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British Journal of Radiology (2005) 78, 803-809
© 2005 British Institute of Radiology
doi: 10.1259/bjr/14000648
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Full Paper

Skin dose alarm levels in cardiac angiography procedures: is a single DAP value sufficient?

A Karambatsakidou, MSc P Tornvall, MD, PhD N Saleh, MD T Chouliaras, MSc P-O Löfberg, Dipl.Ing and A Fransson, PhD

Department of Medical Physics, Karolinska University Hospital, Stockholm, 171 76, Sweden


   Abstract
Top
 Abstract
Introduction
 Methods and materials
 Results and discussion
 Conclusion
 References
 
Maximum estimated skin doses to patients undergoing coronary angiography procedures were obtained using radiographic slow film and diode dosemeters. Conversion factors of maximum entrance skin dose versus dose–area product (MESD/DAP) for diagnostic (coronary angiography (CA); 20 patients; 2 operators) and interventional procedures (percutaneous transluminal coronary angiography (PTCA); 10 patients; 1 operator) were 4.3 (mean value of 10 CA; operator A), 3.5 (mean value of 10 CA; operator B) and 9.7 (mean value of 10 PTCA; operator B) mGy(Gycm2)–1, respectively. The results emphasise a need for both operator- and procedure-specific conversion factors. Compared with a single, global factor for all cardiac procedures and/or operators that is commonly applied today, such a refinement is expected to improve the accuracy in skin dose estimations from these procedures. Consequently, reference DAP values used in the clinic to define patients who could suffer from a radiation induced skin injury following a cardiac procedure, should be defined for each operator/procedure. The film technique was found to be superior to the diode in defining conversion factors in this study, and allowed for a rapid and accurate estimation of MESD for each patient. With appropriate positioning of the diode, a combined film/diode technique has a potential use in the training of new angiography operators. The patient body mass index (BMI) value was a good indicator of the variation in average lung dose (critical organ) between patients. The highest lung dose/DAP value was obtained for normal sized patients (BMI: 19–26), and was close to 1.5 mGy(Gycm2)–1 with both CA and PTCA procedures.


   Introduction
Top
 Abstract
 Introduction
Methods and materials
 Results and discussion
 Conclusion
 References
 
Interventional radiology is defined as a high dose procedure in the European Directive 97/43/Euratom [1]. Patients undergoing such procedures have an increased risk of radiation-induced skin injuries, which may result in carcinoma [2]. Several cases of skin injuries from interventional procedures have been reported [3–5].

In order to monitor the skin dose to patients in interventional radiology, techniques based on thermoluminiscent dosemeters (TLD) [6, 7], film dosimetry [8], combination of TLD and film [9–12], direct-reading semiconductor dosemeters [13], and mathematical modelling of skin dose distribution in real-time [14], have been reported. While the first four techniques can be used with any system, the calculation of skin dose from mathematical models requires on-line monitoring of irradiation geometry and dose-related parameters, and therefore has to be integrated in the X-ray unit.

In this study, slow radiographic film has been used in combination with a new type of semiconductor detector to estimate maximum entrance skin dose (MESD) in patients undergoing coronary angiography (CA) and percutaneous transluminal coronary angiography (PTCA) of the left anterior descending (LAD) artery. Reference values of dose–area product (DAP) levels for preventing deterministic skin injuries from such procedures are reported and compared with previous results based on simulations using an anthropomorphic phantom [6]. Influence of operator-dependent technique factors on dose distributions from cardiac procedures (LAD) are discussed. Dependence of the average lung dose on the body mass index (BMI) of the patient from such procedures is reported.


   Methods and materials
Top
 Abstract
 Introduction
 Methods and materials
Results and discussion
 Conclusion
 References
 
X-ray equipment
All cardiac procedures were performed on a monoplane Philips Integris H 5000 C angiographic X-ray unit (Philips, Eindhoven, The Netherlands). This digital cardiac imaging system has an integrated DAP-meter, Diamentor (PTW-Freiburg, Germany), mounted in the X-ray tube housing. The integrated DAP-meter is checked once a year against a reference DAP-meter (Doseguard 100 (VacuTec 70157); RTI Electronics AB, Molndal, Sweden) calibrated at the secondary standard dosimetry laboratory in Sweden. The image intensifier (II) has three magnification modes, 23/17/14 cm, and is equipped with an antiscatter grid of ratio 10:1. For the II-mode used in the study (17 cm), the air kerma rate at the entrance window of the II (without grid) is 0.17 µGy frame–1 with digital image acquisition, and 1.0 µGy s–1 in fluoroscopy mode. The unit uses automatic exposure control, which includes programs that automatically select beam quality parameters based on the type of examination and patient size. Typical values for the tube peak voltage are between 70 kV and 100 kV. The angiographic X-ray unit is equipped with a spectral filter on the tube side, consisting of a sandwich of copper and aluminium. The total filtration of the tube for cardiology examinations is 4.5 mm Al in digital image acquisition mode and 6 mm Al+0.4 mm Cu in fluoroscopy mode. The program chosen for cardiology procedures uses digital image acquisition of 12.5 frames s–1, and a matrix size of 1024 x 1024.

Skin dose estimations
MESD for CA and PTCA procedures were obtained using two different patient-based techniques. The first refers to measurements using slow radiographic film (EDR2, 35 cm x 43 cm; Eastman Kodak Co., Rochester, NY) positioned on the back of the patient (beam entrance side). The EDR2-film has been reported to display a linear dose response up to 0.5 Gy [9]. This means that for doses below 0.5 Gy the entrance skin dose to the patient should vary linearly with optical film density (OD), and that the distribution of OD is representative also of the relative skin dose distribution. In this way, the film-based technique yields a two-dimensional (2D) dose map, and allows for the definition of high-dose areas. Following each procedure, the film was developed using a film processor (KODAK RP X-OMAT Processor, Model M8) and the maximum film density (used to estimate MESD) was recorded with a transmission densitometer (X-rite 331, X-rite Co., Grand Rapids, MI). The films were digitized with a scanner (VXR-16 Dosimetry PRO; Vidar systems corporation, Herndon, VA) and relative isodose (i.e. isodensity) levels were retrieved using image processing software (RIT 113V4; RIT CONFIDENTIA, CO).

With the second technique, direct reading diode dosemeters (Unfors Patient Skin Dosemeter (PSD); Unfors Instruments, Billdal, Sweden) were used. The PSD can be used with up to three diodes. According to the manufacturer, the angular dependency of the diodes is <5% for a tilt up to ±45° and the detectors show an energy dependence of <±4% in the energy range 50–120 kVp. Prior to the study, the diodes were calibrated for entrance skin dose (ESD) at 70 kVp. As the diode detector provides an estimate of the dose only at a single point, the positioning of the detectors is critical and has to rely on pre-defined regions of high dose typical for each procedure. In addition, as part of the detector (1.7 cm x 0.7 cm) is not radiation transparent, it cannot be placed in regions where it will shadow diagnostic information relevant to the procedure. In this study, two diodes were used for each patient. The diodes were positioned by a medical physicist on the right hand side of the back of the patient (sternum in CA procedures; lowest rib in PTCA procedures). These regions had previously been defined in measurements on an anthropomorphic phantom, as the area of maximum skin dose for the CA and PTCA procedures, respectively [6]. With this procedure, the relevance of using a phantom-based simulation to define regions of maximum skin dose in cardiac procedures could be evaluated. The positions of the diodes were marked on the film for later verification.

The relationship between film OD and radiation dose was established by irradiating a film and two of the diodes to nine different doses in the range 0.04–1.5 Gy. In order to obtain a photon spectrum and scattering conditions similar to the patient examinations, the irradiations were performed on the Philips X-ray unit used in the patient studies by placing the film and the two diodes on a polymethyl methacrylate (PMMA) phantom. The dose was calculated as the mean value from the diode measurements and the OD was estimated as the mean of two OD measurements within a 2.5 cm circular region of the film positioned in the centre of the X-ray beam. The film calibration was verified using the PSD results from the patient examinations. This was done by measuring the OD at the position of the diodes for all patient examinations, thus establishing a relation between measured dose and OD.

The DAP value from each patient examination was recorded using the transmission ion chamber integrated in the angiographic unit. The calibration of this chamber deviated with <5% from a reference DAP meter, using a calibration factor obtained at 80 kVp, half value layer=2.9 mm Al, and with no correction for absorption in the patient couch. This deviation was regarded as negligible, and there was no additional correction applied to the DAP values from the chamber integrated in the Philips unit. Conversion factors relating MESD to DAP (mGy(Gycm2)–1) were calculated for each patient. The mean values of such factors obtained from a series of patient examinations were then compared with previous data from simulations on an anthropomorphic phantom [6].

Lung dose estimations
Exposure parameters (beam projection angles, tube voltage, tube filtration, focus to image intensifier distance, field size) were retrieved for each patient from the dose recording system of the angiography unit. These data, together with the DAP value and relevant patient data, were input to the software program WinODS (version 1.0a; RADOS Technology Oy, Finland) in order to estimate the mean absorbed dose to the lung (organ at risk in cardiac X-ray procedures). A focus–skin distance of 60 cm was used for all patients. The beam projection angles were assigned as the mean of the recorded projection angles within 15° intervals. In this way the multiple beam projection angles commonly used in CA and PTCA could be accounted for in a feasible way. The software WinODS uses anthropomorphic phantom models that take into account the sex, height and weight of the patient in the calculation of organ dose [15, 16]. The dependence of organ size on these parameters is rather complex. The dose calculation procedure using WinODS reported here cannot easily be applied in clinical routine situations. For this purpose, BMI was introduced as a descriptor of body size and shape, and the average lung dose/DAP value obtained for each patient was related to this index. In this way, guidance levels on average lung dose from cardiac procedures were defined.

A total of 20 CA and 10 PTCA patient examinations (BMI of 21–33) performed within a period of 6 months, were included in the study. The CA examinations were equally distributed between two cardiologists having 2 years and 10 years of experience in CA, respectively. The PTCA procedures, consisting of balloon dilatation including one stent, were all performed by the cardiologist having 10 years experience. All examinations were performed on the Philips angiography unit using under–couch tube technique.


   Results and discussion
Top
 Abstract
 Introduction
 Methods and materials
 Results and discussion
Conclusion
 References
 
The range of DAP values for all patients, and the relative contribution to the total DAP from fluoroscopy, is summarized in Table 1Go.


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  		Table 1. Range of dose–area product (DAP) values from the cardiac procedures included in this study

 
A typical distribution of entrance skin dose to a patient from a CA procedure is presented in Figure 1Go. The CA procedures were characterized by a relatively large number of irradiation angles (projections), but with similar irradiation geometry between patients. The MESD was located on the right hand side of the back in 90% of the patients. A slight difference in irradiation technique between the operators was observed. The operator with less experience used almost identical projections with all patients, resulting in an area of maximum dose located within a narrow band on the right hand side of the back. The more experienced operator tended to use fewer projections, and with an almost identical distribution of dose between the left and right hand side of the patient.



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  		Figure 1. The distribution of optical density of the Kodak EDR2 film of a patient who has undergone a coronary angiography (CA) procedure (left image). The crosses show the position of the diodes. The maximum entrance skin dose (MESD) was 71 mGy and was for this patient located on the right shoulder (Dx), which is also illustrated by the isodose map (right image). The area of the MESD (100% dose level) is approximately 5 cm2. (Dx, Right; Sin, left).

 
With the PTCA procedures, fewer projections were used, and there were several irradiated areas showing beam overlap. As the complexity of PTCA interventions can differ considerably from patient to patient, this is reflected also in the irradiation technique and geometry used. As a result, the region of MESD will vary to a larger extent in PTCA examinations compared with CA. In this study the MESD appeared on the right hand side of the patient's back in only 30% of all PTCA procedures. Examples of dose distributions from two PTCA procedures performed by the same operator are illustrated in Figure 2Go.



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  		Figure 2. The distribution of optical density of two cases of percutaneous transluminal coronary angiography (PTCA) procedures (left images) performed by the same operator. The maximum entrance skin dose (MESD) for these two patients was 0.22 Gy (the 100% dose level covers approximately 30 cm2 and is located on the left (Sin) side of the patient's back) and 0.32 Gy (right (Dx) and left (Sin) area of MESD (100% dose level) are approximately 70 cm2 and 20 cm2, respectively).

 
The results from the calibration of the film are displayed in Figure 3Go. The relationship between the dose to the film (FDcalibration) and OD was found to be linear only up to about 200 mGy, with FDcalibration=140.5 x OD–14.6. Above 200 mGy, the film dose versus OD could be modelled by an exponential function: [FDcalibration=36.7 x e1.1055 x OD]. The non-linearity of the EDR2-film at higher doses reported here is supported by results presented by other groups [9, 17]. It should be noticed that the exponential fitting of FD versus OD used in this study for dose levels above 200 mGy yields a somewhat smoother fitting compared with the one used by Guibelalde et al [9]. The film saturation level occurs at an OD of about 3.5 [9]. The results reported in this study cover OD-values up to 3.3 (corresponding to a dose of about 1.5 Gy). 70% of the diagnostic (CA) examinations resulted in OD-values within the linear region of the calibration curve. The corresponding data for PTCA was 30%. Within this OD region the patient data yielded a dependence of film dose (FDpatient) on OD, such that FDpatient=137.4 x OD–4.2. It can be argued that the calibration using the patient data is more accurate than the phantom-based calibration, as variations in film sensitivity between different examinations/films will be reflected in the calibration procedure using this technique. However, our results indicate that the use of the patient data calibration would have only a minor impact on the MESD and MESD/DAP values as compared with using the phantom data, being at most 12% for the patients in this study (linear region). It should be noted that the tube angulation from the patient studies could reach up to about 45° relative to the film plane. This could possibly have an impact on the differences in FD versus OD curves obtained from the calibration and patient measurements, respectively. It should also be noted that the patient data calibration was restricted to diode measurements with OD values ≥2 x fog level (fog=0.19 OD), resulting in a total of 11 data points used to define the calibration curve.



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  		Figure 3. Calibration of optical film density (OD) versus film dose (FD) as obtained from phantom measurements (FDcalibration=36.7 x e1.1055 x OD), and from the series of patient measurements, respectively. A linear fit (up to 200 mGy) yields for the phantom data: FDcalibration=140.5 x OD–14.6 [r=0.99], and for the patient data: FDpatient=137.4 x OD–4.2 [r=0.96].

 
The mean values of the conversion factors (MESD/DAP) were 3.9±1.2 mGy(Gycm2)–1 for CA procedures (1 SD; 20 patients; 2 operators), and 9.7±2.7 mGy(Gycm2)–1 for PTCA (1 SD; 10 patients). The median values of the conversion factor of CA for the two operators were 3.4 mGy(Gycm2)–1 (10 patients; 10 years of experience), and 4.1 mGy(Gycm2)–1 (10 patients; 2 years of experience), respectively (Figure 4Go). The corresponding mean values were 3.5 and 4.3 mGy(Gycm2)–1, respectively. These values indicate somewhat different techniques in terms of irradiation geometry used by each operator for the CA procedure. The results also showed a slightly narrower distribution of MESD values between patients for the more experienced operator. Previous studies using film or TLD have reported conversion factors for CA and PTCA procedures similar to those reported here (see Table 2Go). The linear correlation of MESD versus DAP was relatively good, with r=0.8 and 0.9 for CA and PTCA procedures, respectively. This is similar to the value reported by van de Putte et al [10] for interventional procedures (r=0.8).



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  		Figure 4. The distributions of conversion factors for the two operators yielded median values of maximum entrance skin dose/dose–area product (MESD/DAP) of 4.1 mGy(Gycm2)–1 (operator A: 2 years experience) and 3.4 mGy(Gycm2)–1 (operator B: 10 years experience), respectively. The boxes in the figure enclose 50% of the MESD/DAP values of each operator. The upper and lower MESD/DAP values are indicated by the endpoints of the lines extending from each box.

 

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  		Table 2. Comparison of the mean values of MESD/DAP (mGy(Gycm2)–1) obtained in this study, with previously published values

 
The definition of threshold DAP-values for transient skin erythema (corresponding to 2 Gy absorbed dose to the skin (or 2 Sv equivalent dose)) merits special attention. It can be argued that if the variation in MESD/DAP between patients for a given operator is large, the corresponding threshold DAP should preferably be defined at the higher end of the range of MESD/DAP values observed for this operator. However, should such a "worst-case" DAP value be defined, a large number of patients who had received substantially lower skin doses than the absolute threshold of 2 Gy would fulfil the criteria for a follow-up of possible skin injury. Adopting a more moderate approach based on an "intermediate" MESD/DAP value, there would be a risk of missing patients who had actually received doses that could yield deterministic skin injury. In this study, threshold (or better, reference) DAP values for a given procedure/operator were defined based on the mean value of MESD/DAP of all patient examinations, as obtained from the film measurements. This yielded reference DAP values of 470 Gycm2 (CA; operator A), 570 Gycm2 (CA; operator B), and 210 Gycm2 (PTCA; operator B). These values can be compared with an overall DAP threshold of 300 Gycm2 for various types of cardiac procedures, as established in other European countries [18]. Our results demonstrate that the relation between MESD and DAP varies depending on the type of cardiac procedure, and to some extent also with the operator. A threshold (or reference) DAP value should therefore preferably be established for each procedure/operator. The definition of procedure-dependent threshold DAP values in interventional radiology has also been recommended by other groups [6, 10].

The results using diodes to estimate MESD were scattered, reflecting difficulties in the correct positioning of these detectors. Based on the film information of the diode position it could be concluded that in 4 (out of 20) CA patients, at least one diode was positioned in the region of maximum dose (here defined as ≥70% of MESD). Similarly to CA, the PTCA procedures also have a high rate of failure to position the diodes in the region of maximum dose, and it was only for one patient (out of 10) that a diode was correctly positioned. The results clearly show that the use of phantom-defined regions of MESD to position the diodes failed in the clinical situation, and that this was related mainly to variations in irradiation geometry between different operators (CA), and between patients (PTCA). It can be concluded that the use of diodes to monitor skin dose in cardiac procedures requires the definition of high-dose areas typical of each operator and procedure prior to their application. In retrospect, it is believed that the success rate in positioning diodes (or TLD) can indeed be improved if it is the operator who positions the detectors on the patient, and that this is based on previous evaluations of his/her irradiation technique (projections, etc.). In this way, the combined film–diode technique is expected to have a potential use also in the training of new angiography operators; the 2D dose distribution map obtained from the film allows a retrospective verification of irradiation technique, while the diode detectors allow for a direct indication of patient skin dose during the procedure (alarm trigger levels can be set). The two techniques are easy to use in a clinical setting, and require less time for data analysis compared with methods based on TLD [6, 9–12]. The use of diodes to monitor dose to anatomical, "critical", regions not covered by the film, such as the thyroid, was not specifically evaluated in this study. This could be of interest in certain situations, in which case the diode has a definitive role as an additional dose monitor. It should be emphasised that the film technique is limited by the film saturation level which occurs at an OD of about 3.5 [9]. The film can therefore not be used in situations that require the very high skin doses that can occur especially in complex interventional procedures [8].

The reference DAP values for the prevention of skin erythema reported in this study, and obtained from mean values of MESD/DAP from a series of patient examinations, were similar to previous results using an anthropomorphic phantom [6]. For CA, the difference in reference DAP was at maximum 11%, and for PTCA the deviation was 16%. It can be argued that these data support the use of phantoms to define reference DAP values. However, there are important differences between phantom- and patient-based techniques to be observed. Simulation on a single phantom does not account for variations in patient anatomy, and the corresponding variations in MESD/DAP values typical of each procedure and/or operator cannot be established. In addition, the use of simple phantom models of patients in the training of new angiography operators will not reflect the full complexity of the clinical situation.

The average lung dose/DAP varied with BMI. In normal sized patients (BMI: 19–26) the average dose to the lung in CA procedures was 63 mGy (10 patients), and the average lung dose/DAP was close to 1.5 mGy(Gycm2)–1. In slightly overweight patients (BMI: 27–30) the lung dose/DAP was about 17% lower, while for overweight patients (BMI>30) this difference increased to 21%. The same trend was observed for PTCA procedures (Figure 5Go). The average dose to the lung in PTCA of normal sized patients was 36 mGy (5 patients), while the average lung dose/DAP was the same as in CA (close to 1.5 mGy(Gycm2)–1). We believe these results primarily reflect a higher absorption of the incident beam before reaching the lung tissue in overweight patients, compared with in normal sized patients. The results can be used as guidance levels to estimate average lung dose in patients undergoing cardiac procedures.



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  		Figure 5. Correlation between the conversion factor (average lung dose/dose–area product) and body mass index (BMI). (There were no percutaneous transluminal coronary angiography (PTCA) patients having a BMI >30 in this study).

 

   Conclusion
Top
 Abstract
 Introduction
 Methods and materials
 Results and discussion
 Conclusion
References
 
The results of this study demonstrate the need for both operator- and procedure-specific DAP values to monitor skin dose in interventional radiology. The use of slow radiographic film is an excellent tool to define such reference DAP values, and could possibly be used in combination with diode detectors in the training of new angiography operators. In this way, both the irradiation technique (projections), maximum entrance skin dose, and dose levels in critical areas could be monitored in parallel. The BMI-value of patients undergoing cardiac interventional procedures seems to be a robust indicator of the variation in average lung dose/DAP, and could possibly be used as an indicator of variations in mean dose to internal organs in cardiac procedures between patients.


   Acknowledgments
 
The authors would like to thank Unfors Instruments AB for providing the diode detectors. We also acknowledge the assistance from staff at the Department of Thoracic Radiology, and from BSc Khawla Hadi Abed at the Department of Medical Physics at the Karolinska University Hospital, for helping us with the digitization of the films.

Received for publication October 5, 2004. Revision received February 3, 2005. Accepted for publication March 1, 2005.


   References
Top
 Abstract
 Introduction
 Methods and materials
 Results and discussion
 Conclusion
 References
 

  1. European Community Council Directive 97/43/Euratom of 30 June 1997 on health protection of individuals against the dangers of ionizing radiation in relation to medical exposure. Official Journal 1997;L180:0022–0027.
  2. Goldschmidt H, Sherwin WK. Reactions to ionizing radiation. J Am Acad Dermatol 1980;3:551–79.[Medline]
  3. Barnea Y, Amir A, Sharif R, Weiss J, Gur E. Chronic radiodermatitis injury after cardiac catheterization. Ann Plast Surg 2002;49:668–72; discussion 672.[CrossRef][Medline]
  4. Dehen L, Vilmer C, Humiliere C, Cordos T, Pentousis D, Ollivaud L, et al. Chronic radiodermatitis following cardiac catheterisation: a report of two cases and a brief review of the literature. Heart 1999;81:308–12.[Abstract/Free Full Text]
  5. Aerts A, Decraene T, van den Oord JJ, Dens J, Janssens S, Guelinckx P, et al. Chronic radiodermatitis following percutaneous coronary interventions: a report of two cases. J Eur Acad Dermatol Venereol 2003;17:340–3.[CrossRef][Medline]
  6. Hansson B, Karambatsakidou A. Relationships between entrance skin dose, effective dose and dose area product for patients in diagnostic and interventional cardiac procedures. Radiat Prot Dosim 2000;90:141–4.[Abstract]
  7. Vano E, Gonzales L, Fernandez JM, Guibelalde E. Patient dose values in interventional radiology. Br J Radiol 1995;68:1215–20.[Abstract/Free Full Text]
  8. Quai E, Padovani R, Peterzol A, Vano E, Guibelalde E, Toivonen M. Maximum skin dose assessment in interventional cardiology: results in three different European hospitals. Eur Radiol 2003;13:542.
  9. Guibelalde E, Vano E, Gonzalez L, Prieto C, Fernandez JM, Ten JI. Practical aspects for the evaluation of skin doses in interventional cardiology using a new slow film. Br J Radiol 2003;76:332–6.[Abstract/Free Full Text]
  10. van de Putte S, Verhaegen F, Taeymans Y, Thierens H. Correlation of patient skin doses in cardiac interventional radiology with dose-area product. Br J Radiol 2000;73:504–13.[Abstract]
  11. Vano E, Gonzalez L, Ten JI, Fernandez JM, Guibelalde E, Macaya C. Skin dose and dose-area product values for interventional cardiology procedures. Br J Radiol 2001;74:48–55.[Abstract/Free Full Text]
  12. Vano E, Goicolea J, Galvan C, Gonzalez L, Meiggs L, Ten JI, et al. Skin radiation injuries in patients following repeated coronary angioplasty procedures. Br J Radiol 2001;74:1023–31.[Abstract/Free Full Text]
  13. Meyer P, Regal R, Lung M, Siffert P, Mertz L, Constantinesco A. Feasibility of a semiconductor dosemeter to monitor skin dose in interventional radiology. Med Phys 2001;10:2002–6.[CrossRef]
  14. den Boer A, de Feijter PJ, Serruys PW, Roelandt JR. Real-time quantification and display of skin radiation during coronary angiography and intervention. American Heart Association, Inc. 2001;104:1779–84.
  15. Servomaa A, Rannikko S, Nikitin V, et al. A topographically and anatomically unified phantom model for organ dose determination in radiation hygiene, STUK-A87. Helsinki: Finnish Center for Radiation and Nuclear Safety, 1989.
  16. Rannikko S, Ermakov I, Lampinen JS, Toivonen M, Karila KTK, Chervjakov A. Computing patient doses of X-ray examinations using a patient size- and sex-adjustable phantom. Br J Radiol 1997;70:708–18.[Abstract]
  17. Morrell RE, Rogers AT. Calibration of EDR2 film for skin dosimetry in interventional cardiology. In: Proceedings of UK Radiological Congress; 2004 June 6–8. Manchester. London: British Institute of Radiology, 2004.
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