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British Journal of Radiology (2003) 76, 321-327
© 2003 British Institute of Radiology
doi: 10.1259/bjr/65778215
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Radiation doses to the legs of radiologists performing interventional procedures: are they a cause for concern?

M Whitby, MSc and C J Martin, PhD

Department of Clinical Physics & Bioengineering, Health Physics Division, Lower Ground Floor, Divisional Offices (west), Western Infirmary, Glasgow G11 6NT, UK


   Abstract
Top
 Abstract
Introduction
 Methodology
 Results
 Discussion
 Conclusions
 References
 
The purpose of this study was to ascertain the magnitude and distribution of doses to the legs of radiologists when performing interventional procedures. LiF:Mg,Ti TLD100 chips were used to measure simultaneously doses to the lower limbs and, for comparison, the hands during 100 interventional procedures. Results show leg dose was dependent upon type and complexity of procedure, equipment used and whether lead protection was available. Where no lead protection was used, the doses to the lower limbs were frequently similar to or higher than those received by the hands. The mean dose to the legs ranged from 0.19 mSv to 2.61 mSv per procedure, compared with 0.04 mSv to 1.25 mSv to the hands. During transjugular intrahepatic portosystemic shunt and embolisation procedures the leg dose could be as much as 2–3 times greater than that to the hands. When lead protection was used, the dose to the legs was reduced significantly to 0.02 mSv to 0.5 mSv per procedure. A clear linear relationship was shown between the dose–area product (DAP) reading and the dose to the feet of the radiologist. As a "rule of thumb", a DAP reading of 100 Gy cm2 will give a dose of 1 mSv to the legs, if no lead protection was used, dropping to approximately 0.02 mSv if lead protection was present. This study demonstrates that the dose to the legs of radiologists can be higher than that to the hands when no lead protection is used. The inclusion of a lead screen to protect the legs is an effective method of dose reduction when performing interventional procedures.


   Introduction
Top
 Abstract
 Introduction
Methodology
 Results
 Discussion
 Conclusions
 References
 
Radiologists who perform interventional procedures often have to stand close to the X-ray beam in order to carry out manipulations. As a result their legs, which will not be protected by a conventional lead apron, may receive significant radiation doses from scattered X-rays. The radiation level below the couch is high, because, with the C-arm undercouch X-ray tube configuration commonly used, radiation is produced by scatter of the unattenuated primary beam from the bottom of the couch and from the patient. The radiation scattered in other directions is attenuated by passage through the patient. The potential for interventional radiologists to receive doses to their hands, which are high enough to warrant that they be classified radiation workers, is well established [1–13]. The doses to the lens of the eye and thyroid have also been investigated extensively [2, 4–7, 9, 11–14]. However, little work has been published quantifying the dose received by the legs. The dose limit of 500 mSv applied to the feet and ankles over any 1 calendar year is the same as that to the hands and other parts of the skin [15, 16]. Any worker receiving 3/10ths of this limit would need to be classified.

The purpose of this study was to determine the magnitude and distribution of doses to the legs of radiologists when carrying out interventional procedures, to compare these with doses to the hands and evaluate the effectiveness of different types of shielding in reducing these doses. The results have been used to assess when doses to the legs might approach a dose limit. The doses across the lower limbs and to the hands were measured using themoluminescent dosimeters (TLDs). Magnitudes of leg doses have been related to the dose–area products (DAPs) which quantify the amount of radiation used in each examination. In addition, doses to the legs of other personnel within the room have been investigated. Measurements of direct scatter air kerma were also made during simulated patient examinations. These results have been used in conjunction with clinical data in the interpretation of results.


   Methodology
Top
 Abstract
 Introduction
 Methodology
Results
 Discussion
 Conclusions
 References
 
Studies were undertaken at six hospitals, two large teaching hospitals and four district general hospitals. A total of 100 procedures covering a wide variety of both diagnostic and therapeutic procedures were studied for radiologists of varying experience. Data on the types of X-ray unit, the protection provided and the procedures performed in each hospital are summarized in Table 1Go. Doses to the legs of each radiologist were measured using four LiF:Mg,Ti TLD100 chips attached to the theatre trousers, positioned 80 mm below the apex of the patella and on the upper aspect of the foot for both legs. Results are presented in terms of mean doses (±1 standard deviation) at each position on the leg for all the particular types of procedure monitored. However, the mean dose to the most exposed limb is used for making comparisons between different procedures across different hospitals. The doses to the hands were measured simultaneously using TLDs located at various points across the hand and the mean dose to the most exposed hand was derived for comparison. Pairs of TLDs were also attached to the legs of other staff present in the room during procedures, including the secondary radiologists, scrubbed nursing staff and radiography staff.


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  		Table 1. Summary of the hospitals included in the study, the equipment used, lead protection available and the number and type of procedures undertaken

 
The doses to the lower limbs were measured either over a complete session of interventional procedures or per procedure, depending on the dose level and the local arrangement. The X-ray technique, number of spot films taken, screening time and DAP readings were recorded. After each procedure or session, the TLDs were then read out on a Harshaw 5500 TLD reader (Thermo RMP, Solon, OH), with background TLD measurements being deducted. The TLD responses were calibrated against air kerma measurements made using a Keithley Triad dosimetry system (Keithly Instruments Inc., Cleveland, OH) with 12 cc chamber and a Radcal 9010 electrometer (Radcal Corp., Munrovia, CA) with 6 cc chamber, with calibration traceable to national standards, using a Siemens Polydoros 80s (Siemans AG, Munich, Germany) at a range of X-ray energies, from 60 kVp to 90 kVp. The calibration factor and an appropriate conversion factor [17] were used to derive the shallow soft tissue dose [Hp(0.07)]. The overall accuracy of the TLD measurements was ±20%.

The distribution of scatter air kerma around the couch of a Philips Integris V3000 (Philips Medical Systems, Andover, MA) undercouch C-arm interventional suite (A in Table 1Go) was measured using a RANDO phantom to simulate a patient. The phantom was used in positions routinely encountered in clinical practice and the experimental conditions, such as phantom position on table, table height and source–intensifier distance (SID), were set as close as possible to those employed during clinical procedures.

The scatter air kerma was measured using a Radcal 9010 radiation monitor, with a 180 cc chamber. Measurements were made in both the vertical and horizontal planes with the aid of grids of 100 mm squares marked on 2 m x 2 m polythene sheets to assist in positioning. The sheets were held in position in either plane using clamp stands located at either end side of the table with sections cut away to take the X-ray unit and phantom. The RANDO phantom was then irradiated under fluoroscopy using a 100 mm x 100 mm field size in the midline from the level of T12 to L4 vertebrae, using an image intensifier field size of 38 cm and a general abdominal setting. Under automatic exposure rate control, this exposed the phantom to a beam of quality 70 kV and 3 mA with an entrance surface dose rate of 25 mGy min-1 and a DAP rate of 2.9 Gy cm2 min-1. The scatter air kerma was measured with the 180 cc chamber clamped at the grid intersections at 100 mm intervals in areas of higher dose rate, and at 200 mm intervals at positions further from the X-ray beam. Over 200 individual measurements were made around the table for each plane. The data were used to make isodose contour plots, to aid interpretation of the TLD results.


   Results
Top
 Abstract
 Introduction
 Methodology
 Results
Discussion
 Conclusions
 References
 
For all interventional procedures studied, the average variation in dose from the foot to the knee was 9% across both legs (Table 2Go). The leg nearest to the X-ray field received the highest dose. Usually this was the left leg, but it was dependent upon the room layout and type of procedure being performed.


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  		Table 2. The variation in dose across the legs of radiologists performing different types of interventional procedures, using equipment without lower limb lead protection. Results are expressed in terms of mean dose (±standard deviation) per procedure in mSv

 
Figure 1Go compares the mean dose to the most exposed leg and the mean dose to the hands per procedure for different types of procedure performed in the six hospitals. There were significant differences between hospitals and between procedures, which relate to factors such as the dose performance of the X-ray equipment and the technique employed. The leg doses were also dependent upon the level of lead protection available to the radiologist. Where there was no lead protection for the legs, the mean doses to the legs were frequently similar to or higher than the mean doses to the hands.



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  		Figure 1. The mean dose (mSv) to the most exposed leg and hand of radiologists during different types of procedures, at different hospitals. Y, lead protection used N, lead protection not used.

 
Different patterns of exposure could be identified for each type of procedure. During biliary procedures, which consisted mainly of biliary drainages and stenting, the leg doses ranged from 0.01 mSv to 0.90 mSv. In hospitals A and D where no lead protection was available, the average dose to the lower limb was 0.40±0.24 mSv, while in hospital C, where protection in the form of a mobile lead skirt was used, the average dose was reduced to 0.02 mSv. Lead protection was also available in hospital E. However, this was of the integral type, which resulted in a variation in dose along the legs. During a biliary stent procedure the table was raised too high for the screen to provide adequate protection and the feet therefore received an average dose of 0.22±0.02 mSv compared with 0.04±0.03 mSv to the legs which were better protected. The screen was also poorly positioned to protect the limbs, during other biliary procedures, and it is for these reasons that hospital C has a slightly higher leg dose than expected. In all cases however, the doses to the legs were less than those to the hands.

During transjugular intrahepatic portosystemic shunts (TIPS) the doses to the legs were two to three times greater than those to the hands. This was despite an integral lead screen for protection of the legs being used in hospital E, but not in hospital A. The mean dose to the radiologists' legs in hospital A was 2.61±0.50 mSv per procedure, whilst that in hospital E was 0.50±0.36 mSv per procedure.

During stenting, embolisation and angioplasty procedures the mean dose to the legs ranged from 0.03 mSv to 0.97 mSv, with the highest doses being for embolisations. In hospital A, where no lead protection for the lower limb was available, the leg dose was in most cases greater than that to the hand, and for some types of procedure the lower limb dose was as much as three times the dose to the hand. In hospital B, where lead protection which was integral to the table was used, the leg dose was significantly lower. This was also seen in hospital C and F where a mobile screen was used consistently during biliary and stenting procedures, respectively. In hospital C however, during the embolisation procedure the mobile lead screen was not used, resulting in the lower limb receiving a far higher dose than expected.

The relationship between the DAP and dose to the foot of the most exposed limb was also investigated. There was a clear linear relationship between the dose to the most exposed foot and DAP reading per procedure when no lead protection was used (Figure 2Go) (r=0.96), but there was little correlation between DAP and screening time (r=0.39). Procedures that resulted in a DAP of approximately 100 Gy cm2 gave a dose of 0.9 mSv to the leg nearest to the X-ray field (usually left) and 0.7 mSv to the other leg.



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  		Figure 2. The linear relationship between the dose–area product (DAP) reading per procedure and the dose to the most exposed foot when no lead protection was used (r=0.96).

 
The doses to the legs of some other staff could be significant. The largest doses measured were to the lower limbs of secondary radiologists. The higher doses are likely to be due to the need for secondary radiologists to help in insertion of catheters and deployment of stents. These doses were approximately 20% lower than those to the primary radiologist. Doses for scrubbed nursing staff and radiographers were about a fifth and a tenth, respectively, of the radiologists' doses.

Figures 3 and 4GoGo show plots of the scatter air kerma around the RANDO phantom irradiated in the posteroanterior (PA) projection in the vertical plane at right angles. A maximum air kerma rate between 300 and 600 µGy min-1 was measured along the side of the phantom, and immediately below the level of the table adjacent to the X-ray field. The typical positions adopted by staff around the couch are illustrated in Figure 5Go. In general the radiologist stands to the right of the C-arm. For the particular X-ray unit, phantom and field used for the measurements, the radiologists' legs would be exposed to a scatter air kerma rate of 30 µGy min-1 to 150 µGy min-1. In the area where scrubbed nursing staff or secondary radiologists may stand at around 1 m away from the X-ray tube, the air kerma rate falls to between 15 µGy min-1 and 30 µGy min-1. At the bottom of the table where radiography staff were usually positioned, the scatter air kerma rate dropped to 10 µGy min-1 and below, and in areas where other staff might be present, it was below 10 µGy min-1.



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  		Figure 3. Plot of scatter air kerma in two planes around a RANDO phantom irradiated in the posteroanterior projection. Figure shows the scatter air kerma rate along the edge of the table, parallel to the patient's side.

 


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  		Figure 4. Plot of scatter air kerma in two planes around a RANDO phantom irradiated in the posteroanterior projection. Figure shows the scatter air kerma perpendicular to the patient, at the midline of the image intensifier.

 


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  		Figure 5. The typical areas staff work within, during interventional procedures. Rad, radiologist; Sc, scrubbed nurse or secondary radiologist; R, radiographer; X, radiologist position when performing transjugular intrahepatic portosystemic shunt procedures.

 
Scatter distributions were measured for left and right anterior oblique projections (LAO and RAO) which are also in common use. Figure 6Go shows the scatter air kerma rate around the phantom irradiated in the RAO projection. The air kerma rate where the radiologist stands was approximately 30 µGy min-1 to 75 µGy min-1, which was less than for the PA projection. The greatest scatter is at the side of the patient closest to the X-ray tube, which is the left side of the patient in this instance, where the scatter air kerma rate is between 100 µGy min-1 and 1000 µGy min-1. When the C-arm was moved into the LAO projection, the area with the higher level of scattered radiation was on the right side of the patient, near the position where the radiologist normally stands.



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  		Figure 6. Plot of scatter air kerma around a RANDO phantom irradiated in the right anterior oblique projection.

 
To investigate the effect of a lead screen on the scatter air kerma around the table, a mobile lead screen was introduced and the phantom irradiated with the RAO projection under the same conditions as before. The results shown in Figure 7Go demonstrate that the lead screen removed most of the scattered radiation and reduced the radiation dose rate at the legs by over a factor of 50, from approximately 50 µGy min-1 to 0.5 µGy min-1 to 1.0 µGy min-1.



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  		Figure 7. Plot of scatter air kerma around a RANDO phantom irradiated in the right anterior oblique projection, after the introduction of a mobile lead screen.

 

   Discussion
Top
 Abstract
 Introduction
 Methodology
 Results
 Discussion
Conclusions
 References
 
The results of this study show that radiologists may receive significant doses to their legs from individual interventional procedures, with the dose depending on the type and complexity of the procedure. The relative doses to the hands and legs varied for the different procedures. For some types, the doses to the legs were likely to be greater than those to the hands, particularly where specialized lead protection was not used.

During biliary procedures the doses to the legs are in most cases lower than those to the hands, irrespective of whether lead protection is employed. There is greater potential for the radiologists' hands to receive higher doses in biliary procedures, because they need to be close to the patient's side when screening in order to manipulate the catheter effectively, and therefore in an area of relatively high scatter dose rate (Figure 3Go). However, the procedures do not generally have high DAPs and as a result the doses to the legs are lower.

The mean leg dose during TIPS procedures varied markedly between the two hospitals which performed this procedure, with those for hospital A being the highest of any procedures monitored. The doses for TIPS procedures are likely to be high, as they are commonly the longest procedures undertaken and require the use of several different projections. The differences between the two centres could be attributed to several factors, the most important of which was the dose performance of the X-ray units, but also included the experience of the radiologists in performing TIPS procedures and the techniques used. The doses to the legs in both hospitals were higher than those to the hands. TIPS procedures involve the radiologist inserting a catheter down the internal jugular vein. Once the catheter is inserted the radiologist will screen as the catheter advances through the superior vena cava, inferior vena cava and down to the right hepatic vein. It is from here that an artificial channel will be created from the hepatic vein to the portal vein, thus shunting blood away from liver sinusoids and reducing portal venous pressure. The hands do not need to be close to the X-ray field, as most of the screening will be performed over the hepatic area, while the hands remain up at the neck manipulating the catheter end. Thus the legs are only slightly further from the X-ray beam than the hands. The reason that doses to the legs are higher than those to the hands, is that the legs are exposed to radiation scattered directly from the lower surface of the couch, whereas scattered radiation to which the hands are exposed is attenuated by passage through the body.

It is perhaps surprising that the leg doses for TIPS were higher than those to the hands in hospital E, where an integral type lead screen had been provided. Measurements had shown that for other procedures the introduction of a lead screen had a significant effect on dose to the lower limb, in many cases reducing the leg dose to the minimum detectable level for the TLDs used. The difference with TIPS was that the lead screen, which was fixed to the side of the table, did not provide protection to the top of the table, which is the position where the radiologist stands to insert the catheter in the neck (X in Figure 5Go).

The measured doses to the lower limbs during stenting, embolisation and angioplasty procedures ranged from 0.02 mSv to 0.97 mSv. The corresponding doses to the hands were between 0.04 mSv and 0.59 mSv. In general (excluding biliary procedures) where no lead protection was available (hospital A) the leg doses were higher than those to the hands by a factor of 2–3. If lead protection was available (hospitals B, C and F) the dose to the legs was significantly reduced. In the case of embolisation procedures at hospital C however, the legs received a higher dose than that to the hands because the mobile shield was not used.

The results of this study have shown that lead screens provide an effective method of protecting the lower limbs during fluoroscopy in most cases. There are two basic types of screen, ones that are integral to the table and screens that are freely mobile. Both have inherent advantages and disadvantages. The advantage of the screen that is integral to the table is that it is always in place and no conscious decision is needed to use it. As it is integral to the table, the risk of collision with other parts of the unit is minimal, as the screen will rise and fall with the table as it is moved. This is of particular relevance as newer interventional units also permit cranial and caudal tilting. The main disadvantage of this system in most cases is that it has a restricted range of horizontal movement. The results for TIPS procedures highlight this difficulty. Usually the lead screen is attached to a limited area of the table via studs or is permanently attached. This means that radiologists standing side-on to the patient will be adequately protected. However, when the radiologist stands at the top of the table, as in the case of TIPS procedures, the lead screen provides no protection at all. Therefore the legs, which remain relatively static, receive a high dose.

This particular problem is alleviated by use of a mobile lead screen. Such a screen can be placed in the most appropriate position to protect the radiologist's legs wherever he/she stands. There are, however, problems associated with this type of screen. Firstly there needs to be a conscious decision to use it. The lead screen has to be put into place before the procedure begins, as all procedures require a sterile environment. There is also a greater risk of collision with other pieces of equipment. Of particular concern is collision with the screen when tilting the table, or moving the table up or down. Thus in general for protection where the radiologist stands at the side of the unit, e.g. biliary, stents, embolisations and angioplasties, the integral screen provides the best option, but consideration should be given to the types of procedure being performed when a unit is being purchased and appropriate protection specified.

There was a clear linear relationship between the DAP reading and the dose to the feet of the radiologists (Figure 2Go). From the data in Table 1Go, a "rule of thumb" was established to provide guidance on the approximate magnitude of doses to the legs. This can be used to determine whether protection might be required. The rule is that a DAP of 100 Gy cm2 will give a dose of approximately 1 mSv to the legs, if no shielding is present. If lead protection is available, this dose would drop to approximately 0.02 mSv.

Doses for nursing and radiography staff assisting in interventional procedures were significantly lower than those received by radiologists and should never approach any dose limit for the extremities. However, the education of staff about the location of high scatter areas within the room allows the staff to optimise their dose personally in accordance with the ALARP principle.


   Conclusions
Top
 Abstract
 Introduction
 Methodology
 Results
 Discussion
 Conclusions
References
 
Many radiologists within the UK are now classified radiation workers due to the dose they receive to their hands. Results of this study suggest that for those departments which have a wide and varied workload, the doses that radiologists receive to their lower limbs can be higher, if no lead protection is used, than those to the hands. The routine monitoring of leg doses may be problematic. However departments concerned about such doses may ascertain the magnitude of the dose to their radiologists by using a general rule of thumb. This can be used to decide whether doses to the legs are likely to be high and whether a lead screen and/or dose monitoring are appropriate.

The study has demonstrated that the inclusion of a lead screen to protect the lower limbs is an effective method of dose reduction when performing interventional procedures. It has highlighted the importance not only of using lead screens, but also of good screen design, in order to alleviate the problems associated with protecting the radiologist when performing procedures that require him/her to stand at different positions in relation to the X-ray unit and the couch. The inclusion of lead screens when purchasing new interventional suites is recommended as it provides an excellent and cost effective method in the optimization of radiologist extremity doses. In procedures such as TIPS, where the radiologist stands at the head of the couch, a mobile screen, which is placed in position prior to commencement of the procedure, may provide the most effective method for restricting doses to the legs. However, for most other procedures, a lead screen integral to the table is likely to be the better option.


   Acknowledgments
 
The authors wish to thank the Health and Safety Executive for providing financial support for this project. They also wish to express their gratitude to the interventional radiologists and other radiology staff in all hospitals studied for their forbearance in allowing themselves to be covered with TLDs.

Received for publication April 24, 2002. Revision received November 13, 2002. Accepted for publication February 6, 2003.


   References
Top
 Abstract
 Introduction
 Methodology
 Results
 Discussion
 Conclusions
 References
 

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  11. Coakley KS, Ratcliffe J, Masel J. Measurement of radiation dose received by the hands and thyroid of staff performing gridless fluoroscopic procedures in children. Br J Radiol 1997;70:933–6.[Abstract]
  12. Geterud K, Larsson A, Mattsson S. Radiation dose to the patients and personnel during fluoroscopy at percutanous renal stone extraction. Acta Radiol 1988;30:201–5.
  13. Faulkner K, Moores BM. An assessment of the radiation dose received by staff using fluoroscopic equipment. Br J Radiol 1982;55:272–6.[Abstract/Free Full Text]
  14. Palmer KE, Wright IH. Eye dose limits and the use of overcouch and undercouch x-ray image intensifier systems. Br J Radiol 1985;58:1221–3.[Abstract/Free Full Text]
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