Table of Contents Author Guidelines Submit a Manuscript
BioMed Research International
Volume 2013, Article ID 976962, 11 pages
http://dx.doi.org/10.1155/2013/976962
Review Article

Radiation-Induced Noncancer Risks in Interventional Cardiology: Optimisation of Procedures and Staff and Patient Dose Reduction

1Discipline of Medical Imaging, Department of Imaging and Applied Physics, Curtin University, P.O. Box U1987, Perth, WA 6845, Australia
2Department of Molecular Imaging and Nuclear Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaakob Latif, Cheras, 56000 Kuala Lumpur, Malaysia
3Department of Cardiology, National Heart Institute, 50300 Kuala Lumpur, Malaysia

Received 30 April 2013; Revised 28 June 2013; Accepted 18 July 2013

Academic Editor: Eliseo Vano

Copyright © 2013 Zhonghua Sun et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Linked References

  1. F. A. Mettler Jr., M. Bhargavan, K. Faulkner et al., “Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources, 1950–2007,” Radiology, vol. 253, no. 2, pp. 520–531, 2009. View at Publisher · View at Google Scholar · View at Scopus
  2. K. P. Kim, D. L. Miller, S. Balter et al., “Occupational radiation doses to operators performing cardiac catheterization procedures,” Health Physics, vol. 94, no. 3, pp. 211–227, 2008. View at Publisher · View at Google Scholar · View at Scopus
  3. J. Vassileva, E. Vano, C. Ubeda, M. Rehani, and R. Zotova, “Impact of the X-ray system settings on patient dose and image quality; a case study with two interventional cardiology systems,” Radiation Protection Dosimetry, 2013. View at Google Scholar
  4. E. Vano, R. Sanchez, J. M. Fernandez et al., “Patient dose reference levels for interventional radiology: a national approach,” CardioVascular and Interventional Radiology, vol. 32, no. 1, pp. 19–24, 2009. View at Publisher · View at Google Scholar · View at Scopus
  5. A. J. Einstein, K. W. Moser, R. C. Thompson, M. D. Cerqueira, and M. J. Henzlova, “Radiation dose to patients from cardiac diagnostic imaging,” Circulation, vol. 116, no. 11, pp. 1290–1305, 2007. View at Publisher · View at Google Scholar · View at Scopus
  6. E. Picano, E. Vano, R. Semelka, and D. Regulla, “The American College of Radiology white paper on radiation dose in medicine: deep impact on the practice of cardiovascular imaging,” Cardiovascular Ultrasound, vol. 5, article 37, 2007. View at Publisher · View at Google Scholar · View at Scopus
  7. C. Cousins, D. L. Miller, G. Bernardi et al., “ICRP publication 120: radiological protection in cardiology,” Annals of ICRP, vol. 42, pp. 1–125, 2013. View at Google Scholar
  8. E. Vano and K. Faulkner, “ICRP special radiation protection issues in interventional radiology, digital and cardiac imaging,” Radiation Protection Dosimetry, vol. 117, no. 1–3, pp. 13–17, 2006. View at Publisher · View at Google Scholar · View at Scopus
  9. M. M. Rehani and P. Ortiz-Lopez, “Radiation effects in fluoroscopically guided cardiac interventions—keeping them under control,” International Journal of Cardiology, vol. 109, no. 2, pp. 147–151, 2006. View at Publisher · View at Google Scholar · View at Scopus
  10. J. W. Hirshfeld Jr., S. Baiter, J. A. Brinker et al., “ACCF/AHA/HRS/SCAI clinical competence statement on physician knowledge to optimize patient safety and image quality in fluoroscopically guided invasive cardiovascular procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training,” Circulation, vol. 111, no. 4, pp. 511–532, 2005. View at Publisher · View at Google Scholar · View at Scopus
  11. United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and effects of ionizing radiation, “UNSCEAR 2008 report to the General Assembly,” vol 1. Annex A. Medical Radiation Exposures, United Nations, New York, NY, USA, 2008, http://www.unscear.org/.
  12. T. C. Gerber, J. Jeffrey Carr, A. E. Arai et al., “Ionizing radiation in cardiac imaging: a science advisory from the American Heart Association Committee on cardiac imaging of the council on clinical cardiology and committee on cardiovascular imaging and intervention of the council on cardiovascular radiology and intervention,” Circulation, vol. 119, no. 7, pp. 1056–1065, 2009. View at Publisher · View at Google Scholar · View at Scopus
  13. R. Brindis and P. S. Douglas, “President's page: the ACC encourages multi-pronged approach to radiation safety,” Journal of the American College of Cardiology, vol. 56, no. 6, pp. 522–524, 2010. View at Google Scholar · View at Scopus
  14. The International Commission on Radiological Protection, “Publication 118: ICRP Statement on tissue reactions and early and late effects of radiation in normal tissues and organs: threshold doses for tissue reactions and other non-cancer effects of radiation in a radiation protection context,” Annals of ICRP, vol. 41, pp. 1–322, 2012. View at Google Scholar
  15. The International Commission on Radiological Protection, “The 2007 recommendations of the International Commission on Radiological Protection. ICRP publication 103,” Annals of ICRP, vol. 37, pp. 1–332, 2007. View at Google Scholar
  16. Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation, Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2, The National Academies Press, Washington, DC, USA, 2006.
  17. S. Balter, J. W. Hopewell, D. L. Miller, L. K. Wagner, and M. J. Zelefsky, “Fluoroscopically guided interventional procedures: a review of radiation effects on patients' skin and hair,” Radiology, vol. 254, no. 2, pp. 326–341, 2010. View at Publisher · View at Google Scholar · View at Scopus
  18. A. J. Einstein, “Effects of radiation exposure from cardiac imaging: how good are the data?” Journal of the American College of Cardiology, vol. 59, no. 6, pp. 553–565, 2012. View at Publisher · View at Google Scholar · View at Scopus
  19. S. Jacob, S. Boveda, O. Bar et al., “Interventional cardiologists and risk of radiation-induced cataract: results of a French multicentre observational study,” International Journal of Cardiology, 2012. View at Publisher · View at Google Scholar
  20. National Council on Radiation Protection and Measurement, “Limitation of exposure to ionizing radiation,” NCRP Report 116, Bethesda, Md, USA, 1993. View at Google Scholar
  21. N. Kleiman, “Radiation cataract,” in Radiation Protection: New Insights in Radiation Risk and Basic Safety Standards, European Commission proceedings of the Working Party on Research Implications on Health and Safety Standards of the Article 31 group of Experts, RP-145, pp. 81–95, European Commission. Directorate General for Energy and Transport, Luxembourg, Belgium, 2007, http://ec.europa.eu/energy/nuclear/radiation_protection/doc/publication/145.pdf. View at Google Scholar
  22. B. V. Worgul, Y. I. Kundiev, N. M. Sergienko et al., “Dose related incidence of radiation cataract in a six year follow-up of a cohort of the Chernobyl clean-up workers,” Investigative Ophthalmology and Visual Science, vol. 44, supplement 2, p. 4241, 2003. View at Google Scholar
  23. B. V. Worgul, Y. I. Kundiyev, N. M. Sergiyenko et al., “Cataracts among Chernobyl clean-up workers: implications regarding permissible eye exposures,” Radiation Research, vol. 167, no. 2, pp. 233–243, 2007. View at Publisher · View at Google Scholar · View at Scopus
  24. G. Chodick, N. Bekiroglu, M. Hauptmann et al., “Risk of cataract after exposure to low doses of ionizing radiation: a 20-year prospective cohort study among US radiologic technologists,” American Journal of Epidemiology, vol. 168, no. 6, pp. 620–631, 2008. View at Publisher · View at Google Scholar · View at Scopus
  25. E. Vano, N. J. Kleiman, A. Duran, M. M. Rehani, D. Echeverri, and M. Cabrera, “Radiation cataract risk in interventional cardiology personnel,” Radiation Research, vol. 174, no. 4, pp. 490–495, 2010. View at Publisher · View at Google Scholar · View at Scopus
  26. O. Ciraj-Bjelac, M. M. Rehani, K. H. Sim, H. B. Liew, E. Vano, and N. J. Kleiman, “Risk for radiation-induced cataract for staff in interventional cardiology: is there reason for concern?” Catheterization and Cardiovascular Interventions, vol. 76, no. 6, pp. 826–834, 2010. View at Publisher · View at Google Scholar · View at Scopus
  27. S. Mrena, T. Kivelä, P. Kurttio, and A. Auvinen, “Lens opacities among physicians occupationally exposed to ionizing radiation - a pilot study in Finland,” Scandinavian Journal of Work, Environment and Health, vol. 37, no. 3, pp. 237–243, 2011. View at Publisher · View at Google Scholar · View at Scopus
  28. O. Ciraj-Bjelac, M. Rehani, A. Minamoto A et al., “Radiation-induced eye lens changes and risk for cataract in interventional cardiology,” Cardiology, vol. 123, pp. 168–171, 2012. View at Google Scholar
  29. S. Bouffler, E. Ainsbury, P. Gilvin, and J. Harrison, “Radiation-induced cataracts: the Health Protection Agency’s response to the ICRP statement on tissue reactions and recommendations on the dose limit for the eye lens,” Journal of Radiation Protection, vol. 32, pp. 479–488, 2012. View at Google Scholar
  30. International Atomic Energy Agency, “Radiation Protection and Safety of Radiation Sources: International Basic Safety Standards (BSS)—Interim Edition, IAEA Safety Standards Series GSR Part3 (Interim),” IAEA, Vienna, Austria, 2011.
  31. European Commission, “Proposal for a Council Directive laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation,” 2012, http://ec.europa.eu/energy/nuclear/radiation_protection/doc/2012_com_242.pdf.
  32. M. M. Rehani, E. Vano, O. Ciraj-Bjelac, and N. J. Kleiman, “Radiation and cataract,” Radiation Protection Dosimetry, vol. 147, no. 1-2, pp. 300–304, 2011. View at Publisher · View at Google Scholar · View at Scopus
  33. S. Jacob, L. Donadille, C. Maccia et al., “Eye lens radiation exposure to interventional cardiologists: a retrospective assessment of cumulative doses,” Radiation Protection Dosimetry, vol. 153, pp. 282–293, 2013. View at Google Scholar
  34. A. Junk, Z. Haskal, and B. Worgul, “Cataract in interventional radiology—an occupational hazard?” Investigative Ophthalmology & Visual Science, vol. 45, E-Abstract 388, 2004. View at Google Scholar
  35. E. Vano, N. J. Kleiman, A. Duran et al., “Radiation-associated lens opacities in catheterization personnel: results of a survey and direct assessments,” Journal of Vascular and Interventional Radiology, vol. 24, pp. 197–204, 2013. View at Google Scholar
  36. S. Jacob, M. Michel, C. Spaulding et al., “Occupational cataracts and lens opacities in interventional cardiology (O'CLOC study): are X-Rays involved? Radiation-induced cataracts and lens opacities,” BMC Public Health, vol. 10, article 537, 2010. View at Publisher · View at Google Scholar · View at Scopus
  37. J. Domienik, M. Brodecki, E. Carinou et al., “Extremity and eye lens doses in interventional radiology and cardiology procedures: first results of the oramed project,” Radiation Protection Dosimetry, vol. 144, no. 1–4, Article ID ncq508, pp. 442–447, 2011. View at Publisher · View at Google Scholar · View at Scopus
  38. G. Gualdrini, F. Mariotti, S. Wach et al., “Eye lens dosimetry: task 2 within the oramed project,” Radiation Protection Dosimetry, vol. 144, no. 1-4, Article ID ncr011, pp. 473–477, 2011. View at Publisher · View at Google Scholar · View at Scopus
  39. K. Neriishi, E. Nakashima, M. Akahoshi et al., “Radiation dose and cataract surgery incidence in atomic bomb survivors, 1986–2005,” Radiology, vol. 265, pp. 167–174, 2012. View at Google Scholar
  40. S. C. Finch and C. A. Finch, “Summary of the studies at ABCC-RERF concerning the late hematological effects of Atomic Bomb exposure in Hiroshima and Nagasaki,” Tech. Rep. 23-88, Radiation Effects Research Foundation, 1988. View at Google Scholar
  41. A. Tsuya, Y. Wakano, and M. Otake, “Capillary microscopic observation on the superficial minute vessels of atomic bomb survivors, 1956-1957,” Radiation Research, vol. 46, no. 1, pp. 199–216, 1971. View at Google Scholar · View at Scopus
  42. S. Switzer, “ABCC-JNIH Adult Health Study Hiroshima, 1958–59. Hypertension and ischemic heart disease,” Radiation Effects Research Foundation, Hiroshima, Japan, 1961.
  43. K. Yano and S. Ueda, “Cardiovascular disease in relation to exposure to ionizing radiation,” Radiation Effects Research Foundation, Hiroshima, Japan, 1962.
  44. L. F. Fajardo, “The unique physiology of endothelial cells and its implications in radiobiology,” Frontiers of Radiation Therapy and Oncology, vol. 23, pp. 96–112, 1989. View at Google Scholar · View at Scopus
  45. L. F. Fajardo, “Is the pathology of radiation injury different in small versus large blood vessels?” Cardiovascular Radiation Medicine, vol. 1, no. 1, pp. 108–110, 1999. View at Google Scholar · View at Scopus
  46. J. Vos, M. W. Aarnoudse, F. Dijk, and H. B. Lamberts, “On the cellular origin and development of atheromatous plaques. A light and electron microscopic study of combined X-ray and hypercholesterolemia-induced atheromatosis in the carotid artery of the rabbit,” Virchows Archiv B, vol. 43, no. 1, pp. 1–16, 1983. View at Google Scholar · View at Scopus
  47. J. H. Hendry, M. Akahoshi, L. S. Wang, S. E. Lipshultz, F. A. Stewart, and K. R. Trott, “Radiation-induced cardiovascular injury,” Radiation and Environmental Biophysics, vol. 47, no. 2, pp. 189–193, 2008. View at Publisher · View at Google Scholar · View at Scopus
  48. S. Schultz-Hector and K.-R. Trott, “Radiation-induced cardiovascular diseases: is the epidemiologic evidence compatible with the radiobiologic data?” International Journal of Radiation Oncology Biology Physics, vol. 67, no. 1, pp. 10–18, 2007. View at Publisher · View at Google Scholar · View at Scopus
  49. S. R. Basavaraju and C. E. Easterly, “Pathophysiological effects of radiation on atherosclerosis development and progression, and the incidence of cardiovascular complications,” Medical Physics, vol. 29, no. 10, pp. 2391–2403, 2002. View at Publisher · View at Google Scholar · View at Scopus
  50. G. L. Russo, I. Tedesco, M. Russo, A. Cioppa, M. G. Andreassi, and E. Picano, “Cellular adaptive response to chronic radiation exposure in interventional cardiologists,” European Heart Journal, vol. 33, no. 3, pp. 408–414, 2012. View at Publisher · View at Google Scholar · View at Scopus
  51. J. D. Shadley and S. Wolff, “Very low doses of X-rays can cause human lymphocytes to become less susceptible to ionizing radiation,” Mutagenesis, vol. 2, no. 2, pp. 95–96, 1987. View at Google Scholar · View at Scopus
  52. L. M. Stoilov, L. H. F. Mullenders, F. Darroudi, and A. T. Natarajan, “Adaptive response to DNA and chromosomal damage induced by X-rays in human blood lymphocytes,” Mutagenesis, vol. 22, no. 2, pp. 117–122, 2007. View at Publisher · View at Google Scholar · View at Scopus
  53. Y. Shimizu, H. Kato, W. J. Schull, and D. G. Hoel, “Studies of the mortality of A-bomb survivors—9. Mortality, 1950—1985: part 3. Noncancer mortality based on the revised doses (DS86),” Radiation Research, vol. 130, no. 2, pp. 249–266, 1992. View at Publisher · View at Google Scholar · View at Scopus
  54. D. L. Preston, Y. Shimizu, D. A. Pierce, A. Suyama, and K. Mabuchi, “Studies of mortality of atomic bomb survivors—report 13: solid cancer and noncancer disease mortality: 1950–1997,” Radiation Research, vol. 160, no. 4, pp. 381–407, 2003. View at Publisher · View at Google Scholar · View at Scopus
  55. K. Ozasa, Y. Shimizu, R. Sakata et al., “Risk of cancer and non-cancer diseases in the atomic bomb survivors,” Radiation Protection Dosimetry, vol. 146, no. 1–3, pp. 272–275, 2011. View at Publisher · View at Google Scholar · View at Scopus
  56. M. M. Doody, J. S. Mandel, J. H. Lubin, and J. D. Boice Jr., “Mortality among United States radiologic technologists, 1926–1990,” Cancer Causes and Control, vol. 9, no. 1, pp. 67–75, 1998. View at Publisher · View at Google Scholar · View at Scopus
  57. A. Berrington, S. C. Darby, H. A. Weiss, and R. Doll, “100 years of observation on British radiologists: mortality from cancer and other causes 1897–1997,” British Journal of Radiology, vol. 74, no. 882, pp. 507–519, 2001. View at Google Scholar · View at Scopus
  58. M. Hauptmann, A. K. Mohan, M. M. Doody, M. S. Linet, and K. Mabuchi, “Mortality from diseases of the circulatory system in radiologic technologists in the United States,” American Journal of Epidemiology, vol. 157, no. 3, pp. 239–248, 2003. View at Publisher · View at Google Scholar · View at Scopus
  59. J. P. Ashmore, D. Krewski, J. M. Zielinski, H. Jiang, R. Semenciw, and P. R. Band, “First analysis of mortality and occupational radiation exposure based on the National Dose Registry of Canada,” American Journal of Epidemiology, vol. 148, no. 6, pp. 564–574, 1998. View at Google Scholar · View at Scopus
  60. S. Yoshinaga, T. Aoyama, Y. Yoshimoto, and T. Sugahara, “Cancer mortality among radiological technologists in Japan: updated analysis of follow-up data from 1969 to 1993,” Journal of Epidemiology, vol. 9, no. 2, pp. 61–72, 1999. View at Google Scholar · View at Scopus
  61. M. Andersson, G. Engholm, K. Ennow, K. A. Jessen, and H. H. Storm, “Cancer risk among staff at two radiotherapy departments in Denmark,” British Journal of Radiology, vol. 64, no. 761, pp. 455–460, 1991. View at Google Scholar · View at Scopus
  62. J.-X. Wang, J. D. Boice Jr., B.-X. Li, L.-Y. Zhang, and J. F. Fraumeni Jr., “Cancer among medical diagnostic X-ray workers in China,” Journal of the National Cancer Institute, vol. 80, no. 5, pp. 344–350, 1988. View at Google Scholar · View at Scopus
  63. M. Yamada, F. L. Wong, S. Fujiwara, M. Akahoshi, and G. Suzuki, “Noncancer disease incidence in atomic bomb survivors, 1958-1998,” Radiation Research, vol. 161, no. 6, pp. 622–632, 2004. View at Publisher · View at Google Scholar · View at Scopus
  64. H. Sasaki, F. L. Wong, M. Yamada, and K. Kodama, “The effects of aging and radiation exposure on blood pressure levels of atomic bomb survivors,” Journal of Clinical Epidemiology, vol. 55, no. 10, pp. 974–981, 2002. View at Publisher · View at Google Scholar · View at Scopus
  65. F. Kasagi, K. Kodama, M. Yamada et al., “An association between the prevalence of isolated hypertension and radiation dose in the Adult Health Study,” Nagasaki Medical Journal, vol. 67, pp. 479–482, 1992. View at Google Scholar
  66. F. L. Wong, M. Yamada, H. Sasaki, K. Kodama, and Y. Hosoda, “Effects of radiation on the longitudinal trends of total serum cholesterol levels in the atomic bomb survivors,” Radiation Research, vol. 151, no. 6, pp. 736–746, 1999. View at Publisher · View at Google Scholar · View at Scopus
  67. M. Yamada, K. Naito, F. Kasagi, N. Masunari, and G. Suzuki, “Prevalence of atherosclerosis in relation to atomic bomb radiation exposure: an RERF Adult Health Study,” International Journal of Radiation Biology, vol. 81, no. 11, pp. 821–826, 2005. View at Publisher · View at Google Scholar · View at Scopus
  68. Y. Shimizu, K. Kodama, N. Nishi et al., “Radiation exposure and circulatory disease risk: Hiroshima and Nagasaki atomic bomb survivor data, 1950–2003,” British Medical Journal, vol. 340, no. 7739, article 193, 2010. View at Publisher · View at Google Scholar · View at Scopus
  69. I. Pantos, G. Patatoukas, D. G. Katritsis, and E. Efstathopoulos, “Patient radiation doses in interventional cardiology procedures,” Current Cardiology Reviews, vol. 5, no. 1, pp. 1–11, 2009. View at Publisher · View at Google Scholar · View at Scopus
  70. R. Padovani, G. Bernardi, E. Quia et al., “Retrospective evaluation of occurrence of skin injuries in interventional cardiac procedures,” Radiation Protection Dosimetry, vol. 117, no. 1–3, pp. 247–250, 2006. View at Publisher · View at Google Scholar · View at Scopus
  71. E. Kuon, C. Glaser, and J. B. Dahm, “Effective techniques for reduction of radiation dosage to patients undergoing invasive cardiac procedures,” British Journal of Radiology, vol. 76, no. 906, pp. 406–413, 2003. View at Publisher · View at Google Scholar · View at Scopus
  72. A. L. Clark, A. G. Brennan, L. J. Robertson, and J. D. Mcarthur, “Factors affecting patient radiation exposure during routine coronary angiography in a tertiary referral centre,” British Journal of Radiology, vol. 73, no. 866, pp. 184–189, 2000. View at Google Scholar · View at Scopus
  73. F. Larrazet, A. Dibie, F. Philippe, R. Palau, R. Klausz, and F. Laborde, “Factors influencing fluoroscopy time and dose-area product values during and hoc one-vessel percutaneous coronary angioplasty,” British Journal of Radiology, vol. 76, no. 907, pp. 473–477, 2003. View at Publisher · View at Google Scholar · View at Scopus
  74. R. Padovani, G. Bernardi, M. R. Malisan, E. Vañó, G. Morocutti, and P. M. Fioretti, “Patient dose related to the complexity of interventional cardiology procedures,” Radiation Protection Dosimetry, vol. 94, no. 1-2, pp. 189–192, 2001. View at Google Scholar · View at Scopus
  75. D. Teunen, “The European Directive on health protection of individuals against the dangers of ionising radiation in relation to medical exposures (97/43/EURATOM),” Journal of Radiological Protection, vol. 18, no. 2, pp. 133–137, 1998. View at Publisher · View at Google Scholar · View at Scopus
  76. M. G. Delichas, K. Psarrakos, K. Hatziioannou et al., “The dependence of patient dose on factors relating to the technique and complexity of Interventional Cardiology procedures,” Physica Medica, vol. 21, no. 4, pp. 153–157, 2005. View at Publisher · View at Google Scholar · View at Scopus
  77. V. Neofotistou, E. Vano, R. Padovani et al., “Preliminary reference levels in interventional cardiology,” European Radiology, vol. 13, no. 10, pp. 2259–2263, 2003. View at Publisher · View at Google Scholar · View at Scopus
  78. V. Tsapaki, S. Kottou, E. Vano et al., “Patient dose values in a dedicated Greek cardiac centre,” British Journal of Radiology, vol. 76, no. 910, pp. 726–730, 2003. View at Publisher · View at Google Scholar · View at Scopus
  79. G. Bernardi, R. Padovani, G. Morocutti et al., “Clinical and technical determinants of the complexity of percutaneous transluminal coronary angioplasty procedures: analysis in relation to radiation exposure parameters,” Catheterization and Cardiovascular Interventions, vol. 51, pp. 1–9, 2000. View at Google Scholar
  80. T. R. Koenig, D. Wolff, F. A. Mettler, and L. K. Wagner, “Skin injuries from fluoroscopically guided procedures—part 1, characteristics of radiation injury,” American Journal of Roentgenology, vol. 177, no. 1, pp. 3–11, 2001. View at Google Scholar · View at Scopus
  81. T. R. Koenig, F. A. Mettler, and L. K. Wagner, “Skin injuries from fluoroscopically guided procedures—part 2, review of 73 cases and recommendations for minimizing dose delivered to patient,” American Journal of Roentgenology, vol. 177, no. 1, pp. 13–20, 2001. View at Google Scholar · View at Scopus
  82. Centers for Disease Control and Prevention, “Cutaneous radiation injury: fact sheet for physicians,” Centers for Disease Control and Prevention, 2006, http://www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp.
  83. J. L. Monaco, K. Bowen, P. N. Tadros, and P. D. Witt, “Iatrogenic deep musculocutaneous radiation injury following percutaneous coronary intervention,” Journal of Invasive Cardiology, vol. 15, no. 8, pp. 451–453, 2003. View at Google Scholar · View at Scopus
  84. T. H. Frazier, J. B. Richardson, V. C. Fabré, and J. P. Callen, “Fluoroscopy-induced chronic radiation skin injury: a disease perhaps often overlooked,” Archives of Dermatology, vol. 143, no. 5, pp. 637–640, 2007. View at Publisher · View at Google Scholar · View at Scopus
  85. S. Balter and J. Moses, “Managing patient dose in interventional cardiology,” Catheterization and Cardiovascular Interventions, vol. 70, no. 2, pp. 244–249, 2007. View at Publisher · View at Google Scholar · View at Scopus
  86. A. Den Boer, P. J. De Feijter, P. W. Serruys, and J. R. T. C. Roelandt, “Real-time quantification and display of skin radiation during coronary angiography and intervention,” Circulation, vol. 104, no. 15, pp. 1779–1784, 2001. View at Google Scholar · View at Scopus
  87. E. Hwang, E. Gaxiola, R. E. Vlietstra et al., “Real-time measurement of skin radiation during cardiac catheterisation,” Catheterization and Cardiovascular Diagnosis, vol. 43, pp. 367–370, 1998. View at Google Scholar
  88. M. Kato, K. Chida, T. Sato et al., “The necessity of follow-up for radiation skin injuries in patients after percutaneous coronary interventions: radiation skin injuries will often be overlooked clinically,” Acta Radiologica, vol. 53, pp. 1040–1044, 2012. View at Google Scholar
  89. Radiation Protection of Patients (RPOP), “SAFRAD—Safety in radiological procedures,” 2013, https://rpop.iaea.org/safrad.
  90. O. Holmberg, J. Malone, M. Rehani, D. McLean, and R. Czarwinski, “Current issues and actions in radiation protection of patients,” European Journal of Radiology, vol. 76, no. 1, pp. 15–19, 2010. View at Publisher · View at Google Scholar · View at Scopus
  91. M. M. Rehani and D. P. Frush, “Patient exposure tracking: the IAEA smart card project,” Radiation Protection Dosimetry, vol. 147, no. 1-2, pp. 314–316, 2011. View at Publisher · View at Google Scholar · View at Scopus
  92. R. Padovani and E. Quai, “Patient dosimetry approaches in interventional cardiology and literature dose data review,” Radiation Protection Dosimetry, vol. 117, no. 1–3, pp. 217–221, 2006. View at Publisher · View at Google Scholar · View at Scopus
  93. K. Faulkner, P. Ortiz-Lopez, and E. Vano, “Patient dosimetry in diagnostic and interventional radiology: a practical approach using trigger levels,” Radiation Protection Dosimetry, vol. 117, no. 1–3, pp. 166–168, 2006. View at Publisher · View at Google Scholar · View at Scopus
  94. K. A. Fetterly, V. Mathew, R. Lennon et al., “Radiation dose reduction in the invasive cardiovascular laboratory. Implementing a culture and philosophy of radiation safety,” Cardiovascular Interventions, vol. 5, pp. 866–873, 2012. View at Google Scholar
  95. J.-L. Georges, B. Livarek, G. Gibault-Genty et al., “Reduction of radiation delivered to patients undergoing invasive coronary procedures. Effect of a programme for dose reduction based on radiation-protection training,” Archives of Cardiovascular Diseases, vol. 102, no. 12, pp. 821–827, 2009. View at Publisher · View at Google Scholar · View at Scopus
  96. C. Ubeda, E. Vano, L. Gonzalez et al., “Scatter and staff dose levels in paediatric interventional cardiology: a multicentre study,” Radiation Protection Dosimetry, vol. 140, no. 1, pp. 67–74, 2010. View at Publisher · View at Google Scholar · View at Scopus
  97. P. L. Khong, H. Ringertz, V. Donoghue et al., “ICRP 121: radiological protection in paediatric diagnostic and interventional radiology,” Annals of ICRP, vol. 42, pp. 1–63, 2013. View at Google Scholar
  98. M. C. Limacher, P. S. Douglas, G. Germano et al., “Radiation safety in the practice of cardiology,” Journal of the American College of Cardiology, vol. 31, no. 4, pp. 892–913, 1998. View at Publisher · View at Google Scholar · View at Scopus
  99. C. J. Martin, “A review of radiology staff doses and dose monitoring requirements,” Radiation Protection Dosimetry, vol. 136, no. 3, pp. 140–157, 2009. View at Publisher · View at Google Scholar · View at Scopus
  100. C. P. Shortt, H. Al-Hashimi, L. Malone, and M. J. Lee, “Staff radiation doses to the lower extremities in interventional radiology,” CardioVascular and Interventional Radiology, vol. 30, no. 6, pp. 1206–1209, 2007. View at Publisher · View at Google Scholar · View at Scopus
  101. D. L. Miller, E. Vañó, G. Bartal et al., “Occupational radiation protection in interventional radiology: a joint guideline of the cardiovascular and interventional radiology society of Europe and the society of interventional radiology,” CardioVascular and Interventional Radiology, vol. 33, no. 2, pp. 230–239, 2010. View at Publisher · View at Google Scholar · View at Scopus
  102. S. Balter, F. A. Heupler Jr., J. E. Goss et al., “Guidelines for personnel radiation monitoring in the cardiac catheterization laboratory,” Catheterization and Cardiovascular Diagnosis, vol. 30, no. 4, pp. 277–279, 1993. View at Publisher · View at Google Scholar · View at Scopus
  103. K.-H. Folkerts, A. Münz, and S. Jung, “Estimation of radiation exposure and radiation risk to staff of cardiac catheterization laboratories,” Zeitschrift fur Kardiologie, vol. 86, no. 4, pp. 258–263, 1997. View at Publisher · View at Google Scholar · View at Scopus
  104. K. A. Fetterly, D. J. Magnuson, G. M. Tannahill, M. D. Hindal, and V. Mathew, “Effective use of radiation shields to minimize operator dose during invasive cardiology procedures,” Cardiovascular Interventions, vol. 4, no. 10, pp. 1133–1139, 2011. View at Publisher · View at Google Scholar · View at Scopus
  105. A. Duran, S. K. Hian, D. L. Miller et al., “recommendations for occupational radiation protection in interventional cardiology,” Catheterization and Cardiovascular Interventions, vol. 82, pp. 29–42, 2013. View at Google Scholar
  106. M. Maeder, H. P. Brunner-La Rocca, T. Wolber et al., “Impact of a lead glass screen on scatter radiation to eyes and hands in interventional cardiologists,” Catheterization and Cardiovascular Interventions, vol. 67, no. 1, pp. 18–23, 2006. View at Publisher · View at Google Scholar · View at Scopus
  107. R. H. Thornton, L. T. Dauer, J. P. Altamirano, K. J. Alvarado, J. St. Germain, and S. B. Solomon, “Comparing strategies for operator eye protection in the interventional radiology suite,” Journal of Vascular and Interventional Radiology, vol. 21, no. 11, pp. 1703–1707, 2010. View at Publisher · View at Google Scholar · View at Scopus
  108. European Commission Directorate-General for the Environment, “Radioprotection 116: Guidelines on education and training in radiation protection for medical exposures,” 2000, http://ec.europa.eu/energy/nuclear/radiation_protection/doc/publication/116.pdf.
  109. E. Vano, M. Rosenstein, J. Liniecki, M. Rehani, C. J. Martin, and R. J. Vetter, “ICRP publication 113: education and training in radiological protection for diagnostic and interventional procedures,” Annals of ICRP, vol. 39, 2009. View at Google Scholar
  110. E. Vaño, L. Gonzalez, J. M. Fernandez, F. Alfonso, and C. Macaya, “Occupational radiation doses in interventionals cardiology: a 15-year follow-up,” British Journal of Radiology, vol. 79, no. 941, pp. 383–388, 2006. View at Publisher · View at Google Scholar · View at Scopus
  111. V. A. McCormick, C. C. Schultz, V. Hollingsworth-Schuler, J. M. Campbell, W. W. O'Neill, and R. Ramos, “Reducing radiation dose in the cardiac catheterization laboratory by design alterations and staff education,” American Journal of Cardiology, vol. 90, no. 8, pp. 903–905, 2002. View at Publisher · View at Google Scholar · View at Scopus
  112. MEDRAPET Project ENER/D4/212-2010, “Study on the implementation of the medical exposure directive’s requirements on radiation protection training of medical professionals in the European Union,” 2012, http://www.medrapet.eu/.
  113. International Atomic Energy Agency (IAEA). Radiation protection of patients (RPOP), https://rpop.iaea.org/RPOP/RPoP/Content/AdditionalResources/Training/.
  114. E. Vano, “Radiation exposure to cardiologists: how it could be reduced,” Heart, vol. 89, no. 10, pp. 1123–1124, 2003. View at Google Scholar · View at Scopus
  115. H. Geijer and J. Persliden, “Radiation exposure and patient experience during percutaneous coronary intervention using radial and femoral artery access,” European Radiology, vol. 14, no. 9, pp. 1674–1680, 2004. View at Publisher · View at Google Scholar · View at Scopus
  116. M. Sandborg, S.-G. Fransson, and H. Peterson, “Evaluation of patient-absorbed doses during coronary angiography and intervention by femoral and radial artery access,” European Radiology, vol. 14, no. 4, pp. 653–658, 2004. View at Publisher · View at Google Scholar · View at Scopus
  117. D. Hart, M. C. Hillier, and B. F. Wall, “Doses to patients from medical X-ray examinations in the UK—2000 review,” Chilton, NJ, USA, NRPB-W14, 2000.
  118. L. K. Wagner, B. R. Archer, and A. M. Cohen, “Management of patient skin dose in fluoroscopically guided interventional procedures,” Journal of Vascular and Interventional Radiology, vol. 11, no. 1, pp. 25–33, 2000. View at Google Scholar · View at Scopus
  119. International Electrotechnical Commission, “Medical electrical equipment-Part 2-43 Ed2.0: particular requirements for the basic safety and essential performance of X-ray equipment for interventional procedures,” Report 60601, International Electrotechnical Commission, Geneva, Switzerland, 2010. View at Google Scholar