Diagnostic reference levels in interventional radiology: a systematic review

Borba, Iana Quintanilha de; Lykawka, Rochelle; Soares, Nayron Medeiros; Motta Leal Filho, Joaquim Maurício da; Bacelar, Alexandre; Ruffini, Matheus de Lima; Souza, Adolfo Moraes de; Reis, Fabiano; Duarte, Juliana Ávila

doi:10.1590/0100-3984.2025.0016

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Review Article • Radiol Bras 58 • 2025 • https://doi.org/10.1590/0100-3984.2025.0016 linkcopy

Diagnostic reference levels in interventional radiology: a systematic review

Níveis de referência diagnósticos em radiologia intervencionista: uma revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective: To comprehensively and impartially analyze the scientific evidence available for establishing diagnostic reference levels (DRLs) in interventional radiology.

Method: This was a systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search focused on studies related to interventional radiology and DRLs in PubMed/Medline and Embase. Studies involving computed tomography-guided procedures, studies with incomplete data, and systematic reviews were excluded. Two independent reviewers evaluated the studies, resolving discrepancies with a third reviewer. Articles were tabulated with information such as title, publication year, procedures, DRL values, and type of equipment used.

Results: A total of 475 articles were identified. After duplicates had been excluded and eligibility criteria had been applied, the final sample comprised 30 articles. Most DRL values (73%) were reported at the local level, as defined by International Commission on Radiological Protection criteria, representing typical dose values from a sample within one or a few institutions. A total of 113 procedures were identified, with endovascular aneurysm repair and nephrostomy being the most frequently reported. We identified DRLs at national and regional scales, predominantly within Europe. Influencing factors included technology, operator experience, specific protocols, and optimization strategies. The analysis also identified a lack of longitudinal studies assessing changes over time. The use of dose management software emerged as an effective tool for facilitating data collection and DRL establishment.

Conclusion: The lack of standardized procedural terminology hindered direct DRL comparisons. Our findings highlight a predominance of European studies and emphasize the need for broader international efforts to improve DRL implementation.

Keywords:
Diagnostic reference levels; Radiology, interventional; Radiation protection; Fluoroscopy

Country	Study	Procedure	Sample (n)	DRL value*
Country	Study	Procedure	Sample (n)	KAP (Gycm²)	CAK (Gy)	FT (min)
Malta	Pace et al.(¹⁴)	Central lines	269	1	–	–
		Embolization	297	58	–	–
		Hepatic embolization	215	96	–	–
		Mechanical thrombectomy	122	120	–	–
		Nephrostomy single	148	2	–	–
		PICC lines	135	0.3	–	–
		PTA	762	5	–	–
		PTC	238	8	–	–
Spain	Rial et al.(¹⁸)	EVAR - mobile X-ray systems	165	87	0.292	–
Spain	Rial et al.(¹⁸)	EVAR - hybrid rooms	123	278	1.403	–
France	Farah et al.(¹⁶)	Abdominal aortic aneurysm endoprosthesis	–	81	–	18
		Iliac angioplasty	–	24	–	6
		Flutter ablation	–	14	–	17
Lebanon	Rizk et al.(¹⁷)	Cerebral embolization	117	190	2.42	27
		Cerebral arteriography	210	83	0.69	6
		Lower extremity arteriography	343	31	0.17	3
		Lower extremity arteriography with coronary angiography	86	43	0.41	5
		Lower extremity angioplasty	177	48	0.27	12
		Inferior vena cava filter	26	57	0.31	7
Germany	Schmitz et al.(¹⁹)	Initial percutaneous biliary interventions	240	43	–	–
Germany	Schmitz et al.(¹⁹)	Follow-up percutaneous biliary interventions	320	14	–	–

Region	Study	Procedure	Sample (n)	DRL value *
Region	Study	Procedure	Sample (n)	KAP (Gycm²)	CAK (Gy)	FT (min)
Europe	Schegerer et al.(²⁰)	Iliac artery stenting	–	58	0.251	10
		Hepatic embolization (transarterial chemoembolization)	–	241	1.868	18
		Femoropopliteal artery stenting	–	26	0.99	13
		Treatment of biliary obstruction	–	23	1.95	10
Europe	Tuthill et al.(¹⁵)	Abdominal EVAR	180	158.49	–	18.13

Country	Study	Procedure	Sample (n)	DRL value*
Country	Study	Procedure	Sample (n)	KAP (Gycm²)	CAK (Gy)	FT (min)
Korea	Ihn et al.(²¹)	Diagnostic cerebral angiography	429	101.6	0.711	13.3
		Aneurysm coiling	327	199.9	3.458	57.3
		Stroke thrombolysis	326	225.1	1.590	44.7
		Arteriovenous malformation embolization	78	412.3	4.447	99.3
Italy	Isoardi et al.(²²)	Cerebral angiography	981	159	1.401	10
Germany	Forbrig et al.(²³)	Endovascular carotid artery stenting	102	117	–	–
		Semi elective/elective carotid artery stenting	75	86.7	–	27.1
		Carotid artery stenting + mechanical thrombectomy	19	286.1	–	43.8
Greece	Vossou et al.(²⁴)	Hepatic chemoembolization	218	141	0.634	12.4
		Iliac stent placement		130	0.330	17.9
		Femoropopliteal revascularization		28	0.112	–
Germany	Opitz et al.(²⁵)	Endovascular treatment of UIAs	583	183	–	–
Germany	Opitz et al.(²⁵)	Endovascular treatment of ruptured intracranial aneurysms		246	–	–
Germany	Ozpeynirci et al.(²⁶)	Endovascular coil embolization in carotid-cavernous fistulas	30	376.2	–	241.8
Germany	Ozpeynirci et al.(²⁷)	Spinal angiography in spinal dural arteriovenous fistulas	62	329.41	–	–
Germany	Opitz et al.(²⁸)	Diagnostic angiography in carotid-cavernous fistula	26	215	–	–
Germany	Opitz et al.(²⁸)	Embolization in carotid-cavernous fistula	60	350	–	–
Germany	Opitz et al.(²⁹)	Endovascular therapy in cranial dural arteriovenous fistula	94	507.33	–	–
		Diagnostic angiography in cranial dural arteriovenous fistula		256.65	–	–
		Endovascular therapy in spinal dural arteriovenous fistula	37	482.72	–	–
		Diagnostic angiography in spinal dural arteriovenous fistula		396.39	–	–
Greece	Papanastasiou et al.(³⁰)	Cerebral angiography	142	70	0.494	9.2
		PTC		34	0.194	14.2
		Transarterial chemoembolization		189	1.186	27.5
		Percutaneous transhepatic biliary drainage		54	0.400	22.9
Germany	Forbrig et al.(³¹)	Endovascular treatment in patients with intracranial lateral dural arteriovenous fistulae	70	414	–	142
South Africa	Peter et al.(³²)	Intracranial aneurysm coil embolization	30	52.1	–	17.8
South Africa	Malan et al.(³³)	Leg – aorto-bifemoral angiogram	590	51	0.15	6
		Leg – lower limb angiogram (trauma)	70	42	0.16	8
		Diagnostic cerebral angiogram	61	55	0.289	14
		Leg – aorto-bifemoral intervention	287	73	0.249	18
		Nephrostomy (unilateral)	265	10	0.063	4
		Bronchial artery embolization	208	73	0.259	38
		PTC drainage	173	46	0.227	20
		Nephrostomy (bilateral)	147	9	0.057	4
		Nephrostomy and stent (unilateral)	122	39	0.196	12
		Selective abdominal vessels – interventional angiogram	77	170	0.877	29
		Selective upper extremity – interventional angiogram (trauma)	73	30	0.094	13
		Selective neck vessel – interventional angiogram (trauma)	65	75	0.587	27
		Interventional cerebral angiogram	55	63	0.505	25
		PTC stent ± dilatation	54	80	0.443	19
		Nephrostomy and stent (bilateral)	45	54	0.342	24
Greece	Tzanis et al.(³⁴)	EVAR ≥ 5	24	196.2	1.239	23.8
		EVAR 5–7	35	244.6	1.358	31.1
		EVAR > 7	14	375.6	2.284	44.1
		EVAR	76	230.6	–	–
Germany	Forbrig et al.(³⁵)	Endovascular treatment of UIAs – coiling	26	130	–	–
		UIAs – flow diverter and Woven EndoBridge	45	176	–	–
		UIAs – combined techniques	16	209	–	–
Ireland	Acton et al.(³⁶)	Four-vessel angiogram	189	96	–	–
Ireland	Acton et al.(³⁶)	Aneurysm coiling	109	123	–	–
Greece	Metaxas et al.(³⁷)	Cervical interventions	45	0.10	0.0047	0.15
Greece	Metaxas et al.(³⁷)	Thoracolumbar interventions	111	0.71	0.0032	0.29
South Africa	Slave et al.(³⁸)	Percutaneous transhepatic biliary drainage	146	24	131.8	6.2
		Bronchial artery embolization	57	131	343	33.5
		Pigtail insertion	44	7.5	37	2.4
		Nephrostomy (unilateral)	42	10	26	3.4
		Nephrostomy (bilateral)	37	10	62	6.3
		Selective abdominal vessels-interventional angiogram	26	776	2227.8	28.3
		Diagnostic cerebral angiogram	26	209.3	868.5	28.4
		PICC	25	2	5	4
		Percutaneous transhepatic biliary drainage internalization	20	57	259	16.7
		Uterine artery embolization	18	1463.8	4019	24.8
		Unilateral antegrade ureteric stent	16	23	118.5	15.2
		PTC	15	9	28.5	0.7
		Interventional cerebral angiogram	15	275	1744	34.1
Switzerland	Heilmaier et al.(³⁹)	Insertion of abscess drainage – simple	10	2	–	–
		Insertion of abscess drainage – standard	10	6	–	–
		Insertion of abscess drainage – difficult	6	13	–	–
Switzerland	Heilmaier et al.(³⁹)	Nephrostomy insertion – simple	12	5	–	–
		Nephrostomy insertion – standard	29	12	–	–
		Nephrostomy insertion – difficult	13	30	–	–
		Nephrostomy change/removal – simple	58	6	–	–
		Nephrostomy change/removal – standard	31	8	–	–
		Nephrostomy change/removal – difficult	8	25	–	–
		Percutaneous radiologic gastrostomy tube insertion – standard	6	9	–	–
		Percutaneous radiologic gastrostomy control – standard	7	8	–	–
		PTC drain insertion – simple	7	32	–	–
		PTC drain insertion – standard	41	40	–	–
		PTC drain insertion – difficult	20	85	–	–
		PTC drain change/removal – simple	21	12	–	–
		PTC drain change/removal – standard	29	20	–	–
		PTC drain change/removal – difficult	11	60	–	–
		Selective internal radiotherapy – standard	18	175	–	–
		Transarterial chemoembolization – standard	11	210	–	–
		Transarterial chemoembolization – difficult	7	310	–	–
		Transjugular liver biopsy – simple	6	18	–	–
		Transjugular liver biopsy – standard	9	35	–	–
		Transjugular liver biopsy – difficult	6	50	–	–
		Intervention to superior vena cava – standard venous	14	10	–	–
		Intervention to inferior vena cava – simple	11	22	–	–
		Intervention to inferior vena cava – standard	6	35	–	–
		Fluoroscopy of port-a-cath – simple	9	2	–	–
		Fluoroscopy of port-a-cath – standard	7	5	–	–
		Insertion of PICC – simple	92	1	–	–
		Insertion of PICC – standard	56	2	–	–
		Insertion of PICC – difficult	11	22	–	–
		Embolization therapy of varicocele – simple	10	25	–	–
		Embolization therapy of varicocele – standard	7	40	–	–
		Embolization therapy of varicocele – difficult	6	55	–	–
		Phlebography, lower extremity – standard	6	2	–	–
		Insertion of dialysis graft – simple arterial-venous	7	6	–	–
		Insertion of dialysis graft – difficult	5	10	–	–
		Thrombolysis of dialysis graft – standard	15	3	–	–
		PTA of dialysis graft – standard	7	40	–	–
		EVAR – standard	17	185	–	–
		EVAR – difficult	16	350	–	–
		Visceral artery angiography – standard	12	140	–	–
		Visceral artery angiography – difficult	8	245	–	–
		Visceral artery embolization – standard	15	165	–	–
		Visceral artery embolization – difficult	20	430	–	–
		Renal PTA – difficult	6	220	–	–
		Renal artery embolization – standard	6	105	–	–
		Renal artery embolization – difficult	6	195	–	–
		Pelvic vessel embolization (venous/arterial) – standard	11	150	–	–
		Pelvic vessel embolization (venous/arterial) – difficult	12	205	–	–
		Pelvic PTA – simple	7	50	–	–
		Pelvic PTA – standard	26	60	–	–
		Pelvic PTA – difficult	13	95	–	–
		Pelvic PTA and stent placement – simple	11	20	–	–
		Pelvic PTA and stent placement – standard	22	85	–	–
Switzerland	Heilmaier et al.(³⁹)	Pelvic PTA and stent placement – difficult	28	145	–	–
		Pelvic and femoral PTA – standard	18	65	–	–
		Pelvic and femoral PTA – difficult	16	70	–	–
		Pelvic and femoral PTA and stent placement – standard	13	85	–	–
		Pelvic and femoral PTA and stent placement – difficult	10	100	–	–
		Pelvic, femoral and lower leg PTA – standard	8	25	–	–
		Pelvic, femoral and lower leg PTA – difficult	9	75	–	–
		Diagnostic angiography lower extremity – simple	15	3	–	–
		Diagnostic angiography upper extremity – standard	10	5	–	–
		Insertion of thrombolysis catheter – simple	7	20	–	–
		Insertion of thrombolysis catheter – standard	11	25	–	–
		Insertion of thrombolysis catheter – difficult	8	50	–	–
		Control of thrombolysis catheter – simple	14	4	–	–
		Control of thrombolysis catheter – standard	8	6	–	–
		Femoral PTA – simple	14	8	–	–
		Femoral PTA – standard	59	20	–	–
		Femoral PTA – difficult	14	55	–	–
		Femoral PTA and stent placement – simple	9	6	–	–
		Femoral PTA and stent placement – standard	35	15	–	–
		Femoral PTA and stent placement – difficult	27	45	–	–
		Femoral and lower leg PTA – simple	8	5	–	–
		Femoral and lower leg PTA – standard	49	10	–	–
		Femoral and lower leg PTA – difficult	18	30	–	–
		Femoral and lower leg PTA and stent placement – simple	8	4	–	–
		Femoral and lower leg PTA and stent placement – standard	17	8	–	–
		Femoral and lower leg PTA and stent placement – difficult	20	20	–	–
		Lower leg PTA – simple	10	3	–	–
		Lower leg PTA – standard	42	6	–	–
		Lower leg PTA – difficult	22	25	–	–
		Lower leg PTA and stent placement – standard	15	8	–	–
		Lower leg PTA and stent placement – difficult	15	30	–	–

Country	Study	Procedure	Sample (n)	DRL value*
Country	Study	Procedure	Sample (n)	KAP (Gycm²)	CAK (Gy)	FT (min)
Spain	Morcillo et al.(¹⁰)	Hepatic/biliary interventions (5–15 kg)	39	13.04	–	19.38
		Hepatic/biliary interventions (15–30 kg)	15	21.21	–	22.65
		Sclerotherapy (15–30 kg)	18	7.04	–	5.9
		Sclerotherapy (30–50 kg)	21	40.49	–	7.45
		Sclerotherapy (50–80 kg)	16	37.34	–	23.3
		Central venous catheters (5–15 kg)	21	0.84	–	3.4
Italy	Gerasia et al.(¹¹)	Retrograde wedge portography – children	25	5.6	0.034	–
		Retrograde wedge portography – middle childhood	20	6.4	0.018	–
		Retrograde wedge portography – early adolescence	21	12.8	0.059	–
Germany	Opitz et al.(¹²)	IAC procedures of pediatric patients with RB – A2: 4–12 months	85	3.9	–	–
		IAC procedures of pediatric patients with RB – A3: 13–72 months	157	7.0	–	–
		IAC procedures of pediatric patients with RB – A4: 73 months-10 years	4	14.5	–	–
France	Farah et al.(¹³)	PTC 0–5 kg	7	0.06	0.001	–
		PTC 5–15 kg	56	0.22	0.006	–
		PTC 15–30 kg	43	0.68	0.035	–
		PTC 30–50 kg	42	1.07	0.027	–

DRL type	Study	Procedure	Sample (n)	DRL value*
DRL type	Study	Procedure	Sample (n)	KAP (Gycm²)	CAK (Gy)	FT (min)
Local (Facility in Greece)	Tzanis et al.(³⁴)	EVAR ≥ 5	24	196.2	1.239	23.8
		EVAR 5–7	35	244.6	1.358	31.1
		EVAR > 7	14	375.6	2.284	44.1
		EVAR	76	230.6	–	–
National (Spain)	Rial et al.(¹⁸)	EVAR – mobile X-ray systems	165	87.0	0.292	–
National (Spain)	Rial et al.(¹⁸)	EVAR – hybrid rooms	123	278.0	1.403	–
Regional (Europe)	Tuthill et al.(¹⁵)	Abdominal EVAR	180	158.49	–	18.13

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[TN1] ^*
Reported as the third quartile. PICC, peripherally inserted central catheter; PTA, percutaneous transluminal angioplasty; PTC, percutaneous transhepatic cholangiography.