A dose of prevention for reducing radiation exposure

August 12, 2020
by Sean Ruck, Contributing Editor
It’s well-established that radiation exposure can impact interventional cardiologists in multiple ways. HealthCare Business News spoke with Dr. Dipti Itchhaporia, ACC's vice president, an interventional cardiologist with Hoag Memorial Hospital Presbyterian and associate professor of Medicine at the University of California Irvine, to learn about the specific dangers radiation exposure introduces and how to mitigate those dangers.

To begin, Itchhaporia says there are many possible side effects of radiation. One is the higher incidence of cataracts, specifically posterior subscapular cataract, among interventional cardiologists. “That’s typically why we wear the lead-lined glasses,” she says.

There is also reported thyroid disease due to the result of radiation exposure. Reproductive problems have been reported as well. And most recently, there has been increased attention paid to reports of left-sided brain tumors among the specialty.

While the body of research surrounding radiation risks to providers has grown over the years, the technology and methods to reduce the risks, while improving, has grown at a slower pace. “I can go back to training where the principles of ALARA were enshrined. It stands for ‘as low as reasonably achievable.’ that is what we were taught,” Itchhaporia says.

California, which leads the nation in identifying and labeling cancer risks of various materials, chemicals and products, requires a fluoroscopy license. “It’s meant to educate all of us in the cath lab or those who use fluoroscopy equipment to understand what the risks are and how best to mitigate our exposure,” Itchhaporia says.

But the best training only goes so far – individuals need to act on that training and continue to work to reduce their own exposure. Itchhaporia says the obvious first step is try not to expose yourself to radiation at all, unless it’s unavoidable. Turn to radiation-reliant imaging only when absolutely necessary. She also notes that fluoroscopy has less than 10 percent the radiation exposure compared to cine, delivering a significant decrease in dose. “Utilizing less steep angulation is also a way to reduce exposure, though that can be difficult in certain cases,” she says

She also says minimizing the use of magnification modes helps. “The younger interventionalists have really been attuned to these methods of decreasing exposure. They use less magnification, they use more flouroscopy than cine. They’re more interested in knowing what their exposure is, so they’re following their badges a little better than I think older interventionalists have.”

In her cath lab, Itchhaporia says they’re using disposable lead aprons to decrease the scatter exposure. Having shields, making sure you collimate, keeping the image intensifier close to the patient, and of course wearing lead skirts and thyroid collars decreases the risk. “I think if you’re a female, even wearing a sleeve on the left hand is a good idea,” she says, though she notes that there’s not currently enough research to determine if an interventionalist faces an increased rate of breast cancer.

Ceiling-suspended radiation shields have also come to market in recent years. Itchhaporia’s organization installed one of those systems, but she says in her experience, it’s not comfortable for those performing percutaneous coronary interventions. “So we’ve actually left it for our EP colleagues who have very long cases. Some of the EP doctors really like it and I think it may be more helpful to them.”

While not financially feasible for some facilities, robotic systems can also decrease exposure. On the other side of the tech scale, the relatively recent introduction of skullcaps to the protective gear wardrobe has been welcomed by some. “About 30 percent of interventionalists wear those skullcaps today,” Itchhaporia says. She has also heard about hand cream that can be used to decrease radiation exposure for hands that are in the field, but she hasn’t had personal experience with the products.

Dr. Dipti Itchhaporia
ACC's vice president
Although lead is still the go-to for protective personal shielding, the lead in vests and collars have gotten thinner, lighter and more comfortable over the years. Other materials like bismuth, tungsten and metal-infused polymers are also being explored as potentially safer alternatives to lead both in their ability to shield users and to limit health and environmental issues that can result from lead use. The alternatives can be particularly attractive to those with back pain and limited mobility due to the heavy lead aprons.

Although interventionalists hold the main responsibility for their safety and the reduction of radiation exposure, manufacturers are trying to do their part and are stepping forward to help. New systems continue to decrease radiation dose and offer dose lowering technologies, often while managing to increase image quality and reduce noise. Artificial intelligence is also making inroads, thereby providing another tool to decrease the number of images needed or the intensity of radiation.

Radiation continues to be an important part of healthcare, but is a double-edged sword. It’s an invisible enemy even as it helps healthcare professionals. Careful planning, research into safety equipment and options, and a healthy safety culture are all ways to harness the good while minimizing the bad.