Physica Medica 70 (2020) 169–175

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Physica Medica
journal homepage: www.elsevier.com/locate/ejmp

Original paper

Updating national diagnostic reference levels for interventional cardiology and T

methodological aspects
Roberto Sáncheza,b, , Eliseo Vañóa,b, José M. Fernández Sotoa, Jose Ignacio Tena, Javier Escaneda,
⁎

Clara Delgadoc, Bruno Garcíac, Francisco Carrera Magariñod, José Francisco Díaz Fernándezd,
Rafael Jesús Martinez Lunae, Miguel Angel Romero Morenoe, Antonio Catalánf, Francisco Bosa Ojedaf,
Francisco Javier Rosales Espizuag, Jesús Roberto Sáez Morenog, Xavier Pifarréh, Javier Goicoleah,
José Manuel Ordialesj, Juan Manuel Nogalesi, Ginés Martinezj, Paula Garcíak, Amparo Benedictok,
Manuel Francisco Rodriguez Castillol, Luis Pastor Torresl, Joan Fontm, Armando Bethencourtm,
María Jesús Cesterosn, Armando Pérezn, Eduardo Pinaro, Bonifacio Tobarrao
a
Hospital Clínico San Carlos, Madrid, Spain
b
Universidad Complutense de Madrid, Spain
c
Hospital Valle de Hebrón, Barcelona, Spain
d
Hospital Juan Ramón Jiménez, Huelva, Spain
e
Hospital Reina Sofía, Córdoba, Spain
f
Hospital Universitario de Canarias, Sta. Cruz de Tenerife, Spain
g
Hospital Universitario Basurto, Bilbao, Spain
h
Hospital Puerta de Hierro, Madrid, Spain
i
Hospital Universitario Infanta Cristina, Badajoz, Spain
j
Hospital de Mérida, Badajoz, Spain
k
Hospital de la Princesa, Madrid, Spain
l
Hospital Universitario Valme, Sevilla, Spain
m
Hospital Universitario Son Espases, Mallorca, Spain
n
Hospital de León, Spain
o
Hospital Virgen de Arrixaca, Murcia, Spain

ARTICLE INFO ABSTRACT

Keywords: The aim of this study is to propose national diagnostic reference levels (DRL) for updating in the field of interventional
Interventional cardiology cardiology and to include technical details to help plan optimization.
Patient doses Medical physics experts and interventional cardiologists from 14 hospitals provided patient dose indicators
Diagnostic reference levels from coronary angiography and percutaneous coronary interventions. Information about X-ray system dose
Optimization
settings and image quality was also provided.
The dose values from 30,024 procedures and 26 interventional laboratories were recorded. The national DRLs
proposed for coronary angiography and percutaneous coronary interventions were respectively 39 and 78 Gy·cm2 for
air kerma area product (PKA), 530 and 1300 mGy for air kerma at reference point (Ka,r), 6.7 and 15 min of fluoroscopy
time and 760 and 1300 cine images. 36% of the KAP meters required correction factors from 10 to 35%. The dose
management systems should allow these corrections to be included automatically. The dose per image in cine in
reference conditions differed in a factor of 5.5.
Including X-ray system dose settings in the methodology provides an insight into the differences between hospitals.
The DRLs proposed for Spain in this work were similar to those proposed in the last European survey. The poor
correlation between X-ray systems dose settings and patient dose indicators highlights that other factors such as op-
eration protocols and complexity may have more impact in patient dose indicators, which allows a wide margin for
optimization. Dose reduction technology together with appropriate training programs will be determinant in the future
reduction of patient dose indicators.

⁎
Corresponding author at: Medical Physics Dpt., Hospital Clínico San Carlos, Profesor Martín Lagos sn, 28040 Madrid, Spain.
E-mail address: robsan03@ucm.es (R. Sánchez).

https://doi.org/10.1016/j.ejmp.2020.01.014
Received 12 July 2019; Received in revised form 5 December 2019; Accepted 14 January 2020
1120-1797/ © 2020 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.
R. Sánchez, et al.
1. Introduction
Interventional cardiology is one of the medical practices with the
highest radiation doses to patients. In some complex cases, high doses
likely to produce deterministic effects in the skin might be reached
[1,2]. The benefits of minimally invasive medical practices are un-
questionable both in diagnosis and therapy, as they minimize the risks
derived from open surgery and reduce patient recovery time after in-
terventions. In order to both benefit from these medical procedures and
ensure the radiation protection of patients, the European regulation
requires the member states of the European Union to establish, to
regularly review and to use diagnostic reference levels (DRLs) [3]. The
International Commission on Radiological Protection (ICRP) [4] defines
the DRLs as “a form of investigation level used to aid in optimisation of
protection in the medical exposure of patients”, using “a commonly and
easily measured quantity that assesses the amount of radiation used to
perform a medical task”. In the case of interventional practices, the DRL
quantities are the air kerma area product (PKA, also abbreviate as KAP)
and the air kerma at the patient entrance reference point (Ka,r).
Fluoroscopy time (tf) and the number of acquired images (N) are also
recommended. In the case of a national DRL, the numerical value of
DRLs should be set as the 3rd quartile of the medians of the DRL
quantity observed at multiple health centres. The changes in tech-
nology, the emergence of new image modalities and the use of DRLs in
optimization prompt changes in the values of DRLs. Reviewing DRLs is
therefore a necessity and ICRP recommends doing it every 3–5 years
[4]. In 2009, the Cardiac Catheterization working group from the
Spanish Society of Cardiology launched the DOCCACI program
(Spanish acronym for Dosimetry and quality criteria in interventional
cardiology) to promote national DRLs for the interventional cardiology
procedures [5,6]. The DOCCACI group provided data and gave advice
to the program DOPOES II [7] of the national authority to estimate
collective doses and to establish DRLs. Other countries have promoted
national surveys [8–16,29,30] to the same end. In Europe, some surveys
have also been fostered at regional level [17–20].
In this work, the DOCCACI group has updated the Spanish DRLs for
the period 2014–2017 to be proposed to the national authority as na-
tional DRLs for coronary angiography and percutaneous transluminal
coronary angioplasty. Information on X-ray systems dose settings was
included to help in the optimization.
2. Materials and methods
Since 2009, the DOCCACI group has been working on the proposal
of DRLs for interventional cardiology. 14 hospitals, all of them from the
national public health service and 13 of them university hospitals in-
cluding 29 interventional laboratories, compiled information about
patient dose indicators from January 2014 to December 2017. These 14
hospitals represent all in all 18% of the institutions that declare inter-
ventional cardiology activity to the Spanish Society of Cardiology1.
2.1. Patient dose indicators
Participants collected dose indicators from patient procedures in-
cluding PKA, air kerma at patient entrance reference point (Ka,r),
fluoroscopy time (Tf), total number of cine series and images. Coronary
angiography (CA) and percutaneous transluminal coronary angioplasty
(PTCA) were investigated, as they are the most frequently performed
procedures (89% of the total interventional cardiology procedures). In
the group of PTCA, ad-hoc PTCAs were also included.
Some participants provided more than 100 cases (up to 2095) using
1
See the web site of the hemodynamic working group from the Spanish
Society of Cardiology. https://www.hemodinamica.com/cientifico/registro-de-
actividad/.
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Physica Medica 70 (2020) 169–175
automatic dose management systems: the sample was then considered
to have average or normal complexity and average patient size. Other
participants selected smaller samples (≥30 cases as recommended by
ICRP [4]) by means of manual recording, provided the procedure had
standard complexity and standard patient size (65–95 kg) in line with
the criteria agreed to be part of the DOCCACI program. In all the
centres involved one interventional cardiologist and one medical phy-
sics expert (MPE) were tasked with collecting and sending the data
according to the agreed criteria. For those laboratories with large
samples (> 100 cases) it was considered that the few cases of high
complexity were unlikely to bias the median values. 3 out of the 29
interventional rooms did not reach the minimum sample size of 30
cases and were therefore not included in the analysis.
All data is received at the central database to be reviewed and if any
inconsistency is detected (wrong units, missing or wrong information),
corrections are applied in agreement with the data senders. To obtain
the DRLs, the median of patient dose indicators was calculated for each
interventional laboratory. The national DRLs to be proposed were cal-
culated as the third quartile of the medians distribution.
2.2. Additional information to help in optimization: X-ray systems
Each program participant working in the X-ray units performed a
commonly agreed quality control protocol. The entrance air kerma rate
in fluoroscopy (K a, e ) and entrance air kerma per image (K a, e ) in cine
were measured in reference conditions: a 20 cm PMMA phantom lo-
cated at isocentre and the image detector at approximately 5 cm from
the phantom. The default or most used radiation modes/protocol were
tested. A test object 18FG from the University of Leeds (Leeds test ob-
jects LTD, North Yorkshire, UK) located at the isocentre was used for
the evaluation of image quality. The MPE in charge in each centre
evaluated the images of the test object by visual inspection as re-
commended by the test object manufacturer. The number of 8 mm
copper low contrast details and the groups of lead bar patterns observed
were recorded for the different C-arm radiation modes. Although the
visual inspection may vary according to the observer, it can still give
valuable information. The PKA meter was checked for consistency using
a calibrated dose meter and for one beam quality – cine mode and 80 kV
and no filtration or the lowest additional filtration available – and with
the C-arm at 90° to avoid table and mattress absorption. If the PKA meter
introduced any bias to the dose indicators provided by the modality,
PKA and Ka,r were corrected. As these procedures are performed mostly
with the tube under couch, the beam crosses the examination table and
mattress that absorb part of the X-ray energy before reaching the pa-
tient. Their transmission is a complex function that depends strongly on
beam quality, beam angle and beam size. The effect of couch and
mattress transmission was measured at reference conditions to obtain
its average value: 80 kV, cine mode with the lowest beam filtration. The
couch transmission can be used to estimate the air kerma area product
at patient entrance PKA,corr. When the PKA is used to estimate organ and
effective doses, the couch and mattress attenuation should be con-
sidered.
Bivariate correlations (Pearson r and Spearman ρ) were studied
between the dose delivered by the interventional units Ka,e and the
medians of the PKA and Ka,r for CA and PTCA using the software SPSS
(IBM, USA). While Pearson correlation coefficient seeks for linear re-
lationships, Spearman correlation coefficient (based in rank correla-
tion) may inform on other kind of non-linear dependences between
variables.
3. Results
3.1. Patient dose indicators
A total of 30,024 cases (16631 diagnostic and 13,393 therapeutic)
were recorded for the period 2014–2017. The average ± standard
R. Sánchez, et al. Physica Medica 70 (2020) 169–175

deviation of patient weight and height were 80 ± 16 kg and Therefore, checking for consistency and automatically correcting any
165 ± 10 cm. Table 1 shows the sample sizes presented by each centre device that provides values of radiation dose is a necessity to avoid
for each interventional laboratory. In Fig. 1a)–h) the medians of patient major errors. Dose management systems that record information from
dose indicators are presented for all X-ray systems participating in the modalities should have the capability of including correction factors for
survey. dose values. Regulators, clinicians and manufacturers make a great
Table 2 shows the national diagnostic reference levels proposed for effort to record the X-ray doses delivered to patients: if deviations
updating. of ± 35% in dose records are considered as acceptable, these dose
Table 3 shows the diagnostic reference levels proposed for updating records are nonetheless bound to contain important errors.
compared with the DRLs proposed for the period 2009–2013. The couch and mattress transmission factor resulted in 0.75 on
average with a standard deviation of 0.11. An important fraction of the
3.2. Additional information to help in optimization: X-ray systems X-ray beam can be absorbed by the couch and mattress due to the
undercouch geometry of these interventional systems. The exact
From the PKA-meters consistency check performed in 29 X-ray sys- transmission depends on beam quality and X-ray system angulation,
tems, 18 X-ray systems (64%) were found to have correction factors two variables that continuously change during interventional proce-
close to unity ( ± 10%), 4 X-ray systems needed to be corrected in more dures and are therefore difficult to assess for every procedure. But to get
than 10% but less than 20%, 5 X-ray systems required a correction the best patient collective doses, the average couch and mattress
factor between 20 and 30% and the most biased PKA -meter had a transmission should be applied to estimate real patient doses. In the
correction factor of 0.67, i.e. the system overestimated the dose in 36%. absence of correction, collective doses would be overestimated by
In general, there was a tendency for the modalities to overestimate the around 25%.
PKA. In reference conditions (20 cm of PMMA), results in dose rate reveal
The average couch and mattress transmission was estimated as important differences between X-ray systems. Differences in a factor of
0.75 ± 0.07 (1sd) and ranged from a minimum of 0.63 to a maximum 5 are found between the lowest and the highest values in all operation
of 0.92. modes. Concerning cine mode, a deviation factor of 5.5 between max-
Fig. 2 shows the entrance surface air kerma rate at 20 cm PMMA in imum and minimum dose per image could be partially explained by the
reference conditions delivered by different X-ray systems for fluoro- fact that some systems with the lowest doses per image are equipped
scopy and cine modes. with devices for dose reduction. This is the case of centre 1 with three
For the different X-ray systems tested in the research program, the X-ray systems from the same manufacturer, one of them with a dose
range between minimum and maximum K a, e was [3,15.5] mGy/min for reduction system providing a dose per image in cine 4.7 times lower
the fluoroscopy low mode, [7.6, 29.1] mGy/min for fluoroscopy
medium, and [10, 50] mGy/min for fluoroscopy high. The range in Ka,e Table 1
per image for cine mode resulted in [0.04, 0.22] mGy/img (factor of Sample sizes provided by different centres. All systems have the default cine
5.5). mode with 15 images per second with the exception of centre 7 that had
The correlation between X-ray system dose settings (dose per image 12.5 ips. * Room 3 from centre 1 has dose reduction technology.
in cine, dose rate in fluoroscopy measured with 20 cm PMMA in re- Centre Room Year of Image Number Number Manual or
ference conditions) and patient dose (median values of PKA and Ka,r) installation intensifier of CA of PTCA automatic
was studied. The highest – although not statistically significant – cor- or Flat recording
Pannel
relation coefficient found was the Spearman correlation τ = 0.16
(p = 0.24) for the cine setting in coronary angiography. The highest 1 1 2009 FP 1837 712 Automatic
correlations found were the number of cine images and the fluoroscopy 2 2009 FP 2095 1416
time with the air kerma area product (r = 0.612 and 0.519 respec- 3* 2014 FP 217 151
tively). 2 1 2007 FP 122 81 Manual
Fig. 3a) and b) present the results for the evaluation of image 2 2007 FP 103 119
quality with test object (at the isocentre) in reference conditions (20 cm 3 2012 FP 60 60

PMMA). The low contrast detectability and the high contrast spatial 3 1 2009 FP 542 1137 Automatic
resolution are presented for every X-ray system tested. The maximum, 2 2010 FP 358 818

minimum and mean ± standard deviation for the low contrast sensi- 4 1 2008 FP 34 61 Manual
tivity were 7–14 observed objects and 11 ± 2 for fluoroscopy low, 5 1 2008 FP 1241 624 Automatic
from 8 to 16 and 12 ± 2 for fluoroscopy medium, from 8 to 18 and 2 2008 FP 1048 482
13 ± 2 for fluoroscopy high and from 9 to 16 with 13 ± 2 for cine. In 6 1 2006 FP 134 255 Manual
the case of high contrasts spatial resolution the observed groups ranged
7 1 2001 II 692 784 Automatic
from 7 to 15 with 13 ± 2 (mean ± sd) for fluoroscopy low, from 8 to
16 and 14 ± 2 for fluoroscopy medium, from 8 to 17 and 14 ± 2 for 8 1 2008 FP 858 801 Automatic

fluoroscopy high and from 9 to 18 with 14 ± 2 for cine. 9 1 2007 FP 1756 1191 Automatic

10 1 2007 FP 381 224 Automatic

4. Discussion 2 2007 FP 174 105

11 1 2004 FP 1177 741 Automatic

IEC standard [21] states that the interventional systems shall dis- 2 2016 FP 712 617
play the values of PKA and Ka,r and shall not exceed their values in ± 12 1 2010 FP 102 64 Manual
35%. Spanish recommendations say that the deviation should be lower 2 2011 FP 32 79
than ± 20% [22]. Checking these values is recommended in many 13 1 2013 FP 35 44 Manual
national quality control protocols [23]. It should be easy for a medical 2 2010 FP 230 203
physics expert to check if a dose meter introduces bias greater 14 1 2012 FP 839 650 Automatic
than ± 10% at least in reference conditions. From the results on PKA- 2 2011 FP 1147 1264
meter calibration, we realized that a significant number of X-ray sys- 3 2012 FP 645 710
tems (35%) needed correction factors greater than 10%. The PKA-meter Total: 16,631 13,393
with the highest bias needed a correction factor of 0.64 (36%).

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Fig. 1. For each interventional room, the median values of the main patient dose indicators. Horizontal lines represent the 3rd quartile of all medians as the proposed
diagnostic reference levels. Each interventional laboratory was identified at abscissa axis as “No. Center_No. X-ray system”. Some participants did not provide the
number of images and centre 7 did not provide Ka,r.

than the other two X-ray systems and similar fluoroscopy dose rate in
the low mode (see centre 1 and rooms 1–3 in Fig. 2). In room 1_3, the
total PKA (with fluoroscopy and cine contributions) resulted between 53
and 60% (for PTCA and CA respectively) lower than 1_1 or 1_2 (Fig. 1).
In the last few years, some manufacturers have developed hardware
and software to reduce the dose delivered to patient in interventional
practices and have obtained reductions of 50% in patient dose (or
higher) while keeping an acceptable image quality [24–28].
While the differences in entrance air kerma per image vary in a
factor of five, the differences in image quality scoring differ in a factor
of nearly two. The evaluation was performed by visual inspection and
by different expert observers and usually led to small differences. When

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Table 2
Proposed national DRLs for coronary angiography (CA) and angioplasty (PTCA). PKA and Ka,r are corrected only if the PKA-meter introduced any bias. PKA, couch-corr is
corrected for the bias of the PKA-meter and also for the couch and mattress transmission.
Procedure N PKA (Gycm2) Ka,r (mGy) FT (min) no. Series no. Images

CA 16,631 39 532 6,7 10 759

PTCA 13,393 78 1319 15 18 1337

Table 3 propose corrective actions. The different Spanish Autonomous Com-

DRLs from different periods are compared. munities have their own audit systems to follow the results of these
CA PTCA actions.
When the correlation between typical patient dose indicators
Period 2009-13 2014-17 2009-13 2014-17 (median of PKA) and X-ray system dose settings (air kerma rate in
2
fluoroscopy and air kerma per image in cine in reference conditions)
PKA (Gy·cm ) 42 39 89 78
T fluoro (min) 6,7 6,7 15 15
was investigated, no significant correlation (τ = 0.17; p = 0.24) was
N series 10 10 21 18 found. The X-ray systems with the lowest dose settings could have been
N images 780 759 1300 1337 expected to deliver lower doses to patients. This is true for some rooms
like in the case of 1_3 but is not reflected in the global results. If more
factors were taken into account like kV, filtration, pulse rate… then
high differences were found, they had to be investigated, as was the maybe a more complete analysis could be addressed, but such a thing
system with lowest image quality (centre 6) with only 9 low contrast was not possible in this study. We also have to keep in mind that the
details and 9 resolution groups visible in cine mode, while the average values of dose rate or dose per image at reference conditions were
was 13 low contrast details and 14 resolution groups respectively. Its measured with the default operation modes in the X-ray systems. So it
low image quality was re-evaluated and confirmed, and the compar- may occur that in some cases, an overuse of high dose operation modes
isons with other systems in the group led to the replacement of the X- increased the overall patient dose indicators. Other variables are also to
ray system in 2017. be taken into account like the number of cine images and the fluoro-
In spite of the different sample sizes between participants, using the scopy time that are likely to produce high values of patient dose with
methodology recommended by ICRP [4] all the centers have the same low values of dose per image in cine or dose rate in fluoroscopy. There
importance in the estimation of the DRLs, provided that they contribute is a wide variety of median values for fluoroscopy times (2.4–8 min in
with a minimum of cases per interventional room. Fig. 1 shows how CA and between 7 and 20 min for PTCA) and for the number of images
different the median values for PKA are in the different centres. At between centres (between 453 and 839 images for CA and 693–1600
Centre 1, laboratory 3 obtained the lowest PKA and Ka,r for CA and PTCA for PCTA), which implies that there is still a wide margin for optimi-
and at the same time one of the highest fluoroscopy times and the zation. These high differences show the importance of including
highest number of images. The X-ray system 3 at centre 1 is equipped fluoroscopy time and number of images in the DRLs as recommended
with a dose reduction system, which can explain such an odd result. We by ICRP [4]. Medical physics experts should facilitate this information
see how in this case, dose reduction systems can help reduce patient to clinicians to help them achieve the appropriate image quality and
dose indicators. In Fig. 2 where the entrance air kerma per image in radiation dose for patients. As commented in the introduction, the
reference conditions is represented, X-ray system 1_3 has the lowest current European regulation highlights the importance of the respon-
value (0.04 mGy/img). In Fig. 3 that shows the results of image quality sibility shared by physicians and medical physics experts in optimiza-
with tests object, we can check that the same X-ray system at Centre 1_3 tion. We should all focus on achieving the optimal fluoroscopy time and
produced similar results in cine mode with respect to the other systems number of images required to produce an acceptable clinical outcome.
in the same centre: 12 details for low contrast sensitivity and 14 bar The impact of complexity factors in patient dose indicators should
groups for high contrasts resolution. Some rooms exceed the former therefore be evaluated and considered in the future for interventional
DRL. These centres have the responsibility to investigate the causes and

Fig. 2. An estimation of entrance surface air kerma rate for fluoroscopy and cine operation modes for all X-ray systems tested and using reference conditions
described (20 cm PMMA).

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Fig. 3. An estimation of image quality using test object (18 FG Leeds) for all X-ray systems tested and using the reference conditions described (20 cm PMMA). The
number of objects seen by observers are represented. Upper figure shows the low contrast sensitivity and lower shows results on high contrast spatial resolution.

Table 4 small reduction in PKA (−5%) that might not be significant. As regards
DRLs in terms of PKA in Gy·cm2 for interventional cardiology found in literature PTCA, although the same fluoroscopy time was recorded in both per-
and compared with this study. iods and the number of cine images was quite similar (−2%), the PKA
CA PTCA dropped by 14%. To explain this reduction in PKA, an analysis with
variables that are not included in this study like collimation would be
DIMOND18 2003 57 94 necessary. Many factors can affect these results like the addition of
SENTINEL19 2008 45 85
hospitals to the survey with new angiographic units, but we may also
EURADOS20 2018 35 87
UK8 2009 29 50 assume that this progressive reduction in patient dose indicators can be
USA9 2012 83 193 partly the outcome of the training programs in radiation protection and
Belgium10 2009 71 106 patient dose optimization for interventional practices. In particular in
France11 2017 26 60 Spain, since 1999 all interventionalists must obtain an official certifi-
Crotatia12 2010 32 72
Bulgaria13 2012 40 140
cation on radiological protection in interventional practices issued by
Grece14 2013 53 129 the health authority. A board examination is required to obtain this
Ireland15 2009 42 84 certification.
Germany29 2019 28 48 In Table 4, we show for comparison the DRLs in terms of PKA
Finland30 2019 30 75
published in previous European surveys.
This study 39 78
It can be noted that the national DRLs proposed in this study are
similar to the ones obtained in the last European survey. The value for
procedures as suggested by ICRP [4]. CA resulted 11% higher and for PTCA 8% lower. Should improvement
Table 3 shows the DRLs for CA and PTCA proposed for the period in dose reduction continue to be implemented in the new X-ray systems,
2009–2013 versus the ones proposed now. As regards CA, there is a along with the optimization of fluoroscopy time and number of cine

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images, the tendency towards dose reduction for patient is expected to
evolve positively in the future. The values observed in the European
surveys for the last 15 years, with PKA values dropping by 35% for CA
and 10% for PTCA, show that the optimization actions promoted by
MPEs, cardiologists and the industry, have produced encouraging re-
sults in terms of dose reduction.
Using this approach, MPEs can provide an analysis about the main
causes for potential high values of dose indicators like the X-ray dose
settings, the average number of images and the average fluoroscopy
time. This survey has shown that the dose settings of the X-ray units had
less impact in the patient dose indicators than the operation protocols
used and that we should also pay more attention to the fluoroscopy
time and number of images. MPEs should work together with cardiol-
ogists to refine the imaging protocols and inform them on the radiation
dose required for each cine image and each minute of fluoroscopy on
the impact of the C-arm angulations, of the collimation and of other
operational factors allowing to reduce patient doses (virtual collima-
tion, archiving fluoroscopy runs to avoid cine series, etc). It was
moreover shown that, in some cases, patient dose indicators provided
by the modalities may have deviations that must be corrected. All these
tasks are duties for the medical physics expert.
5. Conclusions
An update of national DRLs has been proposed in Spain for the most
frequent interventional cardiology procedures: CA and PTCA. As
fluoroscopy time and number of images were found to be the variables
the most highly correlated with patient dose indicators, they should be
given a priority for optimization actions. X-ray systems with dose re-
duction post-processing algorithms represent a significant leap forward
in the evolution of dose reduction capability: such a leap should
eventually lead to a redefinition of DRLs with values varying by one
half or one-third compared to the values currently used in standard
technology. Important differences have been found between different
participants, showing a wide margin for optimization. The approach of
this survey includes patient dose data, but also basic information about
X-ray systems, dose settings and image quality with test object. Some
PKA meters needed correction factors of up to 36%: in such cases, dose
management systems should have the capability of applying correction
factors to the dose indicators provided by the modalities. The in-
formation compiled in this survey allows medical physics experts in
cooperation with the cardiology community to investigate the reasons
for any difference and to propose optimization actions.
Acknowledgements
This work has been partially funded by the Spanish Ministry of
Economy and Competitiveness (Carlos III Health Institute) and
European Development Fund (ERDF) under the project MEDICI number
PI16/01413.
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