Radiation Risks for Radial Operators Can Be Cut With Cheap, Effective Pelvic Drapes

Simple and cost-effective protective drapes used on the patient’s pelvis can further reduce the dose of radiation an operator absorbs during transradial coronary procedures, a single-center investigation suggests.

The findings highlight simple alterations in the cath lab setup that could further limit radiation exposure, one expert observed, but changing behaviors of everyone working in the room remains a challenge.

In recent years, conflicting findings have been published regarding the interplay between access site and radiation exposure, with some suggesting that radial procedures confer greater exposure than femoral procedures for the operator and/or patient. Still others, such as RIVAL, have shown similar levels of radiation exposure regardless of access site but slightly higher levels of radiation for left- versus right-radial procedures.

For the new study, known as RADIATION, researchers led by Alessandro Sciahbasi, MD, PhD (Sandro Pertini Hospital, Rome, Italy), randomized 340 patients undergoing one or more radial diagnostic or interventional percutaneous procedures into four groups: no drape, drape on one arm, drape on one arm and pelvic region, or drape on the pelvic region only. The drapes were used in addition to standard lead shields, protective clothing, badges, and glasses worn by the operators. The 452 total procedures were done by two high-volume interventional cardiologists who each performed more than 250 radial procedures per year.

The drapes used were the bismuth-barium RADPAD (Worldwide Innovations & Technologies, Lenexa, KS) for the patient’s arm and a homemade pelvic drape fashioned from a lower-body X-ray curtain. Researchers recorded fluoroscopy time, air kerma, and dose area product. Operators wore personal electronic dosimeters on their left wrist, outside the pocket of the lead apron on their thorax, and in the middle front of their head.

Pelvic Drape Most Effective

Published online January 3, 2017, ahead of print in EuroIntervention, the study showed that when the researchers measured the operators’ radiation dose at the thorax, radiation doses were lower for all three groups in which an adjunctive drape was used compared with when no drape was used. When the three drape groups were compared, radiation absorption with use of the pelvic drape was lower than with use of the arm drape (P < 0.001), while combining the pelvic and arm drape resulted in similar doses as the pelvic drape alone (P = 0.302).

For areas of the operator’s body other than the thorax that absorbed radiation, the study again found that any drape use resulted in lower exposure to the head than no drape. At the left wrist, however, only the pelvic drape or the combination of the pelvic drape and arm drape—but not an arm drape alone—reduced radiation compared with no drape. Additionally, the pelvic drape alone or in combination with the arm drape resulted in lower radiation dose than the arm drape at both the head and wrist level.

More analysis found that the only situation in which the arm drape alone reduced radiation compared with no drape was during diagnostic radial procedures, not during PCI. The pelvic drape, on the other hand, was effective in reducing radiation during both diagnostic procedures and PCI.

Because the study included only two operators, both of their exposures were compared. The effect of the drapes found to be the same.

When analyzed by left- or right-radial access, the median radiation dose to the operator was lower for left than right access as measured at the thorax (3.2 µSv vs 7.8 µSv), left wrist (3 µSv vs 7 µSv), and head (1.6 µSv vs 2.2 µSv; P < 0.0001 for all). Sciahbasi et al say those findings should be reassuring to operators who prefer left radial access, although they note that other research has shown higher radiation absorption for left radial when measuring different areas of the operator’s body than were measured in their study.

Compared with the no-drape control group, use of the arm drape was only effective in lowering the radiation dose in right radial procedures, whereas any use of the pelvic drape lowered radiation dose regardless of left or right access.

Changing Cath Lab ‘Culture’ of Risky Behavior

While drapes like the ones used in RADIATION are easy to acquire and relatively inexpensive, the larger issue is a systemic interventional “culture” among cath lab workers of thinking they can get away without extra protection, said Ian C. Gilchrist, MD (Hershey Medical Center, Hershey, PA), who commented on the study for TCTMD.

“Why do people not put their seat belts on when they are just driving a short distance down the road? It’s one of those ‘it’s probably not going to affect me today’ situations that occur frequently and . . . it’s a sort of justification of imminent risk versus distant risk,” he observed. Gilchrist said stricter oversight and reminders may be the only way to ensure that all cath lab personnel use optimum radiation protection and wear their badges each and every time they work. Just as there is a checklist for the patient before entering the cath lab that makes certain they are going to the right place for the right procedure, he said, a checklist for all proper radiation-reduction measures in the cath lab and among personnel probably could make a difference.

Another thing that could prompt behavior change, Gilchrist said, is showcasing radiation protection setups in cath labs during live cases at national meetings in the same way cutting-edge technology is showcased.

He added that the Italian study findings “speak to some very simple alterations in the setup of the table that could further reduce the radiation,” but only if cath lab workers are motivated and willing to make those alterations. According to Gilchrist, some operators oppose adjunctive drapes because they are known to cause a radiation “bounce” away from the operator and back into the patient. But does this nominal onetime increase in exposure to the patient outweigh the multiple daily and weekly exposures to the operator? Regardless, Gilchrist said, it poses an ethical dilemma for some operators that justifies—at least to them—their position on the drapes.

“Personally, I see a duty to protect everyone in the room from radiation,” he said. “Because this is not just a physician problem.”

Gilchrist added that it is not uncommon for nurses or techs who are not fully protected to get close to the patient for some reason during a procedure, or for them to remove drapes or shields because they feel they either are in the way or impair how the table moves. “And the problem is, it’s not like you can feel heat on you or something when that happens,” he noted. “You don’t know, and you may not notice for a while, that the drapes under the table were removed, for instance, because someone thought they were in the way.

“This is a cath lab culture of risky behavior that occurs everywhere, and it takes concern on the part of everyone to value protection and to apply it,” Gilchrist concluded.