SCAI leaders 'on a mission' to improve cath lab protection from radiation, orthopedic injury

Hermiller spoke to Cardiovascular Business about these safety issues, provided some possible solutions and discussed SCAI's plans to take action. He emphasized that clinician safety is a key priority for SCAI.

"Not many understand how risky it can be and what happens after 30 years of being in the cath lab with this heavy lead," he explained. "There are now technologies that we can use to get out of the lead and reduce our radiation dose by 20 fold or 100 fold. And we are on a mission to make sure everybody that wants it can have these new systems and really move from adequate protection to optimal protection for everyone so we can be healthy enough to take care of our patients."

Orthopedic issues impact the majority of interventional cardiologists

The protective aprons meant to shield staff from X-rays from the angiography imaging system often weight 10 pounds and can take a told on the body after years of wearing it for long hours. The survey found more than 60% of respondents reporting orthopedic injuries or chronic back pain, primarily related to the spine. There was a three-fold higher risk of having significant lumbar issues, and a 10 times higher incidence of cervical spine injuries compared to the general public. Chronic pain related to these injuries remains a leading cause of career limitations and early retirement among interventional cardiologists.

These issues have been a motivator for efforts to use less X-ray fluoro and increase the usage of ultrasound, transesophegeal echo (TEE) and intra-cardiac echo (ICE). This would help operators and staff "shed the lead" and save their backs.

Radiation exposure concerns in the cath lab

Despite the availability of protective equipment, Hermiller said usage remains inconsistent. Many survey respondents cited high costs and administrative barriers as obstacles to adopting newer radiation protection technologies. Additionally, 17% of respondents admitted to limiting their time in the cath lab to reduce their radiation exposure, a significant increase from previous surveys.

Radiation is also seen as a big limiting factor for the number of women entering interventional cardiology. About 28% of female survey respondents reported being discouraged from working in the cath lab due to pregnancy, while 71% expressed a desire to step away during pregnancy, highlighting the need for more flexible policies and better workplace accommodations.

"Right now only 8% of interventional cardiology fellowships are women, so we're just missing out on all these talented people. And one of the barriers is the perceived risk of the radiation," Hermiller said.  

The call for improved radiation safety measures comes at a time when cath lab procedures are becoming increasingly complex with longer procedure times. Complex and high-risk interventional procedures (CHIP), chronic total occlusion (CTO) interventions, structural heart procedures like mitral and tricuspid valve repairs and replacements, and peripheral artery disease (PAD) treatments require longer procedural times and higher radiation doses, Hermiller explained.

Improved radiation protection systems

Robotic PCI and electrophysiology systems were proposed as a lead-free solution for operators, but these technologies have not had a lot of penetration into the market due to the costs. There was also a lot of interest early on in the Zero-Gravity solution, which used a thick, very heavy protective suit suspended from a boom in the lab, but it was cumbersome to work in and it did nothing to help protect other staff in the room. Newer solutions now seen at interventional conferences are more passive shielding systems. These attach around the patient table, offer movable shield walls that separate the X-ray head and detector from the operator and staff on the other side, and automated shielding plates that attach to the angiography system C-arm and slide down to contact the patient each time the X-ray is turned on. Vendors focused on this space include Protego, Rampart, Egg Medical and Radiaction.

Hermiller said this technology is evolving quickly, with other new technologies on the horizon. These include technology built into angiography systems to fuse live TEE on existing X-ray images, or artificial intelligence-powered eye-tracking technology to narrow the amount of X-ray needed.

Cost concerns and a lack of administrative support seem to be keeping many cath lab employees from receiving the protectiong they need. This highlights the need for systemic change, Hermiller said. 

He added that SCAI is pushing for expanded formal radiation safety education to help mitigate cath lab hazards. 

Advocacy for institutional support and policy changes for better shielding

A key focus of SCAI’s advocacy is demonstrating to hospital administrators that investing in radiation protection systems yields financial and operational benefits or better protecting employees.

“If an interventionalist is injured and out for a month, the financial loss is significant,” Hermiller pointed out. “That lost revenue alone could cover the cost of multiple protection units. Additionally, staff turnover is expensive, and safer environments can aid in recruitment and retention.”

SCAI is working toward a formal consensus statement, expected in early 2025, in collaboration with multiple medical societies, including those in peripheral vascular and interventional radiology. The society also plans to host a safety summit, bringing together key stakeholders, including government agencies like OSHA and regulatory bodies focused on radiation safety.