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Radiation Safety in the Cath LabCardiovascular Interventions 2019

La Jolla, California

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David G. Rizik, M.D., F.A.C.C., M.S.C.A.I.David G. Rizik, M.D., F.A.C.C., M.S.C.A.I.Chief Scientific OfficerChief Scientific Officer

Director of Structural and Coronary InterventionDirector of Structural and Coronary InterventionHonorHealth Medical CenterHonorHealth Medical Center

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ter DisclosuresDisclosures

•• Abbott Vascular: Medical Advisory Board.Abbott Vascular: Medical Advisory Board.

•• CordisCordis/Cardinal: Medical Advisory Board./Cardinal: Medical Advisory Board.

•• BiotronikBiotronik: Medical Advisory Board.: Medical Advisory Board.

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•• Boston Scientific: Executive Physician Council;Boston Scientific: Executive Physician Council;Grant/Research Support; Consulting/Proctor;Grant/Research Support; Consulting/Proctor;License Fees/Royalties.License Fees/Royalties.

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Occupational Health Hazards in theInterventional Laboratory

Time for a Safer Environment

Occupational Health Hazards in theInterventional Laboratory

Time for a Safer Environment

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““The Interventional Laboratory Poses WorkplaceThe Interventional Laboratory Poses WorkplaceHazards to Interventional Physicians”Hazards to Interventional Physicians”

KleinKlein etet alal:: OnOn behalfbehalf ofof thethe MultiMulti--SpecialtySpecialty OccupationalOccupational HealthHealth GroupGroup

CathCath andand CVCV InterventIntervent 20092009;; 7373::432432/J/J VascVasc InterventIntervent RadiolRadiol 20092009;; 2020::147147

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Radiation Scatter Patterns: Primary and SecondaryRadiation Scatter Patterns: Primary and Secondary

Primary Beam Rad Source

Main Scatter Source = PatientBigger Patient = More Scatter

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Schueler, Tech Vasc Interv Radiol. 2010;13:167-71

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Cen

ter Causes of Occupational InjuriesCauses of Occupational InjuriesCauses of Occupational InjuriesCauses of Occupational Injuries

X-RayImagingX-Ray

Imaging

RadiationRadiationRadiationRadiation

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Radiation

Exposure

Radiation

Exposure

RadiationInjury

RadiationInjury

OrthopedicInjury

OrthopedicInjury

RadiationProtectionRadiationProtection

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“The chronic bearing ofheavy leaded protectiveaprons is implicated asan important factorcontributing to whatappears to be anepidemic of orthopedic

The Cath Lab: An Unhealthy Work EnvironmentKlein, Goldstein et al Cath CV Intervent 2004

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epidemic of orthopediccomplications… resultingin missed days of work,surgery, or, in some cases,curtailed careers.”Current methods only partially protect operators

from hazardous radiation exposure

Long-term lead apron use causes orthopedicproblems

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ter MODERN INTERVENTIONAL ERAMODERN INTERVENTIONAL ERAMODERN INTERVENTIONAL ERAMODERN INTERVENTIONAL ERA

•• VOLUME OF CASES/OPERATORVOLUME OF CASES/OPERATOR

•• VOLUME OF CASES/Lab (affects techs/nurses)VOLUME OF CASES/Lab (affects techs/nurses)

•• FLUORO & APRON TIME/CASEFLUORO & APRON TIME/CASE

•• VOLUME OF CASES/OPERATORVOLUME OF CASES/OPERATOR

•• VOLUME OF CASES/Lab (affects techs/nurses)VOLUME OF CASES/Lab (affects techs/nurses)

•• FLUORO & APRON TIME/CASEFLUORO & APRON TIME/CASE

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•• COMPLEXITY OF CASESCOMPLEXITY OF CASESCTO’s/StructuralCTO’s/Structural

•• IMAGESIMAGES

Radiation & Ortho ExposureRadiation & Ortho Exposure

•• COMPLEXITY OF CASESCOMPLEXITY OF CASESCTO’s/StructuralCTO’s/Structural

•• IMAGESIMAGES

Radiation & Ortho ExposureRadiation & Ortho Exposure

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Operator Dose Higher with Radial v Femoral Access

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Cen

ter Cath Lab Occupational Health Hazards

Radiation Exposure

Cataracts

Cancers

Cath Lab Occupational Health Hazards

Radiation Exposure

Cataracts

Cancers

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Cancers

Orthopedic Injuries: Lead Apron Burden

Spine (>50%)

Hips, Knees, Ankles >30%

Cancers

Orthopedic Injuries: Lead Apron Burden

Spine (>50%)

Hips, Knees, Ankles >30%

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Biologic Effects of RadiationBiologic Effects of RadiationBiologic Effects of RadiationBiologic Effects of Radiation

Deterministic injuriesDeterministic injuries•• When large numbers of cells are damagedWhen large numbers of cells are damaged

and die immediately or shortly afterand die immediately or shortly afterirradiation. Units of Gy.irradiation. Units of Gy.

•• Threshold doseThreshold dose for visible post procedurefor visible post procedureinjury from erythema to skin necrosis.injury from erythema to skin necrosis.

Deterministic injuriesDeterministic injuries•• When large numbers of cells are damagedWhen large numbers of cells are damaged

and die immediately or shortly afterand die immediately or shortly afterirradiation. Units of Gy.irradiation. Units of Gy.

•• Threshold doseThreshold dose for visible post procedurefor visible post procedureinjury from erythema to skin necrosis.injury from erythema to skin necrosis.

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Stochastic injuriesStochastic injuries•• Post radiation damage, cell descendants arePost radiation damage, cell descendants are

clinically important. Higher dose, the moreclinically important. Higher dose, the morelikellikel the process, and therefore based uponthe process, and therefore based uponprobabilityprobability

•• Linear nonLinear non--threshold dosethreshold dose identifiable foridentifiable forradiationradiation--induced neoplasm and heritableinduced neoplasm and heritablegenetic defects (genetic defects (SvSv).).

Stochastic injuriesStochastic injuries•• Post radiation damage, cell descendants arePost radiation damage, cell descendants are

clinically important. Higher dose, the moreclinically important. Higher dose, the morelikellikel the process, and therefore based uponthe process, and therefore based uponprobabilityprobability

•• Linear nonLinear non--threshold dosethreshold dose identifiable foridentifiable forradiationradiation--induced neoplasm and heritableinduced neoplasm and heritablegenetic defects (genetic defects (SvSv).).

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Risk of Cataract Among interventionalRisk of Cataract Among interventionalCardiologists and Catheterization Lab StaffCardiologists and Catheterization Lab Staff

A systematic review and MetaA systematic review and Meta‐‐analysisanalysis

Catheter CV Intervent 2017; 90: 1-9

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Catheterization and Cardiovascular Interventions

Lens changes found in either or both eyes in >51%

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Occupational Radiation Exposure Linked to Left-sided Brain TumorsOccupational Radiation Exposure Linked to Left-sided Brain Tumors

• Brain tumors in 31 interventionistsGlio 55%, Astro 17%, Mening16%

• Worked in cath lab for prolonged periodMean latency period=23.5 years

• Brain tumors in 31 interventionistsGlio 55%, Astro 17%, Mening16%

• Worked in cath lab for prolonged periodMean latency period=23.5 years

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Roguin A et al, et al Am J Cardiol 2013

• Cancer on Left side of Brain in 85% of cases• Cancer on Left side of Brain in 85% of cases

“Given that the brain is relatively unprotected and the left side of thehead more exposed to radiation than the right, these findingssuggest the possibility of a causal relationship to occupationalradiation exposure”

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Work-Related Musculoskeletal Pain by Job (Mayo)Work-Related Musculoskeletal Pain by Job (Mayo)

Survey: N=1,543N=1,042 Exposedvs501 Unexposed

Back Pain>50%

Age Related

Not just MD’s

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Orme N, et al. JACC 2015

Age>50,Working>15 years= >50% have symptoms!

Yrs Working

Not just MD’sNurses and Techs Suffer too!

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Rate Of Health Problems By Years Of WorkRate Of Health Problems By Years Of Work

Survey: N=466 Exposed vs 280 UnexposedSurvey: N=466 Exposed vs 280 Unexposed

Ortho Illness

CataractsSkin Lesions

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Andreassi et al. Circ Cardiovasc Interv. 2016;9:

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Cen

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Ortho Issues in 48%

ACC SurveyNagelhout CardioSurve 2016;40

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Caused/Worsened by Work in 70%

Retire or cut Back in 50%

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In What Modern Rationale WorkplaceIn What Modern Rationale WorkplaceWould Laborers Subject Themselves toWould Laborers Subject Themselves to

Harm on a Daily Basis?Harm on a Daily Basis?

In What Modern Rationale WorkplaceIn What Modern Rationale WorkplaceWould Laborers Subject Themselves toWould Laborers Subject Themselves to

Harm on a Daily Basis?Harm on a Daily Basis?

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Harm on a Daily Basis?Harm on a Daily Basis?Harm on a Daily Basis?Harm on a Daily Basis?

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We are Like Football Players with Leather Helmets and No Face Masks

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How to Improve Safety and HealthHow to Improve Safety and Healthin the Catheterization Labin the Catheterization Lab

How to Improve Safety and HealthHow to Improve Safety and Healthin the Catheterization Labin the Catheterization Lab

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Mitigating Orthopedic ComplicationsMitigating Orthopedic Complications

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Multifactorial Spine Injury: Posture is Important!Multifactorial Spine Injury: Posture is Important!

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• Head-Forward & upward gaze= highestpressure on C-spine

• Neutral gaze is 11 degrees down• Pressure injures discs, facets, &

neuroforamina• Cervical > lumbar injury

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Posture!!!Posture!!!

• Sternum Up and out

• Shoulders down and back

• Feet Width of Shoulders

• Sternum Up and out

• Shoulders down and back

• Feet Width of Shoulders

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• Feet Width of Shoulders

• Pelvis tilted up

• Stretch Hamstrings

• Feet Width of Shoulders

• Pelvis tilted up

• Stretch Hamstrings

Military Bearing, Not Cro Magnon!

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Exercises, Strengthen Core and PostureMeasures to Reduce Back Pain

Exercises, Strengthen Core and Posture

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How to Improve Safety and HealthHow to Improve Safety and Healthin the Catheterization Labin the Catheterization Lab

How to Improve Safety and HealthHow to Improve Safety and Healthin the Catheterization Labin the Catheterization Lab

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Minimizing Radiation ExposureMinimizing Radiation Exposure

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Radiation Exposure ReductRadiation Exposure Reductiionon“Simple Methods” with Systems in Place“Simple Methods” with Systems in PlaceRadiation Exposure ReductRadiation Exposure Reductiionon

“Simple Methods” with Systems in Place“Simple Methods” with Systems in Place

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Marked Reduction in Operator Radiation DoseMarked Reduction in Operator Radiation Doseby Reducing Frame rate 15 to 7.5 FPSby Reducing Frame rate 15 to 7.5 FPS

Marked Reduction in Operator Radiation DoseMarked Reduction in Operator Radiation Doseby Reducing Frame rate 15 to 7.5 FPSby Reducing Frame rate 15 to 7.5 FPS

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Abdelaal E, et al. JACC Interv 2014;7:567.

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Not Much has ChangedNot Much has ChangedPosition shield betweenpatient and operator

Radiation safety glasseswith side panels

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25

with side panels

Lead skirt, vest andThyroid collar at all times

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Impact of Accessory Lead Shielding on Radiation ExposureAmong Nurses and Technologists

Impact of Accessory Lead Shielding on Radiation ExposureAmong Nurses and Technologists

We are not the only stakeholders

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Madder RD, et al. JACC Cardiol Intv 2018;11(2):20612

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Not Much has ChangedNot Much has ChangedPosition shield betweenpatient and operator

Radiation safety glasseswith side panels

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27

with side panels

Lead skirt, vest andThyroid collar at all times

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Novel Systems for Occupational HealthNovel Systems for Occupational Health

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Protego