April 9, 2025

Study Evaluates Radiation Exposure for Vascular Surgery Trainees During Fluoroscopically Guided Interventions

April 9, 2025—In an article published online in Journal of Vascular Surgery evaluating radiation dose exposure for vascular surgery trainees, Solano et al found higher exposure and scatter fractions for first-year fellows (PGY6) as compared with second-year fellows (PGY7s) during fluroscopically guided interventions.¹

KEY FINDINGS

PGY6 fellows had significantly higher median radiation dose at the level of the thyroid and sternum as compared with PGY7 fellows.
DAP was higher in the PGY7 group versus the PGY6 group.
Scatter fractions were significantly higher for PGY6 fellows as compared with PGY7 fellows.
No significant differences were seen in source-to-image distance or DAP/RAK ratios for level of training.
There was no statistically significant difference in attending surgeon radiation dose when operating with PGY6 or PGY7 fellows.

Investigators conducted a prospective cohort study at a single university hospital to analyze median radiation dose of vascular surgery trainees, an attending surgeon, and patients during fluoroscopically guided interventions over a 5-month period.

The primary operator and fellows wore personal protective equipment consisting of a vest, skirt, and thyroid shield of at least 0.35-mm lead equivalence. The same hybrid operating room was used for all interventions and included AlluraClarity C-arms (Philips) with state-of-the-art software designed to reduce radiation dose, ceiling-mounted protective screens, and lead curtains.

All staff involved in the cases had previously completed training on the ALARA (as low as reasonably achievable) principle, and all fellows had received required hospital- and state-level training for fluoroscopy safety.

Cases were stratified by fellow training stage as PGY6 (the first 6 months in the first year of vascular surgery fellowship) and PGY7 (the final 6 months of the second year). Radiation dose was measured with optically stimulated luminescence dosimeters placed outside the lead apron at the thyroid and sternum positions for one attending and all assisting fellows performing fluoroscopically guided interventions. Procedural reference air kerma (RAK) fluoroscopy time, dose area product (DAP), and patient body mass index were recorded, and the DAP/RAK ratio was used to evaluate intraprocedural magnification and collimation.

The primary endpoint was to determine if stage of training would affect radiation exposure for vascular surgery trainees. Statistical analysis was performed using paired Wilcoxon and chi-square tests for training stage on radiation dose exposure and performance of radiation reduction.

The study included 40 fluoroscopically guided interventions; 21 were performed by PGY6 fellows and 19 were performed by PGY7 fellows. For both groups, most cases were peripheral artery disease interventions. PGY7 fellows had broader case variety with higher case RAK, patient body mass index, and fluoroscopy and operative time, but differences were not significant. The study found the following:

PGY6 fellows had significantly higher median radiation dose at the level of the thyroid and sternum as compared with PGY7 fellows (thyroid: 82 µGy [IQR, 47-94 µGy] vs 44 µGy [IQR, 30-57 µGy)]; P = .009; sternum: 89 µGy [IQR, 75-128 µGy] vs 54 µGy [IQR, 48-77 µGy]; P = .007).
DAP was higher in the PGY7 group versus the PGY6 group (30 Gy/cm³ [IQR, 14-77 Gy/cm³] vs 26 Gy/cm³ [IQR, 21-42 Gy/cm³]; P < .001).
Scatter fractions were significantly higher for the PGY6 group as compared with PGY7 group (thyroid/DAP ratio, 1.97 [1.1-2.76] vs 1 [0.43-1.32]; P = .018; sternum/DAP ratio, 2.64 [1.67-2.99] vs 1.23 [0.64-2.64]; P = .041).
No significant differences were seen in source-to-image distance or DAP/RAK ratios for level of training, and there was no statistically significant difference in attending surgeon radiation dose when operating with either PGY6 or PGY7 fellows.

The investigators noted some limitations, including that it was conducted at a single center and involved one attending surgeon, lack of control for case complexity and amount of time when the attending took over as primary operator, and exclusion of vascular surgery integrated residency trainees (PGY1-5). The higher radiation dose exposure observed in first-year vascular fellows compared to second-year fellows suggests that early and thorough radiation safety training is crucial to ensure best practices are followed, noted the investigators.

1. 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. Published online March 19, 2025. doi: 10.1016/j.jvs.2025.03.178

ENDOVASCULAR TODAY ASKS…

Study investigator Melissa L. Kirkwood, MD, with UT Southwestern Medical Center in Dallas, Texas, provided some insights into the study’s results and what they mean for future radiation safety research and education.

What first prompted the investigators to undertake this study? How were the specific parameters of PGY6, PGY7, and experienced operators decided upon?

We were prompted to investigate the radiation dose difference between fellows with different levels of experience because we noted that more junior fellows were less likely to incorporate aggressive tactics aimed at lowering dose, despite receiving training on the ALARA principles. We have multiple vascular trainees at UT Southwestern, but we thought it best to compare a second-year fellow in her final year of training to a first-year fellow in his first 6 months of training.

What are the real-world training or experience elements that transpire between PGY6 and PGY7 that lead to reduced exposures? Can the findings of this study encourage any earlier behavior adoptions, or is it more a matter of experience accumulation?

I believe it is mostly the accumulation of experience; when a provider is more comfortable doing the procedure, they are more likely to have the bandwidth to focus on radiation safety. However, we hope that this manuscript helps junior trainees realize that early incorporation of routine habits to lower radiation dose is crucial to a long and healthy career in vascular surgery.

How can these findings be built into early career education? Are additional protective measures for PGY6 warranted?

The continuous reinforcement of best practices to lower radiation must be taught by the attending surgeon for every case. This manuscript demonstrates that perhaps more emphasis is needed on these principles when operating with more junior trainees.

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