The Addition of a Leaded Arm Sleeve to Leaded Aprons Further Decreases Operator Upper Outer Quadrant Chest Wall Dose During Fluoroscopically Guided Interventions

Breast cancer most commonly occurs in the upper outer quadrant (UOQ) chest wall (CW). The effectiveness of routine leaded aprons to protect this region of the body in interventionalists during fluoroscopically guided interventions (FGIs) is unknown. Given the high lifetime attributable risks of prolonged occupational exposure to ionizing radiation, and the increasing number of practicing female vascular surgeons and interventionalists, we sought to determine if the use of a leaded arm shield would offer additional protection to the lateral CW and axilla in operators compared to routine leaded aprons. Effectiveness of leaded sleeves in attenuating radiation dose to the axilla and UOQ was evaluated in clinical practice and simulated scenarios. In the clinical setting, optically stimulated luminescence nanoDot detectors (microSTARii System, LANDAUER, Inc., Glenwood, Ill) were placed at the UOQ lateral CW position, both over and under a standard leaded apron vest with and without the addition of an antimony/bismuth Enviro-Lite sleeve (0.35 mm lead equivalency, Burlington Medical, Hampton Roads, VA) on two vascular surgeons performing FGIs. In the simulation, nanoDots were similarly placed on an anthropomorphic phantom (CT Whole Body Phantom PBU-60: Kyoto Kagaku, Kyoto, Japan) positioned to represent a primary operator performing right femoral access. Fluorography was performed on 12-inch thick acrylic scatter phantom at 80 kVp for an exposure of 3Gy reference air kerma. Experiments were done with and without the sleeve. Paired Wilcoxon and χ2 tests were performed to identify statistical significance of radiation attenuation. Operator UOQ CW dose was measured during 39 FGIs: 27 (69%) cases with and 12 cases (21%) without the sleeve. Median procedure reference air kerma and fluoroscopy time was 153 mGy (range, 80-421 minutes) and 21 minutes (range, 10-36 minutes) when the sleeve was worn vs 107 mGy (range, 67-270 mGy) and 10.7 minutes (range, 6.3-33.6 minutes) without the sleeve. Radiation dose to the operator's UOQ was reduced by 93% (P < .001) when the sleeve was present and by 70% (P < .001) without the sleeve. In the simulated setting, the sleeve reduced the radiation dose to the UOQ compared to the apron alone, 96% vs 75% (P < .001). Routine leaded aprons do attenuate the majority of UOQ chest wall dose, however the addition of a lead-equivalent sleeve further significantly reduces this dose. Since this area of the body has the highest incidence of cancer formation, additional protection, especially to female interventionalists seems prudent. Vascular surgeons should consider using a protective sleeve with their personal protective equipment when performing complex fluoroscopically guided procedures.