With an increasing focus on the harmful impact of radiation exposure, as well as the risk of orthopaedic injury related to prolonged usage of lead amongst cath lab staff, new study results have brought into focus the stark need for alternative protective technologies to shield cath lab teams, interventional cardiologists say.
Presented at the 2025 Society for Cardiovascular Angiography and Interventions (SCAI) annual meeting (1–3 May, Washington, DC, USA), results of the ERGO-CATH study—a single-centre analysis of ergonomic strain on interventional cardiology teams—have shown that the use of the traditional lead apron may cause as many as 43% of operatives to experience discomfort.
The ERGO-CATH study, conducted by researchers at Brigham and Women’s Hospital (Boston, USA), saw electromyography electrodes and inertial monitoring units (IMUs) placed on the cervical, thoracic, torso-pelvic, and lumbar regions of the spine on participating cath lab team members.
The primary endpoint was the percentage of time spent in high-risk positions (+/-20°) such as cervical axial rotation (moving the head and neck to the right or left), cervical flexion (the bending of the head towards the chest), and thoracic flexion (bending forward and rounding of the upper back).
Radiation was measured by using a real-time dose monitoring system and divided by the use of a lead-less apron (Rampart device) versus a traditional lead apron approach.
There were 20 operators (38% female, mean age of 40.7 years) including attendings, fellows, and physician assistants/associates (PAs). The comprehensive cohort time spent in a high-risk position was: 35.8% (cervical axial rotation), 15.6% (cervical flexion), and 5.7% (thoracic flexion).
When comparing traditional lead and the lead-less approaches, researchers noted a similar percentage of time spent in high-risk positions: cervical axial rotation (lead: 35.9% versus lead-less 35.6%), and thoracic flexion (lead: 6.4% versus lead-less: 4.4%). Overall, 32% of study participants experienced discomfort (34% in the lead arm and 27% in the Rampart arm), while the average measured radiation for the traditional lead was 55.8 mrem versus 0.5 mrem for the lead-less approach.
“Working in the setting of high radiation exposure, interventional cardiologists and cath lab staff need radiation-related protection traditionally in part through the use of lead vests and skirts. These traditional lead vests/skirts provide reasonable protection from radiation but dramatically increase the axial load on these clinicians. ERGO-CATH shows several important insights (i) it quantifies that interventional cardiologists are in high-risk cervical position for one-third of total case duration and (ii) the reduction in radiation is dramatic with the Rampart device as compared with the traditional approach,” said Ajar Kochar (Brigham and Women’s Hospital, Boston, USA), lead author of the research.
An additional sub-analysis of the study sought to examine cath lab operator ergonomic strain by stratifying for sex-based differences and laboratory roles, with the findings suggesting cath lab operators in fellow and PA positions are exposed to high-risk ergonomics more often and at longer durations than those in attending positions, leading to a strong likelihood of occupationally caused pain.
Female operators were more likely to be fellows or PAs (47%). When separated by sex, average times in high-risk positions were determined as cervical flexion: 17.6% (female) versus 14.1% (male), cervical axial rotation: 33.4% (female) versus 37.6% (male), and thoracic flexion: 6.5% (female) versus 5.1% (male). When graded by operator role, mean times in high-risk positions were cervical flexion: attending (11.9%) versus non-attending (16.6%), cervical axial rotation: attending (32.2%) versus non-attending (36.7%), and thoracic flexion: attending 4.4% versus non-attending 6.1%.
“Our study underscores the urgent need to adopt novel solutions to radiation protection; many of these novel innovations allow cath lab operators to work without any lead or with ultra-light lead which will help reduce the axial load and presumptively decrease musculoskeletal discomfort,” said Greta Campbell, a clinical research coordinator at Brigham and Women’s Hospital. Future clinical studies will be necessary to determine if differences exist between the ergonomic injuries of male and female operators.
As a society, SCAI has been working to raise awareness of the dangers associated with radiation exposure and prolonged lead use through recent activities. Survey results published recently by the organisation suggest that as many as 60% of respondents had reported facing orthopaedic injuries, with 6% having reported a cancer diagnosis. Other types of radiation injury, such as cataracts, were shown to be threefold higher than what is observed in the general population, highlighting the stark need for technologies to protect cath lab teams, the organisation has said.
Technological developments are seeking to meet the needs of cath lab teams to reduce their radiation exposure, but as one operator and researcher told Cardiovascular News, even simple solutions can be difficult to gain traction.
At the recent Cardiovascular Research Technologies (CRT) meeting (8–11 March, Washington, DC, USA), Giorgio Medranda (NYU Langone Health, New York, USA) presented results of the ATTENUATE trial, a large single-centre randomised trial of a protective scatter radiation absorbing shield—Radpad Orange (Worldwide Innovations & Technologies).
The trial demonstrated that the use of the antimony and bismuth drape peripheral shield significantly reduced proximal operator radiation exposure by 50.7% when compared to procedures that did not use the shield system.
Looking at 500 procedures in each arm, including a mixture of structural, coronary and diagnostic procedures, investigators assessed dose-area product (DAP)-normalised operator dose as the trial’s primary endpoint, as well as looking at operate dose, fluoroscopy time and DAP as secondary endpoints.
The study showed that the primary endpoint, DAP-normalised operator dose stood at 3.1uSv/mGycm2 for procedures that used Radpad, compared to 6.3uSv/mGycm2 among procedures that did not use Radpad. Operator exposure stood at 9uSv for procedures using Radpad, and 14uSV without.
Speaking to Cardiovascular News, Medranda said that the study’s results highlight that relatively simple and inexpensive solutions can make a difference to radiation exposure amongst cath lab operators.
“It is strange, and I can’t put myself in everyone’s perspective—but it seems like a no-brainer,” he responded, when asked why he felt there was not a greater uptake of technological solutions like Radpad to address harmful radiation in the cath lab.
“People have done things the way they have done things for 30 years and it is hard to argue with success. Radiation is tricky for some people because you don’t see it or feel it up front. It is like high blood pressure or diabetes. For many years you may be doing tonnes of damage and feel fine, so why are you going to take an antihypertensive or insulin? It is not until the back end of the whole thing that you realise that maybe there is room for improvement.”
Additional research presented at the CRT meeting compared the EggNest (Egg Medical) and Rampart Defender scatter radiation protection systems in reducing radiation exposure around the X-ray table. Both systems are designed to eliminate the need for teams to wear lead.
The study, presented by Thom Dahle (CentraCare Heart & Vascular Center, St Cloud, USA) looked at radiation exposure at five positions around the X-ray table, including the primary operator, assistant, nurse, anaesthesiologist and electrophysiologist or echocardiographer positions. The study showed that scatter radiation was not evenly distributed around the X-ray table, with dose rates at the head of the table greater than at other positions.
