1

X ray systems for Interventional

radiology
Key topics: Filtration effect, pulsed radiation versus continuous, grid
controlled effect on the beam, virtual collimation, temporal
integration and road map, DSA, rotational angiography
ANASTAS LICHEV
Imaging Department,
University Hospital Sveti Georgi
PLOVDIV
X-Ray Equipment Standards And
Regulations
Requirements for angiography equipment, standards
Standards - different groups regarding the kind of the
equipment
Standards are applicable to mechanical, electrical,
electronical and other aspects of the equipment
A part of the standards are requirements for electrical,
mechanical and radiation safety
Standards are applicable at the time of manufacturing
of the equipment and at the time of installing
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Main points concerning radiation protection
If the relevant standards are fulfilled.
If a medical physicist is available.
If radiation protection tools are available.
If patient dose measuring and recording
system is available.
If acceptance tests, commissioning and
quality assurance program have been
foreseen.
Main points concerning radiation protection
If the X rays system selected is
appropriate for the procedures to be
carried out in the catheterization
laboratory.
If some other relevant information
described in standards, guidelines and
regulations have been taken into account.
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Applicable standards
Food and Drug Administration FDA
International electrotechnical commision IEC
American college of radiologists ACR
AAPM reports
Specific pediatric recommendations
Bulgarian standards

()
2004.
No 30

() 31 2005.
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Bulgarian standards
Regulation for radiation protection during
activities with sources of ionizing radiation
(2004)
Regulation No 30 for conditions and for
assuring protection of individuals during medical
procedures 31 October 2005
Limitations FDA
Limitations posed by FDA - May 19, 1994
21 CFR Part 1020
Entrance dose limit
normal operation 100mGr/min (10 R/min)
Entrance dose limit
high level dose operation 200mGr/min (20 R/min)
Not applicable in recording image mode
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Measure
Measuring of the
entrance dose at
the side of the PMMA
phantom object
facing the tube
Typical dose rate
20-80mGr/min
with 24cm PMMA
phantom
Limitations according to
Bulgarian regulations
Limitations posed by Regulation 30 :
at II with input diameter 25cm :
Entrance dose limit
normal operation - 50 mGr/min ( 5R/min)
Entrance dose limit
high level dose operation 100 mGr/min (10R/min)
Measuring of the entrance dose - at the face of the water
phantom object 30x30cm, 20cm thick
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Limitations according to
Bulgarian regulations
Limitations posed by Regulation 30 :
at II with input diameter 25cm :
II entrance dose limit
normal operation - 0.8 micrGr/s ( R/min)
II entrance dose limit
high level dose operation 1 micrGr/s ( R/min)
Measuring of the entrance dose
at the face of the water phantom object 20cm, without
antiscatter grid
Limitations according to
Bulgarian regulations
Concerning image recording mode:
II with input diameter 23m :
100-300 mGr/min in 25 frames/s entranse
dose (skin dose)
0.20 micrGr/frame II entrance dose rate
Measuring of the entrance dose at the face of
the water phantom object 20cm, without
antiscatter grid
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IEC standard on Interventional Radiology
Radioscopically guided invasive (and interventional)
procedures.
Interventional reference point.
Isokerma maps shall be provided.
The anti-scatter grid should be removable without the
use of tools.
Dosimetric indications: reference air kerma rate,
cumulative reference air kerma, cumulative area kerma
product, (shall be accurate to within 50 %).
Supplementary indications: cumulative time of
radioscopy, cumulative number of radiographic
irradiations, integrated reference air kerma.
Requirements to main
components of the system
System includes :
Imaging chain :
X-ray tube, inherent and added filtration, housing
Light Beam Diaphragm (LBD) Collimator
High voltage generator and control circuits
Image intensifier
Electronics and computers, software tools
Dose evaluation tools
Mechanical and Patient support
Patient table
C-arm and motorization
Fluoro and acquisition protocols used for examinations
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Types
Monoplane systems Monoplane systems
one C one C- -arm, floor or arm, floor or
ceiling suspension ceiling suspension
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Types
Bi Bi- -plane systems plane systems
two C two C- -arms, floor and arms, floor and
ceiling suspension ceiling suspension
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High voltage generator - 1
Power 100-150kW
High voltage range 40 140kV
Time of exposure 0.001s - 1s
Digital Cine rate 25-50 frames /s with
1-10ms duration and up to 10mAs per frame
Conventional cine used up to 200 frames/s
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High voltage generator - 2
Typically HV generator is a high frequency
voltage converter (high frequency generator)
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High voltage generator - 3
Control of the exposures :
at the stage of the generator
HF generators
HV tethrode controlled
at the stage of the tube grid controlled
tubes, better radiation bursts
High voltage generator - 4
High voltage pulse
Grid controlled tube
At generator
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High voltage generator - 5
High voltage pulse
Grid controlled tube
At generator
soft radiation
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High voltage generator - 6
High voltage pulse real world
High frequency generator
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High voltage generator - 7
High voltage pulse real world
High voltage generator
with HV tethrodes
commutation
High voltage generator and
pediatrics - 1
If pediatrics is concerned, the generator should allow
imaging on patients from 3 to 140 kg
This places additional demands on the generator
The generator should allow mAs of the tube per cine
pulse to be varied from 0.1 mAs (100 mA and 1 msec)
up to 6 mAs (e.g., 800 mA and 7 msec) according to
patient size in order to maintain a kVp 65 - 75 kVp.
Cine frame rate should be possible more or at least
60fps for small children.
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High voltage generator and
pediatrics - 2
The generator and tube should support three focal
spots.
Patients up to 3 to 4 years old can be imaged with an 0.3 mm
focal spot size
Patients up to 8 to 9 years old can be imaged with cine using an
0.6 mm focal spot
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High voltage generator and
pediatrics - 3
The 0.3 mm focal spot can also be used on small
children in combination with removing the anti-scatter
grid and using a geometric magnification factor up to 2.
This method may reduce patient dose because
the electronic magnification modes of the image intensifier are
not used less dose rate and
the Bucky factor due to the grid is eliminated
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Collimation in cardiac equipment
Beam quality modulation: extra filtering
(Cu, Ta, etc)
Spatial beam modulation: collimation (and
virtual collimation), wedge filters, etc.
Temporal beam modulation: pulsed
fluoroscopy (grid controlled, temporal
integration, etc).
Filtration - 1
Filtration changes the spectrum of the X-ray beam,
removing low-energy part of it the X-ray beam hardens
This contributes to reducing
of the patients dose as
penetration power of
the beam increases
However a degradation
in image quaity is possible
due to beam hardening
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Filtration - 2
Several manufacturers are using relatively thick copper
filtration and relatively reduced kVp during fluoroscopy
to generate an energy spectrum better matched to the
K-edge of iodine contrast media.
This technique requires high fluoroscopic tube
currents with the benefit of
reducing patient exposure to
radiation while improving
image contrast.
Replaceable filters
High filtration - 1
The introduction of
additional filtration in the
X ray beam (copper
filters) reduces the
number of low energy
photons and as
consequence, saves skin
dose for the patients
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High filtration - 2
Reduction of Radiation Exposure with extra filtration
Additional Cu filters can reduce the skin dose by more
than 70%.
Some systems offer variable extra filtration
(0.2 mm - 0.9 mm) that is automatically set according to
patient weight and angulation of the C-arm.
Automatic filter insertion try to keep the dose as low as
possible without degrading image quality.
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Filtration - 3
Replaceable filters
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Collimation - 1
Collimation reduces
area of irradiating to
the region of interest.
Scatter radiation also
decreases with
decrease of the
irradiated area.
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Collimation - 2
Dual-shape
collimators
incorporating both
circular and elliptical
shutters may be used
to modify the field for
cardiac contour
collimation
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Collimation - 3
Dual-shape
collimators
incorporating both
circular and elliptical
shutters may be used
to modify the field for
cardiac contour
collimation
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Collimation and filtration
Partially absorbent
contoured filters are
also available to
control the bright
areas outside of the
ROI
(border of the heart)
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Collimation:
Partially absorbent contoured filters are also available to
control the bright areas outside of the ROI
(border of the heart)
Virtual Collimation
Radiation-free Collimation work with memorized
image and computer
Manipulation of diaphragms in Last Image Hold.
No fluoroscopy required
No dose to the patient
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Image intensifiers 1
Need for imaging of large fields - for ventriculography,
aortography)
Need of imaging of small fields - coronary arteries
Multimode image intensifiers are recommended - with 2 or 3
imaging fields (zooms)
Image intensifiers 2
Material for the screen is cesium iodide CsI
Formats available vary with the manufacturers :
9 in/ 6 in/4.5 in (9/6/4.5) 23/16/11 cm
9/6 23/16 cm
9/5 23/13 cm
10/4 25/10 cm
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Image intensifiers 3
AAPM-70 (2001)
For adult studies, a 9 to 11 inch (23 to 27 cm) size is
preferable
Pediatric cardiac studies use smaller fieldsdue to the
small size of the pediatric heart 4.5 in (11cm) in most
cases should be enough
An image intensifier with a diameter of more than 9-10in
(23-25cm) is not recommended for cardiac
catheterization laboratories because such relatively large
size interferes with the ability to obtain steep sagittal
angulation.
New detectors
Flat panels
Dynamic flat panel
Based on CsI as well as II
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Electronics and computers - 1
Last image hold
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Electronics and computers - 2
Patient dose measurement, display and archive -
DAP meters, time of fluoroscopy
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Electronics and computers - 3
Work stations equipped with software tools for
image and data processing
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Electronics and computers - 4
Work stations equipped with software tools for
image and data processing
(incl. automatic review)
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Electronics and computers - 4
Connectivity and
DICOM compliance
DICOM header
information
Philips Integris 5000 cardio
(0008,0032) : Acquisition Time : 12:36:27
(0018,0060) : KVP : 83
(0018,1030) : Protocol Name : 12.5 IPS Coronaria
(0018,1110) : Distance Source to Detector : 940
(0018,1150) : Exposure Time : 8
(0018,1151) : X-ray Tube Current : 873
(0018,1162) : Intensifier Size : 169.99998
(0018,1510) : Positioner Primary Angle : -32.099998
(0018,1511) : Positioner Secondary Angle : 0.69999999
(0020,0013) : Image Number : 8
(0028,0008) : Number of Frames : 73
GE ADVANTX LCV-DLX (Cardio mode)
(0008,0032) : Acquisition Time : 19:24:33
(0008,103E) : Series Description : CORONARIO
(0018,0060) : KVP : 75
(0018,1110) : Distance Source to Detector : 1060.000
(0018,1111) : Distance Source to Patient : 705
(0018,1149) : Field of View Dimension(s) 152
(0018,1150) : Exposure Time : 328 (number fr x ms per fr)
(0018,1151) : X-ray Tube Current : 81
(0018,1510) : Positioner Primary Angle : -30 (left is +)
(0018,1511) : Positioner Secondary Angle : 0 (cra is +)
(0019,101B) : 1.2 (this is the focus size)
(0019,101C) : 1 (Dose mode: 0,1, 2 and 3 for A,B,C and D)
(0019,101F) : 4 (This is the real pulse time in ms)
(0020,0013) : Image Number : 2 (this is the series number)
(0028,0008) : Number of Frames : 82
Patient and Equipment Support
The ability to obtain very steep sagittal plane
angulation (in excess of 45 ) is desirable.
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Pulsed fluoroscopy
Pulsed fluoroscopy can be used as a method of
reducing radiation dose, particularly when the
pulse rate is reduced.
However pulsed fluoroscopy does not mean that
dose rate automatically is lowered down in
comparison with continuous fluoroscopy
Pulsed fluoroscopy
Dose rate depends of the dose per pulse and the
number of pulses per second
Pulse width modulation
Frequency modulation
One may vary conditions by changing the
frequency and width of the pulses different
modes (lo, high, pediatric)
Measurement for a time period in the same
conditions
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Roadmap
Overlying of two images. An existing subtracted Overlying of two images. An existing subtracted
image of a blood vessel filled with contrast image of a blood vessel filled with contrast
medium can be superimposed on a catheter medium can be superimposed on a catheter
image during fluoroscopy. Very useful in viewing image during fluoroscopy. Very useful in viewing
blood vessels blood vessels
Saves time and contrast medium Saves time and contrast medium
Patient dose Patient dose reduction reduction
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Digital subtraction angiography - DSA
Temporal subtraction refers to a number of computer Temporal subtraction refers to a number of computer- -
assisted techniques whereby an image obtained at one assisted techniques whereby an image obtained at one
time is subtracted from an image obtained at a later time is subtracted from an image obtained at a later
time. time.
If, during the intervening period, contrast material was If, during the intervening period, contrast material was
introduced into the vasculature, the subtracted image introduced into the vasculature, the subtracted image
will contain only the vessels filled with the contrast will contain only the vessels filled with the contrast
material material
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Digital subtraction angiography - DSA
Temporal subtraction Temporal subtraction
Mask mode study Mask mode study
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Digital subtraction angiography - DSA
Temporal subtraction Temporal subtraction
Time interval Time interval differense differense study study
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Rotational angiography
A series of images are acquired A series of images are acquired
during one continuous rotation during one continuous rotation
of the C of the C- -arm around the arm around the
patient, allowing a large patient, allowing a large
number of projections to be number of projections to be
obtained with a single injection obtained with a single injection
of contrast medium of contrast medium
Rotational angiography
A series of images are acquired during one continuous A series of images are acquired during one continuous
rotation of the C rotation of the C- -arm around the patient, allowing a large arm around the patient, allowing a large
number of projections to be obtained with a single number of projections to be obtained with a single
injection of contrast medium injection of contrast medium
Permits rendering images
similar to that from
CT equipment
Patient dose should be
taken into account
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Dose evaluation and limiting tools
The operator should be made aware of the cumulative amount of
exposure time during the procedure.
There have to be mechanical or electronics limitation of the time of
fluoroscopy
Dose evaluation and limiting tools
In training programs there should be a limit to the amount of
fluoroscopic time granted to a trainee to complete a specific task,
based on a number of considerations such as the progress being made
and the complexity of the procedure.
There should be equipment for
recording of the applied
dose-area product (DAP)
DAP meter
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Auxiliary radiation protection apliances
Protective tools in the
system - A freely
movable lead glass or
acrylic shield
suspended from the
ceiling should be
used. Its sterility may
be maintained by
using disposable
plastic covers.
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Auxiliary radiation protection apliances
Ergonomy in the room and system geometry
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Auxiliary radiation protection apliances
Each procedure room
should have a
detailed
determination of
exposure levels
performed by a
qualified radiation
physicist.
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Auxiliary radiation protection apliances
Operational modes and how they are settled
There is a tendency in the busy laboratory to
assign a low priority to preventive maintenance
and quality assurance inspections.
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Conclusions from the IAEA survey
Patient dose and image quality depend largely
on the settings made at the commissioning of
the radiological equipment.
For different systems and different operation
modes, entrance air kerma can increase by a
factor of 20 (including electronic magnification)
for the same patient thickness.
Conclusions from the IAEA survey
Increasing phantom thickness increases
dose by an additional factor of up to 12.
Differences in radiation doses from the
evaluated systems show a potential for
dose reduction whilst maintaining image
quality.
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Importance of testing X ray equipment
Characterization of the X- ray system, that
should be part of the acceptance and status
tests, should inform cardiologists about the dose
rates and dose/frame for the different operation
modes and for the different patient thicknesses.
Image quality has to be evaluated also.
Regular constancy checks should verify if
important changes could been occurred.
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Thanks for attention ! Thanks for attention !