Less risky than traditional surgery, with shorter hospital stays and faster recovery, image-guided minimally invasive procedures are used more and more frequently worldwide. In 2020, the last year for which data is available, 24 million such procedures were performed - a six-fold increase over a dozen years. But there can be a catch: without the proper precautions, both patients and medical staff can be exposed to unnecessary radiation from the X-ray fluoroscopy used so doctors can "see" what they are doing inside the body.
"We have identified new challenges for radiation protection due to the technical developments and increases in the complexity of these procedures and potential gaps in guidance and training to improve radiation protection of patients and staff," said Jenia Vassileva, an IAEA Radiation Protection Specialist.
Fluoroscopy shows a continuous X-ray image - produced by a beam passed through the body - displayed on a monitor.
As part of support to the medical community, at a recent IAEA meeting, over 100 experts from 42 countries and 18 international organizations and professional bodies discussed progress made and challenges for radiation protection in fluoroscopy guided interventional procedures. They focused on ways to enhance radiation protection of patients and medical staff when applying these procedures, which can cause skin injuries in patients and radiation-induced cataract in medical staff performing interventional procedures.
Management of radiation protection of patients and medical staff
Often tissue reactions are skin reddening or loss of hair only, but, in a few cases, particularly when higher doses are applied, more severe reactions such as ulceration or dermal necrosis can arise, sometimes weeks, months of even years later.
"Factors associated with such high doses are patient size and the medical complexity of the procedure, which require prolonged fluoroscopy; but in most cases unintended severe tissue reactions occur as a result of the lack of knowledge and awareness of the operator," said the meeting's Chair Stephen Balter, a Professor of Clinical Radiology (Physics) and Medicine at Columbia University in New York, USA.
Hal Workman, a patient who had suffered from dire skin injury as a result of a cardiac intervention 14 years ago, said: "It took more than a year before anyone could identify that my prolonged fluoroscopy procedure caused my injury, and for over 15 months I had no more than two hours of sleep at any one time. This was the worst pain you can imagine."
Participants also learned about the latest developments in fluoroscopy technology such as a type of skin dose map with a colour or a grey-scale visual distribution of radiation dose to the patient skin. This provides operators information on dose monitoring in order to better adjust the procedure's settings and avoid skin injury to the patient.
"Twenty years of effort has resulted in a dramatic reduction of cases of skin injuries," said Balter. "Improvements in fluoroscopic equipment and in the medical devices used for these procedures are major contributors. In our lab, we pay attention to the skills and competence of the medical staff, as well as to our protocols." He emphasised that it is important to plan, especially for patients with obesity and those undergoing multiple procedures, and to constantly monitor the dose delivered and proactively follow-up for possible skin reactions when a substantial amount of radiation needs to be used in a complex procedure.
Monitoring doses to medical staff is still a challenge in many countries as well. Efforts to increase radiation protection involve, for example, the use of real time electronic dosimeters, video systems for automatic tracking of staff and virtual simulators. "Doses to the medical staff can also be recorded in the IAEA's international database ISEMIR-IC to benchmark and optimize practice," Vassileva said.
Raising awareness among medical staff about radiation protection would already go a long way towards decreasing exposure of staff and patients, she added. Meeting participants said that practice oriented trainings using videos, such as the new IAEA practical tutorials on Radiation protection in interventional procedures, are effective in this regard.
IAEA study to increases awareness
To bridge the existing gaps in data on tissue reactions in patients, and to compare practices internationally, the IAEA has launched an international study of patient doses and tissue reactions from fluoroscopy guided interventional procedures.
"This project will study the frequency of appearance of tissue reactions and the relationship between them and associated factors such as, for example, dose parameters from interventional procedures," said Vassileva. "Our goal is to collect data globally, which will help to update dose values used to initiate follow up procedures of a patient at risk for skin reactions. This will also help the IAEA to make necessary development of the IAEA voluntary reporting system SAFRAD (Safety in Radiological Procedures)."
To participate in this year-long study, medical facilities need to complete this online feedback form
