Since the last recommendations of the International Commission on Radiological Protection (ICRP) in 2007  with a revision of the risk factors for stochastic effects and the statement on tissue reactions (deterministic effects) issued in April 2011 , several regulatory initiatives and scientific activities have been launched to improve patient and staff radiation safety and to foster optimization actions in interventional radiology. When we use the term “interventional radiology” in this article, we are referring to fluoroscopically guided procedures (FGPs).
In 2011, the ICRP alerted the radiological community to the epidemiological evidence suggesting that there are some tissue reaction effects where threshold doses are or might be lower than previously considered: 0.5 Gy for the lens of the eye (radiation-induced opacities) and also 0.5 Gy for circulatory disease of the heart or brain. Exposure of staff (lens of the eye) and patients to doses of this magnitude could be reached during some complex interventional procedures and the ICRP recommended particular emphasis be placed on dose optimization in these circumstances.
It appears that the rate of dose delivery does not modify the incidence of radiation-induced cataracts [3•]. The new proposed threshold dose for radiation-induced eye cataracts of 0.5 Gy is applicable for both short-term and fractionated exposures. Some experimental and animal data suggest that such preclinical radiation-induced lens opacities may progress with time to demonstrable visual disability. The latent period for radiation cataracts is inversely related to the dose.
For occupational exposure, the ICRP recommended an equivalent dose limit for the lens of the eye of 20 mSv/year, averaged over defined periods of 5 years, with the dose in a single year not exceeding 50 mSv [3•]. The immediate consequence was a change in the international basic safety standards (BSS)  and in the draft of the European BSS to adopt this new limit [5•].
Many medical specialties in addition to radiology and cardiology use fluoroscopy to guide interventional procedures as an alternative to more complex open surgery procedures that some elderly patients could have difficulty to support owing to the anesthesia or other clinical constraints. This increasing interest of many clinicians for these minimally invasive techniques together with the new international recommendations on radiation safety has promoted several international research activities on patient and staff dosimetry.
Some examples of these international actions are as follows: Retrospective Evaluation of Lens Injuries and Dose (RELID) [6•], Information System on Occupational Exposure in Medicine, Industry and Research (ISEMIR) , Safety in Radiological Procedures (SAFRAD)  launched by the International Atomic Energy Agency (IAEA), Safety and Efficacy for New Techniques and Imaging Using New Equipment to Support European Legislation (SENTINEL) , and Optimization of Radiation Protection for Medical Staff (ORAMED)  supported by the European Commission.
Within ISEMIR, the Working Group on Interventional Cardiology is assessing staff radiological protection levels and building an international database of occupational exposures. A survey of regulatory bodies has provided information at the country level on RP practices for staff in interventional cardiology [11•].
The evaluation of the radiation dose to the eye is not a straightforward issue. The current measurement techniques are still not adequately developed and are not available for routine use. Retrospective estimations are necessary to look for correlations with radiation lens opacities. The RELID program is using surveys for retrospective evaluation of staff doses. Participants are asked to provide information on the number of years of work in an interventional laboratory, use of protective screens and eyewear, workload with fluoroscopy time and cine acquisition details, and other information pertaining to the technique that may have a bearing on the radiation dose to the eye lens. The radiation dose is estimated on the basis of this information. The availability of personal monitoring badge data helps in correlation. The location of the staff in the interventional room is also taken into account [6•].
SAFRAD is a voluntary reporting system launched by the IAEA where the patient’s dose report and relevant data are included in an international database when these patients are submitted to defined trigger levels or events with risk of skin radiation injuries in fluoroscopically guided diagnostic and interventional procedures .
The ICRP has produced three new documents containing recommendations for interventional procedures: publication 117 (“Radiological protection in fluoroscopically guided procedures performed outside the imaging department”) [12••], publication 120 (“Radiological protection in cardiology”) [13•], and publication 121 (“Radiological protection in paediatric diagnostic and interventional radiology”) [14•].
A relevant success of the international cooperation on patient dosimetry with expected important impact on interventional radiology is the “Joint position statement on the IAEA patient radiation exposure tracking” [15•] supported by the European Society of Radiology, the US Food and Drug Administration, the IAEA, the International Organization for Medical Physics, the International Society of Radiographers and Radiological Technologists, the World Health Organization, and the Conference of Radiation Control Program Directors. The scope of patient radiation exposure tracking is to cover all imaging modalities which use ionizing radiation for interventional procedures and radiographic, fluoroscopic, computed tomography, and nuclear diagnostic examinations. The scope also includes radiation dose recording, reporting, and tracking.
This statement and other improvements in the upcoming European regulation [5•] will push the radiology industry and users to develop better strategies to evaluate patient doses, to transfer these values to patient reports (contributing to the patient dose tracking system), but also to make available software to process these dosimetric data and to do some automatic analysis with the results.
Finally, education and training in RP is a key aspect to reduce radiation doses to the staff and to maintain at the appropriate level radiation doses to the patients during interventional procedures. In April 2011, the ICRP published a set of recommendations entitled “Education and training in radiological protection for diagnostic and interventional procedures” [16•].
Some relevant clinicians are promoting radiation safety in their respective specialties. Picano [17•] is trying to attract the cardiology community to the issue. Cardiologists have a special mission to avoid unjustified or nonoptimized use of radiation, since they are responsible for 45 % of the entire cumulative effective dose of 3.0 mSv per head per year to the US population from all medical sources except radiotherapy. Interventional cardiologists have an occupational exposure per head per year two to three times higher than that of radiologists. The most active and experienced interventional cardiologists in high-volume catheterization laboratories have an annual exposure equivalent to around 5 mSv per head and a professional lifetime attributable to excess cancer risk on the order of one in 100. Cardiologists are the contemporary radiologists, but are sometimes imperfectly aware of the radiological dose for the examination they prescribe or practice, which can be in range of the equivalent of 1–60 mSv. A good cardiologist cannot be afraid of life-saving radiation, but must be afraid of radiation unawareness and negligence [17•].
Chambers [18•] recently highlighted the importance of radiation management and radiological protection training. He stated that managing radiation dose is an important component for all invasive cardiac procedures and necessitates accurate dose assessment to establish proper patient notification, education, and follow-up. To manage the radiation dose, it must be measured. Structural and congenital interventions often have longer procedure times, are performed on younger patients, and require further procedures. All physicians and staff involved with interventional fluoroscopy must be properly trained on the basic principles of radiation physics and safety. A qualified medical physicist must be involved with the physician in equipment selection and staff education. The best quality image with the most effective radiation dose provides the best patient care. Radiation dose management involves preprocedural, procedural, and postprocedural dose management. Adverse effects on skin from exposure to radiation occur weeks after the patient has been discharge and require follow-up protocols for detection [18•].