European Radiology

, Volume 22, Issue 6, pp 1240–1249 | Cite as

A national patient dose survey and setting of reference levels for interventional radiology in Bulgaria

  • R. Zotova
  • J. Vassileva
  • J. Hristova
  • M. Pirinen
  • H. Järvinen



A national study on patient dose values in interventional radiology and cardiology was performed in order to assess current practice in Bulgaria, to estimate the typical patient doses and to propose reference levels for the most common procedures.


Fifteen units and more than 1,000 cases were included. Average values of the measured parameters for three procedures—coronary angiography (CA), combined procedure (CA + PCI) and lower limb arteriography (LLA)—were compared with data published in the literature.


Substantial variations were observed in equipment and procedure protocols used. This resulted in variations in patient dose: air-kerma area product ranges were 4–339, 6–1,003 and 0.2–288 Gy cm2 for CA, CA + PCI and LLA respectively. Reference levels for air kerma-area product were proposed: 40 Gy cm2 for CA, 140 Gy cm2 for CA + PCI and 45 Gy cm2 for LLA. Auxiliary reference intervals were proposed for other dose-related parameters: fluoroscopy time, number of images and entrance surface air kerma rate in fluoroscopy and cine mode.


There is an apparent necessity for improvement in the classification of peripheral procedures and for standardisation of the protocols applied. It is important that patient doses are routinely recorded and compared with reference levels.

Key Points

Patient doses in interventional radiology are high and vary greatly

Better standardisation of procedures and techniques is needed to improve practice

Dose reference levels for most common procedures are proposed


Interventional radiology Interventional cardiology Radiation protection Patient dosimetry Patient dose Reference levels 


  1. 1.
    World Health Organisation (2000) Efficacy and radiation safety in interventional radiology. WHO, GenevaGoogle Scholar
  2. 2.
    International Commission on Radiological Protection (2000) Avoidance of radiation injuries from medical interventional procedures, ICRP Publication 85. Annals of the ICRP. 30(2). Pergamon Press, OxfordGoogle Scholar
  3. 3.
    International Atomic Energy Agency (2007) Dosimetry in diagnostic radiology: an international code of practice. Technical Reports Series No. 457. IAEA, ViennaGoogle Scholar
  4. 4.
    ICRU (2005) Patient dosimetry for X-rays used in medical imaging. Report 74. J ICRU 5(2)Google Scholar
  5. 5.
    International Electrotechnical Commission (2000) Medical electrical equipment—dose area product meters, 2nd edn, 2000–01. Publication 60580. IEC, GenevaGoogle Scholar
  6. 6.
    National Radiation Protection Board (1992) National protocol for patient dose measurements in diagnostic radiology. NRPB, ChiltonGoogle Scholar
  7. 7.
    International Organisation for Standardisation (1995) Guide to the expression of uncertainty in measurement. ISO, GenevaGoogle Scholar
  8. 8.
    International Electrotechnical Commission (2008) Medical electrical equipment. General requirements for safety. Collateral standard. General requirements for radiation protection in diagnostic X-ray equipment. Publication 60601-1-3. IEC, EnglewoodGoogle Scholar
  9. 9.
    Trianni A, Gasparini D, Padovani R (2009) Trigger levels to prevent tissue reaction in interventional radiology procedures. IFMBE Proceedings 25:410–413CrossRefGoogle Scholar
  10. 10.
    Žontar D, Kuhelj D, Škrk D, Zdešar U (2010) Patient peak skin doses from cardiac interventional procedures. Radiat Prot Dosimetry 139:262–265PubMedCrossRefGoogle Scholar
  11. 11.
    Vano E, Jarvinen H, Kosunen A et al (2008) Patient dose in interventional radiology: a European survey. Radiat Prot Dosimetry 129:39–45PubMedCrossRefGoogle Scholar
  12. 12.
    Padovani R, Vano E, Trianni A et al (2008) Reference levels at European level for cardiac interventional procedures. Radiat Prot Dosimetry 129:104–107PubMedCrossRefGoogle Scholar
  13. 13.
    Hart D, Hillier M, Wall B (2007) Doses to patients from radiographic and fluoroscopic x-ray imaging procedures in the UK—2005 review. HPA-RPD-029. Health Protection Agency, Porton DownGoogle Scholar
  14. 14.
    Holm L-E, Leitz W (2002) Regulations and general advice on diagnostic standard doses and reference levels within medical X-ray diagnostics. SSI FS 2002:2. Swedish Radiation Protection Authority, StockholmGoogle Scholar
  15. 15.
    Balter S, Miller D, Vano E et al (2008) A pilot study exploring the possibility of establishing guidance levels in X-ray directed interventional procedures. Med Phys 35:673–680PubMedCrossRefGoogle Scholar
  16. 16.
    D’Helft C, McGee A, Rainford L et al (2008) Proposed preliminary diagnostic reference levels for three common interventional cardiology procedures in Ireland. Radiat Prot Dosimetry 129:63–66PubMedCrossRefGoogle Scholar
  17. 17.
    Aroua A, Rickli H, Stauffer J-C et al (2007) How to set up and apply reference levels in fluoroscopy at national level. Eur Radiol 17:1621–1633PubMedCrossRefGoogle Scholar
  18. 18.
    Ruiz Cruces R, Garcia-Granados J, Diaz Romero FJ, Hernandez Armas J (1998) Estimation of effective dose in some digital angiographic and interventional procedures. Br J Radiol 71:42–47PubMedGoogle Scholar
  19. 19.
    Vano E, Gonzalez L, Fernandez JM, Guibelalde E (1995) Patient dose values in interventional radiology. Br J Radiol 68:1215–1220PubMedCrossRefGoogle Scholar
  20. 20.
    Neofotistou V, Vano E, Padovani R et al (2003) Preliminary reference levels in interventional cardiology. Eur Radiol 13:2259–2263PubMedCrossRefGoogle Scholar
  21. 21.
    Veit R, Bauer B (2003) Introduction of diagnostic reference levels into diagnostic radiology in Germany. Internal Report. Federal Office for Radiological Protection. SalzgitterGoogle Scholar
  22. 22.
    Bleeser F, Hoornaert MT, Smans K et al (2008) Diagnostic reference levels in angiography and interventional radiology: a Belgian multi-centre study. Radiat Prot Dosimetry 129:50–55PubMedCrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2012

Authors and Affiliations

  • R. Zotova
    • 1
  • J. Vassileva
    • 1
  • J. Hristova
    • 1
  • M. Pirinen
    • 2
  • H. Järvinen
    • 2
  1. 1.National Centre of Radiobiology and Radiation ProtectionSofiaBulgaria
  2. 2.Radiation and Nuclear Safety Authority (STUK)HelsinkiFinland

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