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British Journal of Radiology (2004) 77, 562-567
© 2004 British Institute of Radiology
doi: 10.1259/bjr/83257582
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Full Paper

Comparison of a conventional and a flat-panel digital system in interventional cardiology procedures

V Tsapaki, MSc, PhD 1 S Kottou, MSc, PhD 2 N Kollaros, MSc 3 P Dafnomili, Techn 3 M Koutelou, MD 3 E Vano, PhD 1 and V Neofotistou, MSc, PhD 4

1 Medical Physics Department, Konstantopoulio Agia Olga Hospital, 2 Medical Physics Department, Medical School, Athens University, Athens, 3 Onassis Cardiac Surgery Centre, Athens, Greece, 4 Medical Physics Service and Radiology Department, San Carlos University Hospital and Complutense University, Madrid, Spain and 5 Medical Physics Department Regional Athens General Hospital "G.Gennimatas", Athens, Greece


   Abstract
Top
 Abstract
Introduction
 Materials and methods
 Results
 Discussion
 Conclusions
 References
 
The purpose of the study was to analyse the technical characteristics of a newly installed flat-panel fluoroscopy (FPF) system in an interventional cardiology (IC) department and compare it with an older conventional system. A patient survey was performed to investigate the radiation doses delivered by the X-ray systems. Finally, methods of technique optimization regarding the new digital system were investigated. Dose rates in all fluoroscopic and cine modes were measured and image quality assessed using a dedicated test tool. 200 patients were investigated, half using the conventional and half using the digital FPF system. Patient data collected were: sex, age, weight, height, dose–area product (DAP), fluoroscopy time (T) and total number of frames (F). Our results are: (1) Digital FPF system: high contrast resolution (HCR) is not affected by fluoroscopic mode, whereas low contrast resolution (LCR) is slightly decreased in the low mode. (2) The digital FPF system has 2.5 times better HCR than the conventional system, with 5 times lower dose in the fluoroscopy mode. (3) Median values of DAP, T and F, respectively, in coronary angiography (CA) are: 27.7 Gycm2, 4.1 min and 876 for the digital and 39.3 Gycm2, 5.3 min and 1600 for the conventional system. Median values for percutaneous transluminal coronary angioplasty (PTCA) are: 51.1 Gycm2, 12.7 min and 1184 for the digital and 44.3 Gycm2, 7.4 min and 1936 for the conventional system. Digital DAP in CA is reduced by 30%, suggesting that a dose reduction in the FPF system is possible. The results of the study concerning the FPF system lead to the conclusion that the lowest fluoroscopic mode and the lowest frame rate should be used in routine practice.


   Introduction
Top
 Abstract
 Introduction
Materials and methods
 Results
 Discussion
 Conclusions
 References
 
Digital imaging has made large steps since its introduction in the 1980s and progress is motivated by its wide acceptance by radiologists. Some of the factors that make digital imaging so popular are: (i) the growing need for a filmless environment; (ii) the capability to store images easily in a picture archiving and communications system (PACS) and modify them on request at any time [1]; (iii) the ability to view these images on more than one site at the same time; (iv) the acceleration of patient throughput in a clinical department and (v) the elimination of running costs due to film processing or reduction of retakes [2]. Furthermore, the introduction of flat panel detectors promises not only increased image quality but also significant reduction in the radiation dose, due to improved detective quantum efficiency (DQE) [3–5].

On the other hand, interventional cardiology (IC) procedures are high dose procedures for both patients and staff [6–10] resulting, on some occasions, in deterministic effects [11–14]. There is a growing concern regarding doses from interventional procedures [15] and advice has been given by formal bodies for the avoidance of skin injuries due to radiation [16]. Attempts to optimize IC techniques may be found in the literature [17, 18]. With the introduction of digital techniques, the optimization of interventional procedures plays a very important role, since the amount of radiation required to produce the image is not specific as in conventional X-ray systems, where more radiation makes the film darker and decreases the contrast of the examination.

There are several studies in the literature which investigate the use of flat panel detectors in radiography [19–22] but very few in fluoroscopy [23]. Furthermore, there are no studies dealing with the comparison of conventional image intensifier (II) X-ray systems and the new flat-panel detector systems in IC. The purpose of this study was to analyse the technical characteristics of a newly installed flat-panel fluoroscopy (FPF) system in an IC department and compare results with those of the older conventional system. A patient survey was also performed to investigate the radiation doses arising from the new system in comparison with the older system. Finally, methods of technique optimization for the new digital system were investigated.


   Materials and methods
Top
 Abstract
 Introduction
 Materials and methods
Results
 Discussion
 Conclusions
 References
 
The study was conducted in the Onassis Cardiac Surgery Centre, a dedicated Greek IC centre. The X-ray system which had been in routine use for about 10 years, was a Siemens Angioscop-33 (Siemens Medical Systems, Erlangen, Germany) with an undercouch tube and an overcouch II with three fields of view (FOVs) 33 cm, 23 cm and 17 cm. It has recently been replaced by a Philips Integris Allura 9 X-ray system (Philips Medical Systems, Best, The Netherlands), a fully digital monoplane system consisting of a dynamic flat-panel detector with three FOVs, 25 cm, 19 cm and 15 cm diagonal square. The conventional system performed under automatic exposure control and utilized three fluoroscopy modes (i.e. continuous, 12.5 pulses s–1 and 25 pulses s–1). The fluoroscopy mode routinely used was 12.5 pulses s–1. There were two cine modes available: 25 frames s–1, routinely used for adult patients, and 50 frames s–1 routinely used for paediatric patients. There was no "last image hold" available in that system and the recording was done through cine film. In order to measure patient doses, a calibrated dose–area product (DAP) meter (Gammex-RMI, Nottingham, UK) was attached to the X-ray tube. For DAP calibration, the National Protocol for Patient Dose Measurements in Diagnostic Radiology was followed [24]. The uncertainty in the reading of the instrument, as quoted by the manufacturer, was ±4% for tube potentials ranging from 50 kVp to 100 kVp.

The digital system has three programmable fluoroscopic modes each of which has different characteristics such as filter, dose rate and image processing: Low, Normal and High mode. The fluoroscopy pulse modes are 12.5 pulses s–1, 15 pulses s–1, 25 pulses s–1 and 30 pulses s–1. The two cine modes available are 12.5 frames s–1 and 25 frames s–1. The system comprises a DAP meter and the following parameters are presented on the operator console: accumulated fluoroscopic DAP (DAPf), accumulated cine DAP (DAPc) and accumulated total DAP (DAPt), total number of frames (F) and total fluoroscopy time (T). The DAP meter is also calibrated according to the same protocol [24]. The unit has cine digital imaging with CD archiving and it is connected to the PACS workstation.

In the study, the dose rates in all fluoroscopic and cine modes available were measured using a protocol developed by the DIMOND II consortium [25] and optimized by the DIMOND III working group [26]. Dose measurements were performed using a digital dosemeter (Solidose 400, RTI Electronics, Mölndal, Sweden) with a solid state detector (R100) with a calibration traceable to a Standards Laboratory. The chamber was attached either to the II or to the flat-panel detector together with 2 mmCu that was used as a scattering medium simulating a normal patient.

Image quality was assessed for both systems using a FAXiL test object TOR 18FDG attached to the X-ray detector. The phantom is composed of two sections, one of which is located centrally and contains batches of lead bars of different width and spaces in each batch and is used for high contrast resolution (HCR) measurements. The remaining section is used for low contrast resolution (LCR) measurements and includes discs of different contrasts located along the periphery of the phantom. LCR was assessed in our study by placing a 1 mm sheet of copper on the X-ray tube.

Both systems underwent periodic quality control measurements in terms of imaging performance and at all times they conformed with manufacturer's specifications. Patient doses were investigated so as to compare the conventional and the digital FPF system. The patient dose survey consisted of 200 IC procedures from which 100 patients had a coronary angiography (CA). Half of these patients were examined using the conventional system and half using the digital FPF system. The remaining 100 patients had percutaneous transluminal coronary angioplasty (PTCA) half of which examinations were also carried out using the conventional and the other half using the digital FPF system. Patient data collected were sex, age, weight, height, DAPt reading (DAPf and DAPc were also collected for the digital FPF system), T and F.


   Results
Top
 Abstract
 Introduction
 Materials and methods
 Results
Discussion
 Conclusions
 References
 
Table 1Go presents the technical characteristics of the X-ray systems. One may see that the newly installed digital FPF system presents certain advantages over the conventional system that facilitate IC procedures and give the opportunity to optimize the technique in terms of radiation dose. The last image hold, for example, is a well-known method of lowering the dose since the operator can view the image for unlimited periods of time without irradiating the patient [27]. The three fluoroscopy modes (Low, Normal and High) have different penetrating characteristics enabling the matching of X-ray spectrum transmitted from the patient to the detector. Moreover, the reduced frame rate in the cine mode of the digital system (12.5 frames s–1) also optimizes patient and occupational dose [28].


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  		Table 1. Technical characteristics of the conventional and the flat-panel digital X-ray systems in the Onassis Cardiac Surgery Centre

 
In Table 2Go, the comparison of fluoroscopic dose rates and cine doses are presented. It should be noted that the fluoroscopic mode routinely used by most operators with the digital FPF system is the Low mode. Both systems operate below 100 mGy min–1 entrance surface dose rate that is a limiting value in the Hellenic Radiation Protection Law [29] and in the UK recommendations [30]. When the two systems are compared, the digital fluoroscopic dose rate in the Normal mode is half the value of the conventional system. Even if High mode is considered, the dose rates are comparable for all available FOVs. Furthermore, the digital FPF system follows international recommendations on typical dose rates that range from 25 mGy min–1 to 65 mGy min–1 for the Normal mode [31–33] and 100 mGy min–1 for the High mode [31]. However, regarding the cine dose in the digital FPF system, it presents higher values by a factor that ranges from 2.2 to 2.7 of the conventional system's values and is beyond the recommended American Association of Physicists in Medicine (AAPM) range of 80–200 µGy in both magnification modes [33]. It should be noted, however, that these recommendations apply only to conventional systems and requirements for digital IC are completely absent [27].


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  		Table 2. Entrance skin dose rate and dose per frame values are presented for the conventional and the digital X-ray system for all fields of view (FOVs) (Source to detector distance (SDD)=70 cm). A 2 mm Cu filter was placed on the image intensifier and on the flat-panel detector

 
Table 3Go presents the results of HCR and LCR measurements. The digital FPF system has a HCR of 3.15 lp mm–1 in the Low and Normal fluoroscopic mode and 3.55 lp mm–1 in the cine mode, values that are beyond the AAPM recommendations of 1.8–2.0 lp mm–1 for the 23 cm fluoroscopic mode and 2.2–2.8 lp mm–1 for cine mode. The system performs similarly regarding LCR in the cine mode (in all FOVs LCR is below 2.0%) and in the high fluoroscopy mode (below 2.5%). As seen in Table 3Go the HCR is much superior in the digital FPF system whereas the opposite occurs for LCR. The inferior LCR is partially explained by the fact that flat-panel systems suffer from additive noise such as thin-film transistor thermal noise and pre-amplifier noise [34]. The imaging equipment plays the most important role regarding noise and the radiation dose required to eliminate the noise depends strongly on this factor. In our system the increased matrix size (1024 x 1024) provides increased HCR but on the other hand it is subject to more noise and possibly more radiation dose [33]. Another probable reason is that the X-ray beam is perpendicular at the centre of the phantom but is divergent at the edges inhibiting the detection of the peripheral LCR structures in the phantom [4]. However, LCR can always be optimized via image processing provided that the individual performing this task is adequately trained [27, 35]. The problem is that when image processing is used to improve visualization of certain structures, this is most often done at the expense of other structures.


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  		Table 3. (a) High contrast resolution and (b) low contrast resolution results, for the conventional and the digital X-ray system for all fields of view (FOVs)

 
Patient dose measurements in terms of DAP, T and F are given in Table 4Go. Since the DAP values measured did not exhibit a normal distribution, the range and median values are presented. As expected, PTCA presents higher median values of DAP, T, and F than CA. The pronounced reduction in F for the digital FPF system is explained because most operators routinely used half the cine frame rate (i.e. 12.5 frames s–1 instead of 25 frames s–1 previously used). As it is clearly seen in CA, the reduction in DAP and F is marked. In PTCA, the median value of T is increased by 58% in the digital FPF system and the median value of F is decreased by 61% in the same system when compared with the corresponding values in the conventional system. The PTCA DAP values do not present a significant difference that can be partially explained by the increasing T and the fact that although F is almost half, the dose per frame is two to three higher in the digital FPF system.


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  		Table 4. Dose–area product (DAP) results, fluoroscopy time (T) and total number of cine frames (F) on (a) coronary angiography (CA) and (b) percutaneous transluminal coronary angioplasty (PTCA) for both the conventional and digital systems

 
In Figure 1Go, the analytical results of DAPf, DAPc and DAPt are presented for the digital FPF system. These DAP values are much lower than those found in the literature suggesting that most of the dose in our study comes from cine mode [36, 37]. It is seen that DAPf accounts for only 23% of the total for CA and 33% for PTCA. Unfortunately, comparison of the X-ray systems could not be made since the conventional system has no capability of measuring DAPf and DAPc.



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  		Figure 1. Fluoroscopic dose–area product (DAP) in Gycm2 (DAPf), cine DAP (DAPc) and total DAP (DAPt) is presented for coronary angioplasty (CA) and percutaneous transluminal coronary angiography (PTCA) using the digital flat-panel fluoroscopy system.

 

   Discussion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
Conclusions
 References
 
The dose and image quality measurements regarding the digital FPF system reveal that HCR is not affected by fluoroscopic mode, whereas LCR is slightly decreased (reduction of 0.5%) in Low and Normal mode. Therefore, it is recommended that Low mode should be used as a default mode in everyday routine. When the two systems are compared (Low mode for digital and Normal mode for conventional), it is found that the digital FPF system provides 2.5 times better spatial resolution with 5 times lower dose in the fluoroscopy mode. This is very important since spatial resolution reflects the ability of a system to visualize small vessels and catheter wires and this is essential for the success of a clinical procedure. The resolution is increased by 0.4 lp mm–1 when going from fluoroscopy mode to cine mode.

Patient doses are comparable with those found in the literature. The median DAP (27.7 Gycm2, digital FPF system) for CA is lower than the range of 30 Gycm2 to 72 Gycm2 found in the literature [6] suggesting that the radiation dose can be reduced in FPF. Similarly, median DAP (51.1 Gycm2, digital system) for PTCA is in the range of 32.3 Gycm2 to 101.9 Gycm2 found in the literature [6]. Figures 2 and 3GoGo show the comparison of patient doses, concerning both X-ray systems, with the reference levels proposed by Neofotistou et al [38]. The digital FPF system conforms to these levels and the doses are half the reference level for both CA and PTCA.



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  		Figure 2. Median values of dose–area product (DAP), fluoroscopy time (T) and total cine frames (F) for the conventional and the digital flat-panel fluoroscopy systems and comparison with coronary angiography reference levels [38].

 


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  		Figure 3. Median values of dose–area product (DAP), fluoroscopy time (T) and total cine frames (F) for the conventional and the digital flat-panel fluoroscopy systems and comparison with the percutaneous transluminal coronary angioplasty reference level [38].

 
Concerning the dose performance of the digital FPF system, it should be noted that no clinical study dealing with this kind of digital detector was found in the literature. Therefore, it was not possible to compare our results with those of other authors. However, certain studies investigate image quality and dose reduction possibilities in digital radiography [1, 3–5]. These studies conclude that flat-panel technology can demonstrate comparable image quality to screen film at almost 50% of the dose. These findings suggest that a future investigation of cine dose reduction without significant loss in image quality could be performed. One possible explanation for the high cine dose found in this study could be that the flat-panel digital technology suffers from additive noise and the vendors tend to adjust the dose to higher values in order to obtain the desirable level of image quality to satisfy operators.

As far as comparison of conventional and digital systems is concerned, very few studies are found in the literature and these are contradictory. Broadhead et al [39] in 1995 compared 10 digital with 4 non-digital systems performing barium studies and found a reduction in dose for the digital system by a factor of two. They concluded that the replacement of conventional systems with digital systems would eventually lower radiation doses. Ruiz-Cruces et al [40] in 1997 compared one digital and one conventional system in 15 different vascular and interventional procedures. They found higher DAP values in the digital equipment and recommended that complex procedures should be made with conventional systems. However, these studies may be out of date since digital imaging has evolved greatly over the last few years. Furthermore, both studies deal with II systems and should not be strictly considered in our study.


   Conclusions
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusions
References
 
The introduction of FPF fluoroscopy technology in digital imaging is opening new possibilities in IC in terms of imaging performance and patient dose. The high spatial resolution with the lowest fluoroscopy dose certainly optimizes clinical procedures. The findings of the study lead to a strong recommendation for the routine use of low mode fluoroscopy by all operators. The increased cine dose reveals the need for dose/frame reduction and for an attempt to reduce total number of frames. The fact that there are only a few studies in the literature regarding performance of such detectors and no studies dealing with the use of these systems and taking also into consideration that our sample is rather small, lead to the conclusion that: 1. More extensive studies should be performed to investigate in more detail the performance of the flat-panel detector in IC; and 2. A dedicated study regarding image quality and dose while maintaining clinical diagnosis is suggested.


   Footnotes
 
This work has been partially funded by the European Commission 5th Framework Programme (1998–2002) Nuclear Fission and Radiation Protection Contract. "Measures for optimizing radiological information and dose in digital imaging and interventional radiology". Program Acronym: FP5-EAECTP C.Project Reference:FIGM-2000–00061.Project Acronym: DIMOND III. http://dbs.cordis.lu/fep/FP5/FP5_PROJl_search.html Back

Received for publication April 22, 2003. Revision received November 20, 2003. Accepted for publication December 10, 2003.


   References
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusions
 References
 

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V. Tsapaki, R. Padovani, E. Vano, A. Schreiner, M. Molfetas, V. Neofotistou, and S. Kottou
Commissioning and constancy protocols for digital angiographic units
Radiat Prot Dosimetry, March 1, 2008; 129(1-3): 258 - 260.
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An investigation into patient and staff doses from X-ray angiography during coronary interventional procedures
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G Compagnone, M C. Baleni, L Pagan, F L Calzolaio, L Barozzi, and C Bergamini
Comparison of radiation doses to patients undergoing standard radiographic examinations with conventional screen-film radiography, computed radiography and direct digital radiography.
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Are new technologies always reducing patient doses in cardiac procedures?
Radiat Prot Dosimetry, December 1, 2005; 117(1-3): 97 - 101.
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Comparison of a CCD and a flat-panel digital system in an Interventional Cardiology Laboratory
Radiat Prot Dosimetry, December 1, 2005; 117(1-3): 93 - 96.
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Does digital imaging decrease patient dose? A pilot study and review of the literature
Radiat Prot Dosimetry, December 1, 2005; 117(1-3): 204 - 210.
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S. Suzuki, S. Furui, I. Kobayashi, T. Yamauchi, H. Kohtake, K. Takeshita, K. Takada, and M. Yamagishi
Radiation Dose to Patients and Radiologists During Transcatheter Arterial Embolization: Comparison of a Digital Flat-Panel System and Conventional Unit
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