Radiation Safety: Don’t Wait Until It’s Too Late

Staying Safe During Fluoroscopically Guided Interventions: Recognizing and Reducing Radiation and Lead Risks

By Melissa L. Kirkwood, MD

The number of complex endovascular procedures continues to increase, and consequently so does the risk of radiation injury to providers. Radiation injury can manifest as deterministic changes, which are dose dependent (most commonly, skin injuries) or stochastic effects, which are not dose dependent but the potential increases with increased exposure (ie, the development of malignancy).

In general, only about 1% of the primary x-ray beam makes it to the detector, while approximately 70% is released as scatter radiation at the table level and below. The patient is the largest source of scatter radiation to operators. As such, interventionalists have six times the risk of cataracts, three times the risk of malignancy, and two times the risk of coronary artery disease compared to the general population. In one study, 60% of interventionalists exceeded their ocular dose limit, and 80% were noted to have radiation-related cataracts on ophthalmic examination.¹

Musculoskeletal problems from personal protective equipment are also a significant issue for providers. In a survey of interventionalists, 66% reported having experienced musculoskeletal pain related to wearing lead, and 60% reported having at least one orthopedic injury; 25% and 34% had experienced cervical spine and lumbar spine injuries, respectively. The growing concern for interventionalists of both orthopedic problems and radiation risks is contributing to physician burnout and possibly attrition in our field.²

It is imperative that operators start protecting themselves from these occupational risks early in their career. At the Southern Association of Vascular Surgery’s 2025 annual meeting, we presented that radiation dose to the vascular trainee is related to their level of experience.³ Higher median thyroid and sternum radiation doses were observed for PGY6 fellows compared to PGY7 fellows for similar endovascular procedures, demonstrating that it is never too early to start taking these risks seriously. The good news is that we have shown that applying basic principles during fluoroscopic-guided interventions can significantly lower the radiation exposure to the entire team.⁴ Going a step further, it is crucial to stay current with fluoroscopy equipment and software updates that are designed to lower dose. Using adjuncts during complex endovascular procedures whenever possible—like digital zoom, Fiber Optic RealShape technology (FORS, Philips), and two-dimensional vessel navigation roadmap—can further minimize dose. Next-generation protection systems that include dynamic shielding to actively block scatter radiation at the source are on the horizon and gaining significant support for their dose-lowering potential.

All interventionalists, including trainees and both early career and more senior providers, should be equally familiar with dose-lowering strategies to fully adhere to the ALARA (as low as reasonably achievable) principles. Focusing attention on procedural dose protects not only our patients but also our workforce, ensuring long and healthy careers.

1. Andreassi MG, Piccaluga E, Guagliumi G, et al. Occupational health risks in cardiac catheterization laboratory workers. Circ Cardiovasc Interv. 2016;9:e003273. doi: 10.1161/CIRCINTERVENTIONS.115.003273

2. Abudayyeh I, Dupont AG, Hermiller JB, et al. Occupational health hazards in the cardiac catheterization laboratory: results of the 2023 SCAI survey. J Soc Cardiovasc Angiogr Interv. 2025;4:102493. doi: 10.1016/j.jscai.2024.102493

3. Solano A, Shih M, Klein A, et al. Analysis of radiation exposure learning curves for vascular surgery trainees during fluoroscopically guided interventions. J Vasc Surg. 2025;82:267-272. doi: 10.1016/j.jvs.2025.03.178

4. Kirkwood ML, Arbique GM, Guild JB, et al. Surgeon education decreases radiation dose in complex endovascular procedures and improves patient safety. J Vasc Surg. 2013;58:715-21. doi: 10.1016/j.jvs.2013.04.004

Radiation Safety and Musculoskeletal Health: What I Wish I Knew Sooner

Lakshmi A. Ratnam, MBChB, MRCP, FRCR, EBIR

“Looking back, I think it would have been helpful to have the everyday basics of radiation safety made clearer and simpler: things like a poster in the procedure room with reminders on where best to stand, stepping back during digital subtraction angiography runs, and a quick checklist for shields, glasses, and aprons. Hospital procurement teams should have greater awareness about the range of lead apron designs, such as lighter designs, those with additional back support, and aprons tailored for women with axillary panels to better protect breast tissue. A little more awareness and visibility of these basics can make a difference.”

Patrick Muck, MD

“As a vascular surgeon, I wish I had known earlier the hidden risks of cataracts, cancer, and, perhaps, cognitive decline associated with radiation exposure. This was the subject of my 2025 Midwestern Vascular Surgical Society Presidential Address, ‘Ask Not What Vascular Surgery Can Do for You, But What it Can Do to You.’ Endovascular procedures are displacing open surgery, and the result is more radiation to not only the surgeon but the entire team. It is my generation’s moral imperative to emphasize radiation mitigation and demand total team protection (registered technologists and registered nurses) with systems like the Guardian system (Rampart). Our team recently performed an endovascular aneurysm repair and not one member of the team had personal lead protection. I truly believe barrier protection with systems like the Guardian is in its infancy.”

Kenneth Rosenfield, MD, MHCDS

“Prioritizing your own physical health (and mental well-being too!) is crucial for anyone who will be exposed to scatter radiation and wearing burdensome lead or even standing for prolonged periods of time during procedures. Focusing on core strengthening prepares you for wearing lead and other physical stress of cath lab work. Set aside time to do regular exercise, with an emphasis on stretching and core strengthening (eg, planks, sit-ups, push-ups, Pilates, yoga).

Although I ran and biked, I was not tuned into this early in my career, and I think it clearly needs to be part of our basic training and curriculum. This job is not just mentally and technically challenging—it’s also physically challenging. And yet this physical component is not built into our training. Aside from maintaining your own health, it is important to recognize that, if you’re not in physical condition to be in the cath lab to wear lead painlessly, you may not be able to focus on the patient and are potentially compromising your ability to deliver the best care possible. Training on radiation protection and physical preparation should be part of our formal curriculum in some way, shape, or form.” (Portions of this response were published in MSK Injuries: What the Next Generation Must Understand Now, which appeared in the June 2025 issue of Endovascular Today.)