Feasibility of setting up generic alert levels for maximum skin dose in fluoroscopically guided procedures

Purpose: The feasibility of setting-up generic, hospital-independent dose alert levels to initiate vigilance on possible skin injuries in interventional procedures was studied for three high-dose procedures (chemoembolization (TACE) of the liver, neuro-embolization (NE) and percutaneous coronary intervention (PCI)) in 9 European countries. Methods: Gafchromic (R) films and thermoluminescent dosimeters (TLD) were used to determine the Maximum Skin Dose (MSD). Correlation of the online dose indicators (fluoroscopy time, kerma- or dose-area product (KAP or DAP) and cumulative air kerma at interventional reference point (K-a,K-r)) with MSD was evaluated and used to establish the alert levels corresponding to a MSD of 2 Gy and 5 Gy. The uncertainties of alert levels in terms of DAP and K-a,K-r, and uncertainty of MSD were calculated. Results: About 20-30% of all MSD values exceeded 2 Gy while only 2-6% exceeded 5 Gy. The correlations suggest that both DAP and K-a,K-r can be used as a dose indicator for alert levels (Pearson correlation coefficient p mostly > 0.8), while fluoroscopy time is not suitable (p mostly < 0.6). Generic alert levels based on DAP (Gy cm(2)) were suggested for MSD of both 2 Gy and 5 Gy (for 5 Gy: TACE 750, PCI 250 and NE 400). The suggested levels are close to the lowest values published in several other studies. The uncertainty of the MSD was estimated to be around 10-15% and of hospital-specific skin dose alert levels about 20-30% (with coverage factor k = 1). Conclusions: The generic alert levels are feasible for some cases but should be used with caution, only as the first approximation, while hospital-specific alert levels are preferred as the final approach