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Radiation dose and diagnostic reference levels for four interventional radiology procedures: results of the prospective European multicenter survey EUCLID



To assess information reflecting radiation dose and define diagnostic reference levels (DRL) on a European basis for four interventional radiology (IR) procedures considering clinical indication, anatomical region, and procedure.


A prospective European study was performed to provide data on the IR procedures percutaneous recanalization of iliac arteries, percutaneous recanalization of femoropopliteal arteries, transarterial chemoembolization of hepatocellular carcinoma, and percutaneous transhepatic biliary drainage. Hospitals were asked to complete a questionnaire giving information on procedure, equipment, and protocol. Patient size and weight, experience of the operator graded in number of procedures performed, and complexity level of each procedure were reported. Sixteen hospitals from 13 countries could be surveyed. The percentiles of the kerma-area product, fluoroscopy time, cumulative air kerma at the interventional reference point, and number of images were determined. The impact of equipment, year of installation, and complexity level of the procedure on dose were analyzed.


DRLs based on clinical indication were defined. Dose values varied considerably within hospitals, between them, and within each subgroup of complexity level. The use of state-of-the-art equipment reduced dose significantly by 52%. Although dose also varied within each subgroup of complexity level, for transarterial chemoembolization of hepatocellular carcinoma and percutaneous transhepatic biliary drainage, dose significantly correlated with complexity.


This was the first study reporting exposure practice and defining DRLs based on clinical indication for four IR procedures on a European basis. These DRLs can serve as a baseline for comparison with local practice, the study as a guideline for future surveys.

Key Points

• The use of state-of-the-art angiographic equipment reduces dose significantly.

• A significant correlation between radiation dose and complexity level is found.

• Dose values vary considerably, both within and between individual hospitals, and within each complexity level of interventional radiology procedure.

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Automatic exposure control


Clinical indication


Diagnostic reference level


European Society of Radiology


European Study on Clinical DRLs


Frames per second


International Commission on Radiological Protection


Interventional radiology

K a,r :

Cumulative air kerma at the patient entrance reference

NI :

Number of frames in cine mode



P KA :

Kerma-area product


Percutaneous transluminal angioplasty


Percutaneous transhepatic cholangiography and biliary drainage

T :

Fluoroscopy time


Transarterial chemoembolization of hepatocellular carcinoma


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The authors are grateful to the participating hospitals for their contribution to this study. Furthermore, the support of the representatives of national authorities and professional societies is gratefully acknowledged. In particular, the authors thank Jonathan Clark, Ulrike Mayerhofer-Sebera, and Monika Hierath, ESR, for their untiring commitment in organizing and administrating this project. The EUCLID project was financially supported by the grant ENER/2017/NUCL/SI2.759174 of the European Commission.


This study has received funding from the European Commission, grant no. ENER/2017/NUCL/SI2.759174.

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Correspondence to Alexander A. Schegerer.

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The scientific guarantor of this publication is Prof. Guy Frija.

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The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

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• cross-sectional study

• multicenter study

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Schegerer, A.A., Frija, G., Paulo, G. et al. Radiation dose and diagnostic reference levels for four interventional radiology procedures: results of the prospective European multicenter survey EUCLID. Eur Radiol 31, 9346–9360 (2021).

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