TECHNOLOGY TALK
MAHADEVAPPA MAHESH, MS, PHD, RICHARD L. MORIN, PHD
Personal Protective Equipment in
Interventional Fluoroscopy: Distinguishing
Evidence From Hype
Rebecca M. Marsh, PhD, Stephen Balter, PhD, Mahadevappa Mahesh, MS, PhD
As the number of interventional SURGICAL CAPS 0.025% to 0.0014%. Over a 40-year
fluoroscopic procedures increases Surgical caps lined with lead (or career, the per-operator cost,
each year, numerous devices and lead-equivalent materials) were including the initial purchase price,
techniques claiming improved radi- developed in response to growing periodic radiation safety checks,
ation protection for the operator concerns that interventionalists are maintenance, and occasional
have emerged in response to at increased risk for developing replacement, has been estimated at
increased concerns about radiation radiation-induced brain tumors [2]. $4,000 for reusable products and
exposure. These are typically mar- Several reports have garnered $40,000 for disposable products [1].
keted toward interventionalists and widespread interest, reporting dose Consequently, the protection
often in a sensationalistic manner, reductions by the caps of up to provided by lead caps has an
including anecdotes of the harm 94% and most concluding that estimated cost of approximately
that will likely befall the inter- their use is beneficial. However, a $17 million per theoretical brain
ventionalist who does not use the recent study demonstrated that the tumor that is prevented when using
product. The purpose of this article use of such surgical caps under a reusable product and $170
is to provide a framework for eval- clinical conditions reduces whole- million when using a disposable
uating the efficacy of personal brain exposure only by 3% [3]. product. A more realistic, but still
radiation-protective devices used Even numerically large re- high, 10% reduction would
during fluoroscopy-guided inter- ductions in radiation are often re- increase these costs by an order of
ventional procedures. An analysis of ported and interpreted without magnitude.
existing products is used to high- considering what adverse health ef-
light current discrepancies between fects are caused by base (unshielded)
science-based evidence and fear- levels of exposure. For example, if RADIATION PROTECTION
based hype. the dose to the unshielded brain is CREAMS
This article focuses on three 10.6 mGy per case [2], what is the Fluoroscopy operators’ hands are
products marketed as radiation pro- health benefit of using a lead cap to exposed to both the primary radia-
tective devices: lead (or lead- reduce operator exposure to 0.6 tion beam and scattered radiation.
equivalent) surgical caps, surgical mGy? Using methodology outlined Although once more common,
pads, and radiation protection previously [1], and assuming an radiation-attenuating gloves are
creams. It includes discussions unrealistically high 94% reduction decreasing in popularity because of
within the context of decreased risk in radiation dose to the brain, one growing concerns about reduced
and associated economic burden. can estimate that performing 1,200 dexterity and tactile sensation. A
Risk estimates are based on con- cases each year over a 40-year recent alternative for radiation pro-
verting the reported doses to effec- career while wearing a lead cap may tection of the hands is the use of
tive dose and applying a 5%/Sv risk decrease the number of inter- radiation-attenuating cream [4]. A
for developing a radiation-induced ventionalists who develop radiation- recent study showed that
fatal cancer [1]. induced fatal brain cancer from application of the cream can reduce
ª 2017 Published by Elsevier on behalf of American College of Radiology
1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.08.017 1
dose to fluoroscopy operators’ hands actual dose savings decreases to to support the stance that if a device
by an average of 40% [4], from an approximately 2.4 mSv/case. This or technique can potentially reduce
effective dose of approximately 0.24 has an associated theoretical radiation dose, it should be used.
to 0.14 mSv per case. Performing a decrease in fatal cancers of 0.6% at Furthermore, failure to adopt such a
similar analysis to that presented a cost of approximately $640 practice is often viewed as reckless or
for lead caps and assuming a million per theoretical fatal cancer ignorant. When the ALARA concept
similar workload of 1,200 cases a avoided. Surgical pads also have the was initially introduced in the 1960s
year over a 40-year career, this can potential to enter the imaging field by the International Commission on
be compared with decreasing the and obscure relevant anatomy and Radiation Protection, it specified
number of fatal cancers by 0.02%. increase radiation output, increasing that the determination of “reason-
Regarding deterministic effects, the dose to both the patient and ably achievable” must include eco-
reported annual unshielded dose to operator. Pads might be indicated nomic factors. Failure to do so
the hands (11.8 mGy) is orders of for special cases in which there is makes the use of radiation in medi-
magnitude lower than the levels insufficient distance between the cine unjustifiably expensive.
known to cause radiation damage operator and the irradiated field or Another common misconception
to the skin or hair. Economically, sterility concerns make the use of surrounds the application of radia-
cream provides radiation protection conventional radioprotective devices tion risk estimates. Risks associated
at a cost of $9.1 billion for each impractical. with stochastic effects (ie, develop-
theoretical fatal cancer prevented. ment of a fatal cancer), and the term
Most radioprotective surgical effective dose specifically, describe the
gloves and this protective cream, DISCUSSION increased risk posed to a population.
have an FDA-mandated black-box Some radiation protection devices The term does not indicate the risk
warning against use in the primary x- may exist to solve a problem that to an individual, although it is often
ray beam. However, users of pro- does not exist. Any discussion of risk used in this way. Reducing the
tective gloves and protective creams inherently contains cognitive bias, effective dose from 0.24 to 0.14 mSv
may inappropriately keep their making it particularly difficult to per case does not decrease any in-
hands in the primary beam. Placing separate science-backed information dividual’s risk for developing fatal
any attenuating object in the beam from the claims of increased safety. cancer by 0.02%; it reduces the
will increase x-ray output, poten- This includes consideration of the number of estimated fatal cancers by
tially increasing radiation exposure baseline (ie, unshielded) risk. It is 0.02% among the population. An
to both the operator and patient. human nature to try to ascribe a individual’s risk, and hence inter-
cause to adverse events, whether it is pretation of anecdotal stories of
an automobile accident or a cancer interventionalists’ developing fatal
SURGICAL PADS diagnosis. It is important not to cancers, is influenced by a number of
A third popular radiation protection confuse correlation (“I worked as an other lifestyle and genetic factors.
device is the surgical pad or drape. interventional radiologist for 30 In summary, when considering
These pads are placed over patients years and I have brain cancer”) with any new radiation protection device
during fluoroscopic procedures, causation (“I got brain cancer or technique, the following ques-
typically on the arm (for transradial because I worked as an interven- tions must be asked:
approaches) or pelvis. Although the tional radiologist for 30 years”). The n Is there a risk posed by the current
exact results vary, use of lead surgical truth of the first statement does not
practice?
pads or drapes has been reported to mean that the second statement is n Does this technique mitigate this
decrease effective dose to the oper- also true. Few people want to admit
risk? If so, does the decrease in
ator by approximately 48 mSv per that their unfortunate circumstance
risk improve overall health?
case [5]. However, these studies do is random. However, it is incumbent n What is the financial burden?
not account for the effect of the upon the medical community to n Might adoption of this technique
operator’s own protective lead recognize cognitive bias and not
increase risk?
apron, which attenuates allow it to guide clinical practice.
approximately 95% of the scattered The ALARA principle (“as low as Only through careful consider-
x-ray beam. Consequently, the reasonably achievable”) is often cited ation of these points can one
2 Journal of the American College of Radiology
Volume - n Number - n - 2017
promote a radiation safety culture facts and fears. Radiat Prot Dosimetry 4. Subramanian S, Waller BR, Winders N,
2017;173:180-4. et al. Clinical evaluation of a radio-protective
that is based on evidence rather than 2. Roguin A, Goldstein J, Bar O, Goldstein JA. cream for the hands of the pediatric inter-
playing on people’s fears of a very Brain and neck tumors among physicians ventional cardiologist. Catheter Cardiovasc
small, theoretical risk. performing interventional procedures. Am J Interv 2017;89:709-16.
Cardiol 2013;111:1368-72. 5. Power S, Mirza M, Thakorlal A, Ganai B,
3. Fetterly K, Schueler B, Grams M, Gavagan LD, Given MF, et al. Efficacy of a
Sturchio G, Bell M, Gulati R. Head and radiation absorbing shield in reducing dose to
REFERENCES neck radiation dose and radiation safety for the interventionalist during peripheral endo-
1. Balter S. Promoting fluoroscopic personal ra- interventional physicians. JACC Cardiovasc vascular procedures: a single centre pilot study.
diation protection equipment: unfamiliarity, Interv 2017;10:520-8. Cardiovasc Intervent Radiol 2015;38:573-8.
Rebecca M. Marsh, PhD, is from the University of Colorado School of Medicine, Aurora, Colorado. Stephen Balter, PhD, is from
the Departments of Radiology and Medicine, Columbia University Medical Center, New York, New York. Mahadevappa Mahesh,
MS, PhD, is from The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University
School of Medicine, Baltimore, Maryland.
Dr. Balter has received fees from Mavig GmBh as part of a speakers’ bureau, outside the submitted work. All other authors have no
conflicts of interest related to the material discussed in this article.
Mahadevappa Mahesh, MS, PhD: Johns Hopkins University, The Russell H. Morgan Department of Radiology and Radiological
Science, 601 N Caroline Street, Baltimore, MD 21287-0856; e-mail: mmahesh@jhmi.edu.
Journal of the American College of Radiology 3
Marsh, Balter, Mahesh n Technology Talk
