Dose Reduction in CT Fluoroscopy

  • N. Buls
  • F. Vandenbroucke
  • J. de Mey
Part of the Medical Radiology book series (MEDRAD)


CT Fluoroscopy (CTF) is a technique that requires adequate radiation protection management for both patient and staff. Since the scanning plane is kept constant during the entire procedure, the same skin area is repeatedly exposed and cumulative patient skin doses can be substantial. Whereas, with conventional fluoroscopy the 2 Gy threshold dose for tissue reactions is reached after 100–200 min of fluoroscopy, it can be reached in CTF only after 3–10 min of scanning when a high tube current is applied. In contrast to diagnostic CT where the operator is protected behind the lead screen of the console, CTF procedures require the presence of the staff in the examination room. For the physician, particularly the doses to the lens of the eyes and the hands are of concern. Doses to the eyes can be anywhere in the range of 0.01–0.2 mGy per procedure. If protection is not used, there can be a substantial risk of lens opacity for procedures that require long fluoroscopy times and with several procedures per day, such as in busy department. Effective protection can be used to reduce the probability of cataract to a negligible level. Operators need to be aware of different methods of CTF guidance and the factors that determine radiation exposure of both patient and staff. This becomes more important as the spectrum of CTF procedures might expand to more complex procedures that may require longer fluoroscopy times.


Skin Dose Surface Dose Scanning Plane Needle Holder Compute Tomography Fluoroscopy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Avilés LP, Castellano IA, Dance DR, Vañò E (2001) Analysis of surface dose variation in CT procedures. Br J Radiol 74:1128–1136Google Scholar
  2. Avilés LP, Dance DR, Castellano IA, Vañò E (2004) Monte Carlo simulations in CT for the study of the surface air kerma and energy imparted to phantoms of varying size and position. Phys Med Biol 49:1439–1454CrossRefGoogle Scholar
  3. Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ (2010) Fluoroscopically guided interventional procedures: a review of radiation effects on patients’ skin and hair. Radiology 254:327–341CrossRefGoogle Scholar
  4. Baran GW, Haaga JR, Shurin SB, Alfidi RJ (1984) CT-guided percutaneous biopsies in pediatric patients. Pediatr Radiol 14:161–164PubMedCrossRefGoogle Scholar
  5. Brennan SB, Byrne B, Shortt M, Gilligan P, Kenny P, Fenlon HM (2003) Evaluation of staff radiation doses from ‘Quick-Check’ CT for CT-guided interventional procedures. Ir J Med Sci 172(4):1–16Google Scholar
  6. Buls N, Pages J, de Mey J, Osteaux M (2003) Evaluation of patient and staff doses during various CT Fluoroscopy guided interventions. Health Phys 85(2):165–173PubMedCrossRefGoogle Scholar
  7. Buls N, de Mey J, Vandenbroucke F, Vanderdood K, Osteaux M (2004) Dose reduction in CT fluoroscopy. 16th European Congress of Radiology 5–9 March 2004, Vienna. Abstract proceedings Eur RadiolGoogle Scholar
  8. Bushberg JT, Seibert JA, Leidholdt EM, Boone JM (2002) The essential physics of medical imaging. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  9. Cahill AM, Baskin KM, Kaye RD, Fitz CR, Towbin RB (2004) CT-guided percutaneous lung biopsy in children. J Vasc Interv Radiol 15:955–960PubMedCrossRefGoogle Scholar
  10. Carlson SK, Bender CE, Classic KL, Zink FE, Quam JP, Ward EM, Oberg AL (2001) Benefits and safety of CT fluoroscopy in interventional radiologic procedures. Radiology 219:515–520PubMedGoogle Scholar
  11. Carlson SK, Felmlee JP, Bender CE, Ehman RL, Classic KL, Hoskin TL, Harmsen WS, Hu HH (2005) CT Fluoroscopy-guided biopsy of the lung or upper abdomen with a breath-hold monitoring and feedback system: a prospective randomized controlled clinical trial. Radiology 237:701–708PubMedCrossRefGoogle Scholar
  12. Council directive 97/43/Euratom on health protection of individuals against the dangers of ionising radiation in relation to medical exposure (1997) Official J Eur Community L180:22Google Scholar
  13. Daly B, Templeton Krebs TL, Carroll K, Wong-You-Cheong JJ (1998) Evaluation of biopsy needles and prototypic needle guide devices with CT fluoroscopic guidance in simulated organ tissue. Radiology 209:850–855PubMedGoogle Scholar
  14. Froelich JJ, Saar B, Hoppe M, Ishaque N, Walthers EM, Regn J, Klose KJ (1998) Real-time CT-fluoroscopy for guidance of percutaneous drainage procedures. J Vasc Interv Radiol 9(5):735–740PubMedCrossRefGoogle Scholar
  15. Geraghty PR, Kee ST, McFarlane G, Razavi MK, Sze DY, Dake MD (2003) CT-guided transthoracic needle aspiration biopsy of pulmonary nodules: needle size and pneumothorax rate. Radiology 229:475–481PubMedCrossRefGoogle Scholar
  16. Gianfelice D, Lepanto L, Perreault P, Chartrand-Lefebvre C, Milette PC (2000) Effect of the learning process on procedure times and radiation exposure for CT fluoroscopy-guided percutaneous biopsy procedures. J Vasc Interv Radiol 11:1217–1221PubMedCrossRefGoogle Scholar
  17. Haaga JR, Alfidi RJ (1976) Precise biopsy localisation by computed tomography. Radiology 118:603PubMedGoogle Scholar
  18. Hohl C, Suess C, Wildberger JE, Honnef D, Das M, Mühlenbruch G, Schaller A, Günther RW, Mahnken AH (2008) Dose reduction during CT fluoroscopy: phantom study of angular beam modulation. Radiology 246(2):519–525PubMedCrossRefGoogle Scholar
  19. International Commission on Radiation Protection (1982) General principles of monitoring for radiation protection of workers ICRP Publication, p. 35Google Scholar
  20. International Commission on Radiological Protection (2000) Managing patient dose in Computed Tomography ICRP Publication 87. Ann. ICRP 30(4):1–43Google Scholar
  21. International Commission on Radiological Protection (2001) Avoidance of Radiation Injuries from Medical Interventional Procedures ICRP Publication 85: Ann ICRP 30(2)Google Scholar
  22. International Commission on Radiological Protection (2007) Recommendations of the ICRP, Pergamon Press; ICRP Publication, Oxford, p. 103Google Scholar
  23. International Commission on Radiological Protection (2011) Statement on tissue reactions. ICRP ref 4825-3093-1464. Approved by the Commission on 21 April 2011Google Scholar
  24. Irie T, Kajitani M, Yoshioka H, Matsueda K, Inaba Y, Arai Y, Nakajima K, Nozawa K, Itai Y (2000) CT fluoroscopy for lung nodule biopsy: a new device for needle placement and phantom study. J Vasc Interv Radiol 11:359–364PubMedCrossRefGoogle Scholar
  25. Irie T, Kajitani M, Matsueda K, Arai Y, Inaba Y, Kujiraoka Y, Itai Y (2001a) Biopsy of lung nodules with use of I–I device under intermittent CT fluoroscopy guidance: preliminary clinical study. J Vasc Interv Radiol 12:215–219PubMedCrossRefGoogle Scholar
  26. Irie T, Kajitani M, Itai Y (2001b) CT fluoroscopy-guided intervention: Marked reduction of scattered radiation dose to the physician’s hand by use of a lead plate and an improved I–I device. J Vasc Interv Radiol 12:1417–1421PubMedCrossRefGoogle Scholar
  27. Katada K, Anno H, Koga S (1994) Initial trial with CT fluoroscopy. Radiology 190:662Google Scholar
  28. Katada K, Kato R, Anno H, Ogura Y, Koga S, Ida Y, Sato M, Nonomura K (1996) Guidance with real-time CT fluoroscopy: early clinical experience. Radiology 200:851–856PubMedGoogle Scholar
  29. Kataoka ML, Raptopoulos VD, Lin PJ, Siewert B, Goldberg SN, Kruskal J (2006) Multiple-image in-room CT imaging guidance for interventional procedures. Radiology 239:863–868PubMedCrossRefGoogle Scholar
  30. Kato R, Katada K, Anno H, Suzuki S, Ida Y, Koga S (1996) Radiation dosimetry at CT fluoroscopy: physician’s hand dose and development of needle holders. Radiology 201:576–578PubMedGoogle Scholar
  31. Keat N (2001) Real-time CT and CT fluoroscopy. Br J Radiol 74:1088–1090PubMedGoogle Scholar
  32. Klose KC (1993) CT-guided large-bore biopsy: extrapleural injection of saline for safe transpleural access to pulmonary lesions. Cardiovasc Intervent Radiol 16:259–261Google Scholar
  33. Koenig TR, Wolff D, Mettler FA, Wagner LK (2001) Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. AJR 177:3–11PubMedGoogle Scholar
  34. Laufer U, Kirchner J, Kickuth R, Adams S, Jendreck M, Liermann D (2001) A comparative study of CT fluoroscopy combined with fluoroscopy versus fluoroscopy alone for percutaneous transhepatic biliary drainage. Cardiovasc Intervent Radiol 24:240–244PubMedCrossRefGoogle Scholar
  35. Laurent F, Michel P, Latrabe V, Tunon de Lara M, Marthan R (1999) Pneumothoraces and chest tube placement after CT-guided transthoracic lung biopsy using a coaxial technique: incidence and risk factors. Am J Roentgenol 172:1049–1053Google Scholar
  36. Lee JM (2000) CT-guided celiac plexus block for intractable abdominal pain. J Korean Med Sci 15:173–178PubMedGoogle Scholar
  37. Li X, Fan W, Zhang L, Zhao M, Huang Z, Li W, Gu Y, Gao F, Huang J, Li C, Zhang F, Wu P (2011) CT-guided percutaneous microwave ablation of adrenal malignant carcinoma: Preliminary Results. Cancer. doi:  10.1002/cncr.26128. [Epub ahead of print]
  38. Mcparland BJ (1998) Entrance skin dose estimates derived from dose-area product measurements in interventional radiological procedures. Br J Radiol 71:1288–1295PubMedGoogle Scholar
  39. Meleka S, Patra A, Minkoff E, Murphy K (2005) Value of CT fluoroscopy for lumbar facet blocks. Am J Neuroradiol 26:1001–1003PubMedGoogle Scholar
  40. Meyer CA, White CS, Wu J, Futterer SF, Templeton PA (1998) Real-time CT fluoroscopy: usefulness in thoracic drainage. Am J Roentgenol 171:1097–1101Google Scholar
  41. Miller DL, Balter S, Cole PE, Lu HT et al (2003) Radiation doses in interventional radiology procedures: the RAD-IR study. J Vasc Interv Radiol 14:977–990PubMedCrossRefGoogle Scholar
  42. Moran CJ, Naidich TP, Gado MH, Marchosky JA (1979) Central nervous system lesions biopsied or treated by CT-guided needle placement. Radiology 131:681–686PubMedGoogle Scholar
  43. Nawfel RD, Philip F, Judy PF, Silverman SG, Hooton S, Tuncali K, Adams DF (2000) Patient and personnel exposure during CT fluoroscopy-guided interventional procedures. Radiology 216:180–184PubMedGoogle Scholar
  44. Neeman Z, Dromi SA, Sarin S, Wood BJ (2006) CT fluoroscopy shielding: decreases in scattered radiation for the patient and operator. J Vasc Interv Radiol 17(12):1999–2004Google Scholar
  45. Nickoloff EL, Khandji A, Dutta A (2000) Radiation doses during CT fluoroscopy. Health Phys 79(6):675–681PubMedCrossRefGoogle Scholar
  46. Paulson EK, Sheafor DH, Enterline DS, McAdams HP, Yoshizumi T (2001) CT fluoroscopy-guided interventional procedures: techniques and radiation dose to radiologists. Radiology 220:161–167PubMedGoogle Scholar
  47. Rosenthal DI, Hornicek FJ, Torriani M, Gebhardt MC, Mankin HJ (2003) Osteoid osteoma: percutaneous treatment with radiofrequency energy. Radiology 229:171–175PubMedCrossRefGoogle Scholar
  48. Silverman SG, Tuncali K, Adams DF, Nawfel RD, Zou KH, Judy PF (1999) CT fluoroscopy-guided abdominal interventions: techniques, results and radiation exposure. Radiology 212:673–681PubMedGoogle Scholar
  49. Solomon SB, Patriciu A, Bohlman ME, Kavoussi LR, Stoianovici D (2002) Robotically driven interventions: a method of using CT fluoroscopy without radiation exposure to the physician. Radiology 225:277–282PubMedCrossRefGoogle Scholar
  50. Stecker MS, Balter S, Towbin RB, Miller DL, Vañó E, Bartal G, Angle JF et al (2009) Guidelines for patient radiation dose management. J Vasc Interv Radiol 20:S263–S273PubMedCrossRefGoogle Scholar
  51. Stoeckelhuber BM, Leibecke T, Schulz E, Melchert UH, Bergmann-Koester CU, Helmberger T, Gelissen J (2005) Radiation dose to the radiologist’s hand during continuous CT Fluoroscopy-guided interventions. Cardiovasc Intervent Radiol 28:589–594PubMedCrossRefGoogle Scholar
  52. Teeuwisse WM, Geleijns J, Broerse JJ, Obermann WR, Van Persijn Van Meerten EL (2001) Patient and staff dose during CT guided biopsy, drainage and coagulation. Br J Radiol 74:720–726PubMedGoogle Scholar
  53. Trout ED, Kelley JP (1972) Scattered radiation from a tissue equivalent phantom for X-rays from 50 to 300 kVp. Radiology 104:161–169PubMedGoogle Scholar
  54. Trumm CG, Jakobs TF, Zech CJ, Helmberger TK, Reiser MF, Hoffmann RT (2008) CT fluoroscopy-guided percutaneous vertebroplasty for the treatment of osteolytic breast cancer metastases: results in 62 sessions with 86 vertebrae treated. J Vasc Interv Radiol 19(11):1596–1606PubMedCrossRefGoogle Scholar
  55. United Nations Scientific Committee on the Effects of Atomic Radiation (2000) Sources and effects of ionizing radiation. New York: United Nations: vol 1 SourcesGoogle Scholar
  56. United States Food and Drug Administration (1994) Public health advisory. Avoidance of serious X-ray-induced skin injuries to patients during fluoroscopically-guided procedures. Rockville, MD, Center for devices and radiological health, United States Food and Drug Administration, September 30Google Scholar
  57. Wagner LK (2000) CT fluoroscopy: another advancement with additional challenges in radiation management. Radiology 216:9–10PubMedGoogle Scholar
  58. Wagner LK (2007) Radiation injury is a potentially serious complication to fluoroscopically-guided complex interventions. Biomed Imaging Interv J32:e22Google Scholar
  59. Yamagami T, Iida S, Kato T, Tanaka O, Nishimura T (2003) Combining fine-needle aspiration and core biopsy under CT fluoroscopy guidance: a better way to treat patients with lung nodules? Am J Roentgenol 180:811–815Google Scholar
  60. Zech CJ, Helmberger T, Wichmann MW, Holzknecht N, Diebold J, Reiser MF (2002) Large core biopsy of the pancreas under CT fluoroscopy control: results and complications. J Comput Assist Tomogr 26:743–749PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2011

Authors and Affiliations

  1. 1.UZ BrusselBrusselBelgium

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