. The corresponding values were 21.5 s, 0.77 Gy cm2, 3.51 mGy, 17.5 mGy, 0.09 mSv for the first, 23.0 s, 1.44 Gy cm2, 6.52 mGy, 30.2 mGy, 0.18 mSv for the second and 14.2 s, 0.64 Gy cm2, 2.91 mGy, 17.0 mGy, 0.08 mSv for the third surgeon. Overweight patients received 83% and 38% higher ESD and ED, while obese patients 816% and 450%, compared to normal patients, respectively. The CD values should be implemented with caution, as a skin dose indicator, for all patient sizes. The weight-FT product could be useful in estimating KAP during LDF procedures. The third surgeon achieved the lowest dose values. Although the first surgeon had the same FT with the second surgeon, the corresponding dose values were decreased by 50%. The differences in FT, KAP, CD and ED values among the groups of patients studied were not statistically significant (Kruskal-Wallis test, p > 0.05), although the p-values were close to the threshold of statistical significance. The pairwise comparisons showed statistically significant differences for KAP, CD and ED values between obese and normal patients and between surgeon 1 and surgeon 3 (Mann-Whitney test, p < 0.05). The ESD values showed statistically significant differences among the BMI-based groups and among the surgeon-based groups studied (Kruskal-Wallis test, p < 0.05). This fact can be attributed to the better implementation of the fluoroscopy system technical parameters concerning the patients' size, clinical conditions and complexity of the procedures. Training and awareness of neurosurgeons on radiation protection issues are of critical importance; however, further studies should be performed towards optimisation procedures regarding patient dose.

Assessment of Local Dose Reference Values for Recanalization of Chronic Total Occlusions and Other Occlusions in a High-Volume Catheterization Center

The purpose of this work has been to dosimetrically investigate four fluoroscopically guided interventions: the percutaneous vertebroplasty (PVP), the percutaneous disc decompression (PDD), the radiofrequency medial branch neurolysis (RF) (hereafter named spine procedures), and the endovascular treatment for the critical limb ischemia (CLI). The X‐ray equipment used was a Philips Integris Allura Xper FD20 imaging system provided with a dose‐area product (DAP) meter. The parameters investigated were: maximum skin dose (MSD), air kerma (Ka,r), DAP, and fluoroscopy time (FT). In order to measure the maximum skin dose, we employed a system based on MOSFET detectors. Before using the system on patients, a calibration factor Fc and correction factors for energy (CkV) and field size (CFD) dependence were determined. Ka,r, DAP, and FT were extrapolated from the X‐ray equipment. The analysis was carried out on 40 patients, 10 for each procedure. The average fluoroscopy time and DAP values were compared with the reference levels (RLs) proposed in literature. Finally, the correlations between MSD, FT, Ka,r, and DAP values, as well as between DAP and FT values, were studied in terms of Pearson's product‐moment coefficients for spine procedures only. An Fc value of 0.20 and a very low dependence of CFD on field size were found. A third‐order polynomial function was chosen for CkV. The mean values of MSD ranged from 2.3 to 10.8 cGy for CLI and PVP, respectively. For these procedures, the DAP and FT values were within the proposed RL values. The statistical analysis showed little correlation between the investigated parameters. The interventional procedures investigated were found to be both safe with regard to deterministic effects and optimized for stochastic ones. In the spine procedures, the observed correlations indicated that the estimation of MSD from Ka,r or DAP was not accurate and a direct measure of MSD is therefore recommended.PACS number: 87

Recent recommendations of the International Commission on Radiological Protection state that the use of effective dose (E) for assessing patient exposure has severe limitations, though it can be kept for dose comparisons. In cardiology procedures, the equivalent dose (H(T)) is one of the most appropriate dose quantity to be evaluated for risk-benefit assessment. In this study, both E and H(T) values for ten critical organs in coronary angiography (CA) and percutaneous coronary interventions (PCI) were derived from in-the-field dose-area-product (DAP) measurements in order to provide a database for doses in those procedures. Conversion factors E/DAP calculated by Monte Carlo methods in two different mathematical human phantoms were applied to DAP values measured on 193 patients (118 CA and 75 PCI). Partial DAP values were recorded in-the-field for each projection and for all patients. The partial effective doses of all projections were summed up to calculate the E of the entire procedure. Similarly, equivalent doses for ten critical organs/tissues (bone, colon, heart, liver, lung, esophagus, red bone marrow, skin, stomach, and thyroid) were derived from H(T)/DAP conversion factors for different projections calculated by Monte Carlo method. All parameters related to the patient dose, i.e., fluoroscopy times, number of images, DAP, effective doses, and equivalent doses, show a wide range of values depending on the complexity of the patient case and the experience of the cardiologist. The mean fluoroscopy time, DAP, and E values for coronary angiography patients were approximately threefold lower than those for PCI patients; the number of images for CA was half that for PCI. The correlation between effective dose and DAP was excellent for both CA and PCI. The equivalent doses values were in good correlations with DAP values in CA examinations, with Pearson's coefficients ranging from 0.87 (stomach) to 0.99 (skin) and r(mean) = 0.94. The same analysis was performed for PCI procedures. In this case, the trends were only slightly worse because "r" ranged from 0.70 (stomach) to 0.92 (bone) and r(mean) = 0.85. Simple conversion coefficients to estimate equivalent doses to ten critical organs/tissues from DAP values, for both CA and PCI, were provided for avoiding the need to carry out detailed in-the-field analysis for all projections and for all patients. Measurements in-the-field of DAP values were carried out for two common cardiology procedures and effective doses were derived for each technique from detailed analysis of dose and projection data, using conversion factors provided by two different theoretical models. Equivalent doses to organs/tissues were also calculated using conversion factors proposed in the literature for different projections and cumulative conversion factors (H)T/DAP for ten organs/tissues were estimated.

To provide detailed reports on radiation doses during transarterial chemoembolization (TACE) in the cone-beam computed tomography (CBCT) era and to identify the associated factors. This retrospective study included 385 consecutive patients who underwent initial conventional TACE for hepatocellular carcinoma (HCC) between January 2016 and December 2017. In most cases, CBCT was performed at the common hepatic artery or celiac axis to confirm the location of the tumor and the three-dimensional hepatic artery anatomy. Superselective TACE was performed for all technically feasible cases. Information on total dose area product (DAP), total cumulative air kerma (CAK), fluoroscopy time, and DAP and CAK of each digital subtraction angiography (DSA) and CBCT scan was recorded. Multiple linear regression analysis was performed to identify the factors associated with increased DAP during TACE. The mean values of total DAP and CAK were 165.2 ± 81.2 (Gy·cm²) and 837.1 ± 571.0 (mGy), respectively. The mean fluoroscopy time was 19.1 ± 10.3min. The mean DAP caused by fluoroscopy, DSA, and CBCT was 51.8 ± 43.9, 28.0 ± 24.1, and 83.9 ± 42.1Gy·cm², respectively. Male sex, a high body mass index, largest tumor size > 3cm, presence of aberrant right and left hepatic arteries, and superselective TACE were identified as independent predictors of increased total DAP during TACE. We were able to provide detailed reports on radiation doses during TACE and associated factors.

1625 DECREASE IN RADIATION EXPOSURE DURING FLUORO URODYNAMICS (FUDS)

Is Dual-Axis Rotational Coronary Angiography Radiation Dose Reduction Achievable in a Population with 100% Suspected Coronary Artery Disease? A Randomized Trial

Background During transarterial chemoembolization (TACE), cone-beam computed tomography (CBCT) can be used for tumor and feeding vessel detection as well as postembolization CT imaging. However, there will be additional radiation exposure from CBCT. Purpose To evaluate the additional dose raised through CBCT-assisted guidance in comparison to TACE procedures guided with pulsed digital subtraction angiography (DSA) alone. Material and Methods In 70 of 140 consecutive patients undergoing TACE for liver cancer, CBCT was used to facilitate the TACE. Cumulative dose area product (DAP), cumulative kerma(air), DAP values of DSA, total and cine specific fluoroscopy times (FT) of 1375 DSA runs, and DAP of 91 CBCTs were recorded and analyzed using Spearman's correlation, Mann-Whitney U-test, and Kruskal-Wallis test. P values < 0.05 were considered significant. Results Additional CBCT increased DAP by 2% ( P = 0.737), kerma(air) by 24.6% ( P = 0.206), and FT by 0.02% ( P = 0.453). Subgroup analysis revealed that postembolization CBCT for detection of ethiodized oil deposits added more DAP to the procedure. Performing CBCT-assisted TACE, DSA until first CBCT contributed about 38% to the total DAP. Guidance CBCT acquisitions conduced to 6% of the procedure's DAP. Additional DSA for guidance after CBCT acquisition required approximately 46% of the mean DAP. The last DSA run for documentation purposes contributed about 10% of the DAP. Conclusion CBCT adds radiation exposure in TACE. However, the capability of CBCT to detect vessels and overlay in real-time during fluoroscopy facilitates TACE with resultant reduction of DAPs up to 46%.

&lt;b&gt;Background:&lt;/b&gt; Cerebral Digital Subtraction Angiography (DSA) is still the standard method for diagnosing and treating neurovascular disorders, including arteriovenous malformations (AVMs), aneurysm formation, or ischemic stroke. Nevertheless, the high radiation exposure required for these procedures endangers patients and clinicians, especially in low-resource environments. Even with advances in radiation safety, there is a lack of data on DSA-induced radiation exposure from rural tertiary care centers where potentially the most recently introduced dose-reduction technologies may not be as accessible. &lt;b&gt;Aim:&lt;/b&gt; The present study was designed to evaluate the radiation exposure metrics of cerebral DSA procedures at a rural Indian tertiary care center, compare these with global reference standards, and suggest some strategies for minimizing radiation dose. &lt;b&gt;Methods:&lt;/b&gt; 112 cerebral DSA procedures were performed between January 2020 and March 2022 among adult patients encompassed by the present retrospective observational study. Radiation exposure parameters fluoroscopic time, dose-area product (DAP), cumulative dose (CD), effective dose (EFF.DOSE), and peak skin dose (PSD) were collected. The number of frames was also noted. Descriptive statistics were analyzed, and comparisons were based on the DSA finding type pre-DSA diagnosis. &lt;b&gt;Results:&lt;/b&gt; 112 patients underwent cerebral digital subtraction angiography (DSA) during the study. The mean fluoroscopic time was 17.65 minutes, with a DAP of 45.1 Gy·cm² and a cumulative dose (CD) of 544.62 mGy. The peak skin dose (PSD) averaged 304.99 mGy, and the mean effective dose (EFF.DOSE) was 3.93 mSv. Variation in radiation exposure was observed based on pre-DSA diagnoses and DSA findings. Subarachnoid hemorrhage (SAH) cases exhibited the highest exposure, with a fluoroscopic time of 19.11 minutes, a DAP of 48.91 Gy·cm², and a cumulative dose of 659.6 mGy. Comparatively, arteriovenous malformation (AVM) cases had shorter fluoroscopic times (14.67 minutes) and lower DAP (38.81 Gy·cm²). Aneurysm and vasculitis cases had the most extended fluoroscopic times, while "normal" cases had the highest DAP at 67.63 Gy·cm², resulting in the highest effective dose of 5.88 mSv. These findings underscore the variability in radiation exposure across different diagnosis types, highlighting the need for targeted radiation management strategies. &lt;b&gt;Conclusion:&lt;/b&gt; Radiation exposure from cerebral DSA using a biplane angiography unit in a rural setting is similar to that published in global literature, although room dose could still be optimized. Practicing in line with the ALARA principles, optimizing fluoroscopic time, and adopting emerging dose-reduction technologies may lower radiation exposure, particularly within resource-sensitive environments. Prompt radiation safety is critically dependent on routine operator training and continuous monitoring of doses in real-time.