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Operator lower leg radiation dose during fluoroscopically guided interventions is effectively reduced by wearing lead-equivalent leg wraps

  • Author Footnotes
    Shared first authorship: Bala Ramanan MBBS, MS1,∗, Alejandro Pizano MD1,∗, This study was a poster presentation at the Southern Association of Vascular Surgery Annual Meeting, Manalapan, Fl, Jan 19-22
    Bala Ramanan
    Correspondence
    Correspondence: Bala Ramanan, MBBS, MS. UT Southwestern Medical Center, Professional Office Building 1, Ste 620, 5959 Harry Hines Blvd, Dallas, TX, 75390-9157
    Footnotes
    Shared first authorship: Bala Ramanan MBBS, MS1,∗, Alejandro Pizano MD1,∗, This study was a poster presentation at the Southern Association of Vascular Surgery Annual Meeting, Manalapan, Fl, Jan 19-22
    Affiliations
    Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
    Search for articles by this author
  • Author Footnotes
    Shared first authorship: Bala Ramanan MBBS, MS1,∗, Alejandro Pizano MD1,∗, This study was a poster presentation at the Southern Association of Vascular Surgery Annual Meeting, Manalapan, Fl, Jan 19-22
    Alejandro Pizano
    Footnotes
    Shared first authorship: Bala Ramanan MBBS, MS1,∗, Alejandro Pizano MD1,∗, This study was a poster presentation at the Southern Association of Vascular Surgery Annual Meeting, Manalapan, Fl, Jan 19-22
    Affiliations
    Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
    Search for articles by this author
  • Carlos H. Timaran
    Affiliations
    Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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  • Michael Siah
    Affiliations
    Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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  • Shadman Baig
    Affiliations
    Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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  • Micheal Shih
    Affiliations
    Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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  • Jeffrey Guild
    Affiliations
    Division of Medical Physics, Department of Radiology, The University of Texas Southwestern Medical Center, Dallas, TX
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  • Melissa L. Kirkwood
    Affiliations
    Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
    Search for articles by this author
  • Author Footnotes
    Shared first authorship: Bala Ramanan MBBS, MS1,∗, Alejandro Pizano MD1,∗, This study was a poster presentation at the Southern Association of Vascular Surgery Annual Meeting, Manalapan, Fl, Jan 19-22
Published:September 23, 2022DOI:https://doi.org/10.1016/j.avsg.2022.09.031

      Highlights

      • Radiation exposure was analyzed in 40 fenestrated and branched endovascular aortic aneurysm repairs
      • Lead-equivalent protective leg wraps reduce up to 95% of scattered radiation to interventionalists’ lower legs
      • Operators performing frequent complex fluoroscopically guided procedures should wear protective leg wraps

      Abstract

      Objectives

      The intensity of radiation scatter that emanates from the x-ray beam during fluoroscopically guided interventions is greater below the fluoroscopy table than above. Yet interventionalists' lower legs are typically unshielded, and table skirts are often positioned incorrectly. We sought to characterize the efficacy of the leg protector wraps (Leg Wraps, Burlington Medical Inc.) in reducing the radiation dose to the operator's lower leg during fenestrated and branched endovascular aneurysm repair (F-BEVAR).

      Methods

      A prospective cohort study was performed evaluating the lower leg radiation dose reduction of one vascular surgeon during F/BEVAR using antimony/bismuth Enviro-Lite™ leg wraps (0.35 mm lead equivalency - 99.7% attenuation at 50 kVp; Burlington Medical, Hampton Roads, VA). Optically Stimulated Luminescence (OSL) nanoDot™ detectors (microSTAR®ii System, LANDAUER®, Inc., Glenwood, IL) were placed over and under the left leg wrap at the anterior tibial tuberosity position to compare operator leg dose with and without this additional protection. The table-mounted lead skirt was used consistently in all cases. The nanoDot detectors were cross-calibrated with a survey meter (RaySafe X2 survey sensor, Fluke Biomedical, Cleveland, OH) by measuring scattered radiation at a position equivalent to an operator's mid-tibia while performing digital acquisitions of a 25cm thick, 30cm x 30cm acrylic phantom with a Philips FD20 fluoroscope (Philips Healthcare, Best, The Netherlands) with the table skirt removed. The measured radiation doses were converted to a Hp (0.07) skin dose, assuming an RQR6 beam spectrum (IEC-61267). Paired Wilcoxon test was performed to identify significant attenuation of radiation exposure.

      Results

      Leg dose measurements from 40 fenestrated and branched endovascular aneurysm repairs were analyzed. The patients had a median (interquartile range [IQR]) body mass index of 27 (24-32) kg/m2. Median procedure reference air kerma (RAK) was 1,100 (728-1,601) mGy, kerma-area product (KAP) was 127 (73-184) Gycm
      • Kokkinidis D.G.
      • Armstrong E.J.
      Current developments in endovascular therapy of peripheral vascular disease.
      , and fluoroscopy time (FT) was 69 (54-86) min. The median skin dose Hp (0.07) over the leg wraps (n = 40) was 54.2 (24-100) μSv, and under the leg wraps (n = 40) was 2.7 μSv (1.0-5.8). The leg wraps attenuated the radiation dose by 95 (89-98) %, (P < .001). The unprotected, Hp (0.07) per kerma-area product was determined to be 0.38 (0.30-0.55) μSv/ Gycm
      • Kokkinidis D.G.
      • Armstrong E.J.
      Current developments in endovascular therapy of peripheral vascular disease.
      .

      Conclusions

      The 0.35 mm lead-equivalent leg wraps significantly decreased scattered radiation to the lower leg during F-BEVAR. Protective leg wraps should be recommended to operators performing complex fluoroscopically guided procedures.

      Keywords

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