AAPM REPORT NO. 125

Functionality and Operation of Fluoroscopic
Automatic Brightness Control/Automatic Dose Rate
Control Logic in Modern Cardiovascularand Interventional Angiography Systems

A Report of AAPM Task Group 125
Radiography/Fluoroscopy Subcommittee,
Imaging Physics Committee, Science Council
June 2012DISCLAIMER: This publication is based on sources
and information believed to be reliable, but the
AAPM, the authors, and the editors disclaim any warranty or liability based on or relating to the contents ofthis publication.
The AAPM does not endorse any products, manufacturers, or suppliers. Nothing in this publication should
be interpreted as implying such endorsement.

© 2012 by American Association of Physicists in Medicine

DISCLAIMER: This publication is based on sources and information believed to be reliable,
but the AAPM, the authors, and the publisher disclaim any warranty or liability
based on or relating to the contents of this publication.
The AAPM does not endorse any products, manufacturers, or suppliers. Nothing in thispublication should be interpreted as implying such endorsement.

ISBN: 978-1-936366-16-3
ISSN: 0271-7344© 2012 by American Association of Physicists in Medicine

All rights reserved.

Published byAmerican Association of Physicists in Medicine
One Physics Ellipse
College Park, MD 20740-3846

Task Group 125

Co-Chairmen
Pei-Jan Paul Lin
Beth Israel Deaconess Medical Center, Boston MA 02115
Phillip RauchHenry Ford Health System, Detroit, MI 48202

Task Group Members
Stephen Balter
Columbia University Medical Center, New York, NY 10032
Atsushi Fukuda
Shiga Medical Center for Children, Moriyama City, Shiga-Ken, Japan 524-0022
Allen Goode
University of Virginia Health Science Center, Charlottesville, VA 22908
Gary Hartwell
University of Virginia Health Science Center, Charlottesville, VA 22908
Terry LaFrance
Baystate Health Systems, Inc., Springfield, MA 01199
Edward Nickoloff
Columbia University Medical Center, New York, NY 10032
Jeff Shepard
University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
Keith Strauss
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229

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Contents

Abstract ............................................................................................................................ vii

1.

Introduction........................................................................................................... 1

II.

Task Group Charge ............................................................................................ 3

III. Radiation Exposure ............................................................................................ 4
III.A.
III.B.
III.C.

III.D.

Entrance Exposure Rate to the Detector ...............................................
Nominal Patient Skin Entrance Exposure Rate .....................................
Maximum Patient Skin Entrance Exposure Rate...................................
III.C.1.
Regulatory Limits.........................................................................
III.C.2.
Measurement Point .....................................................................
III.C.3.
SID Output Compensation..........................................................
III.C.4.
Critical Lead Thickness and Automatic Shutoff
of Fluoroscopy ..............................................................................
Scattered Radiation ....................................................................................

4
5
7
7
7
8
8
9

IV. Spectral Filtration............................................................................................... 9
IV.A.
IV.B.

IV.C.

V.

Traditional Method of Filter Selection .................................................... 10
Program-Switched Method of Filter Selection....................................... 11
IV.B.1.
Anatomical Program–Based Filter Selection .............................. 11
IV.B.2.
Seissl Method of Filter Selection................................................. 11
Display of Filtration Utilized ..................................................................... 11

The Automatic Brightness/Automatic Dose Rate Control .............. 13
V.A.
V.B.

Types of Automatic Control...................................................................... 13
Automatic Gain Control............................................................................ 13
V.B.1.
Optical Sampling AGC................................................................. 13
V.B.2.
Video Sampling AGC .................................................................... 14

VI. Block Diagram of ABC/ADRIQ Circuit ..................................................... 14VII. Task Group Field Evaluation of ABC/ADRIQ ......................................... 19
VII.A. Angiography Systems Investigated........................................................... 19
VII.B. Experimental Arrangements .................................................................... 20v

AAPM REPORT NO. 125

VII.C. Evaluation of Results .................................................................................. 21
VII.C.1. Systems Using the Seissl Filter Method ...................................... 22
VII.C.2. Systems Using the Programmable Filter Method ....................... 25
VII.C.2(i).
Philips Allura Xper System ......................................... 25
VII.C.2(ii).
Shimadzu BRANSIST Cardiovascular .......................... 26
VII.C.2(iii).
Toshiba Infinix CF-i and Infinix VF-i .............................. 30
VII.C.2(iv).
Hitachi Medical Systems ............................................. 30

VIII. Problem with Lack of Appropriate Standard Beam Qualities ........ 30
VIII.A. Measured Fluoroscopic X-Ray Beam Quality ......................................... 30
VIII.B. The Beam Quality Available for Calibration .......................................... 31
VIII.C. The Mismatch of Beam Quality for Dosimetry ..................................... 31

IX. Limitations of the Report ................................................................................ 34
X.

Conclusion and Discussion .............................................................................. 34

XI. Acknowledgments and Disclaimer .............................................................. 35
Acronyms and Abbreviations in TG-125 Report .......................................................... 37
Appendix: TG-125 Data Collection Methodology......................................................... 39
References........................................................................................................................... 40vi

Abstract

Task Group 125 (TG-125) was charged with investigating the functionality of fluoroscopic
Automatic Dose Rate and Image Quality control logic in modern angiographic systems, paying
specific attention to the spectral shaping filters and variations in the selected radiologic imaging
parameters. The task group was also charged with describing the operational aspects of theimaging equipment for the purpose of assisting the clinical medical physicist with clinical setup
and performance evaluation. Although there are clear distinctions between the fluoroscopic
operation of an angiographic system and its acquisition modes (digital cine, digital angiography,
digital subtraction angiography, etc.), the scope of this work was limited to the fluoroscopic
operation of the systems studied.
The use of spectral shaping filters in cardiovascular and interventional angiography equipment has been shown to reduce patient dose. If the imaging control algorithm were programmed
to work in conjunction with the selected spectral filter, and if the generator parameters were
optimized for the selected filter, then image quality could also be improved. Although assessment of image quality was not included as part of this report, it was recognized that for fluoroscopic imaging the parameters that influence radiation output, differential absorption, andpatient dose are also the same parameters that influence image quality. Therefore this report will
utilize the terminology “Automatic Dose Rate and Image Quality” (ADRIQ) when describing
the control logic in modern interventional angiographic systems and, where relevant, will
describe the influence of controlled parameters on the subsequent image quality.
A total of 22 angiography units were investigated by the task group and, of these, one each
was chosen as representative of the equipment manufactured by GE Healthcare, Philips Medical
Systems, Shimadzu Medical USA, and Siemens Medical Systems. All equipment, for whichmeasurement data were included in this report, was manufactured within the 3-year period from2006 to 2008.
Using polymethylmethacrylate (PMMA) plastic to simulate patient attenuation, each angiographic imaging system was evaluated by recording the parameters Tube Potential in units ofkilovolts peak (kVp), Tube Current in units of milliamperes (mA), Pulse Width (PW) in units ofmilliseconds (ms), spectral filtration setting, and Patient Air Kerma Rate (PAKR) as a functionof the attenuator thickness. Data were graphically plotted to reveal the manner in which theADRIQ control logic responded to changes in object attenuation. There were similarities in themanner in which the ADRIQ control logic operated that allowed the four chosen devices to be
divided into two groups, with two of the systems in each group. There were also uniqueapproaches to the ADRIQ control logic that were associated with some of the systems, and theseare described in the report. The evaluation revealed relevant information about the testing procedure and also about the manner in which different manufacturers approach the utilization ofvii

AAPM REPORT NO. 125

spectral filtration, pulsed fluoroscopy, and maximum PAKR limitation. This information shouldbe particularly valuable to the clinical medical physicist charged with acceptance testing andperformance evaluation of modern angiographic systems.
Key words: operational logic, fluoroscopy, filtration, Automatic Dose Rate Control, Automatic
Brightness Control, patient exposure, acceptance testing, angiography.

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I. Introduction
The use of spectral shaping filters in the fluoroscopic imaging procedures of cardiovascularand interventional angiography equipment has been shown to reduce Patient Air Kerma (PAK)
while maintaining fluoroscopic image quality and extending the dynamic range in patient thickness.1–5 Traditional x-ray image intensifier (XRII) fluoroscopic imaging systems have served an
important role in medical imaging for many decades. With these imaging systems the operator
controlled the exposure production via a footswitch while observing the dynamic image display
through an optical lens or television display. Whenever the footswitch was activated, the x-ray
production was continuous. These systems had many limitations that rigidly linked the image
quality and the associated patient dose (Figure 1). The factors that played a role in limiting XRII
imaging performance included a single, pre-set image intensifier input exposure rate; a fixed
optical aperture; limited image processing; predefined image display parameters, fixed beam filtration, the use of anti-isowatt power curves, and limitations in the rate of heat input to the x-ray
tube. Examples of traditional generator control curves are shown in Figure 2. With the opticalaperture and filtration fixed, and with the x-ray production in continuous mode, the only generator parameters being controlled were the kVp and the mA. The x-ray generator control curve
could thus be simply described in a plot of the kVp versus the mA. As the patient size changed,
or the image was magnified via switching to a smaller field of view (FOV), the output brightness
would change and the x-ray generator would have to respond. The control curves were a meansof defining exactly how the generator would respond to adjust the kVp and mA as needed tomaintain the output signal. These curves were called “anti-isowatt” because the kVp and mA
increased or decreased simultaneously. For a given curve, when the kVp and mA reached the

Figure 1. Limiting factors that keep patient dose and image quality rigidly linked in a manner that causes image
quality to decrease as patient dose is reduced.

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AAPM REPORT NO. 125

Figure 2. Traditional fluoroscopy x-ray generator control curves. The x-ray generator will follow the selectedcurve in response to a demand for more or less brightness at the output phosphor of the image intensifier.

limit of x-ray tube loading, the curve automatically switched to isowatt control. Along theisowatt line, the kVp increases while the mA decreases such that the product of kVp and mA
remains constant.
For the sample curves of Figure 2, if the operator was interested in greater contrast in theimage, the “High Contrast” control curve would be selected and the generator would favor alower kVp. In comparison, selection of the “normal” contrast curve would result in a higher kVp
for the same patient and procedure but would also result in a loss of image contrast. With thistype of control, the most common means of reducing patient dose was to utilize a high kVp setting (Low Dose Curve in Figure 2), but this resulted in a lower differential absorption and anincreased scatter fraction, both of which negatively impacted the image quality.
As shown in Figure 3, moving objects imaged with continuous fluoroscopy were blurred
over the integration time of the image, which was 33.3 ms. Also note that the contrast was
degraded. Modern fluoroscopy systems employ pulsed fluoroscopy, which has the potential to
improve temporal resolution via the use of a short PW.6 However, with pulsed fluoroscopy, caution must be taken to ensure that the PW does not exceed a value that would introduce image
degradation effects.7,8 Modern systems also have the means of controlling the XRII optical aperture, the PW, the beam filtration, and even the input dose to the detector, in addition to controlling the kVp and mA generator parameters. The control of additional parameters beyond kVp
and mA make modern systems more complex. However, understanding how the modern
Automatic Brightness Control/Automatic Dose Rate and Image Quality Control Logic(ABC/ADRIQ) logic functions is integral to any attempt to optimize the balance between patient
dose and image quality.
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FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

Figure 3. Pulsed versus continuous fluoroscopy. With pulsed fluoroscopy (left) the x-rays are produced for only a
few milliseconds and temporal resolution was improved.With continuous fluoroscopy (right) each image frame was
integrated over 33.3 ms and motion blur degrades the image. Also note the loss of contrast associated with thesmall black circles.

II. Task Group Charge
TG-125 was established and charged with two specific purposes. The first was to explore
and investigate the functionality of fluoroscopic ABC/ADRIQ in modern cardiovascular andinterventional angiography systems (hereafter designated “angiography systems”); that is, toinvestigate the operation of newer systems currently on the market and from a variety of manufacturers, paying specific attention to the spectral shaping filters and variations in the selectedradiologic imaging parameters. The scope of this work was limited to the fluoroscopic operationof these systems.
The second purpose was to describe the operational aspects of the imaging equipment forthe purpose of assisting the clinical medical physicist with clinical setup and performance evaluation. This report will provide an understanding of how generator control logic, aggressive
spectral filtration, and imaging parameters are programmed to work together to maintain or to
improve image quality while reducing the patient skin dose.
It is the opinion of the task group that a thorough understanding of ABC/ADRIQ is essential to the proper assessment of a modern fluoroscopic imaging system performance. For example, with modern fluoroscopy equipment the measurement of the radiation beam quality underclinically relevant conditions may yield an unexpectedly high value for the half-value layer(HVL). The clinical physicist must understand that this result is due to combinations of relatively
thick spectral filtration and associated low kVp setting, and that this combination is an essential
part of the means by which patient skin dose can be reduced while maintaining or even improving image quality. The clinical physicist must also be cognizant of the fact that the combinationsof kVp and filter thickness are considerably different from those that are utilized by radiation
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AAPM REPORT NO. 125

dosimeter calibration laboratories, and that the calibration of ionization chambers and solidstate detectors becomes an issue. At the time of this writing, there was no calibration beam
available from any of the national calibration laboratories that matched the beam qualities of
those employed by the angiography equipment included in this study. The lack of properly calibrated radiation detectors for the accurate measurement of air kerma makes estimation of PAK
and PAKR more difficult.

III. Radiation Exposure
Since the parameters that are utilized by the ABC/ADRIQ control logic to maintain a constant average detector signal are also the same parameters that govern the x-ray tube output
intensity and photon energy spectrum, we need to consider the types of radiation exposure
involved in fluoroscopic imaging. There are four types of radiation exposure of interest when
considering fluoroscopy as a visualization device for diagnostic and therapeutic procedures: (1)the Entrance Exposure Rate to the Detector (EERD), (2) the nominal patient Skin Entrance
Exposure Rate (SEER), (3) the maximum patient SEER, and (4) the scattered radiation from thepatient and other materials in the path of the x-ray beam.
III.A. Entrance Exposure Rate to the Detector
For both XRII and flat-panel imaging detectors the photon energy distribution of the radiation incident on the detector, the spectral sensitivity of the detector, the energy conversion efficiency, and the spatial sampling array will determine the absorbed energy fluence per pictureelement (pixel) at the input to the detector’s radiation capture layer. These factors together will
determine the intensity of the output signal per pixel. Statistical fluctuations in the pixel-to-pixel
output signal will determine the image quantum mottle and, in conjunction with the Detective
Quantum Efficiency (DQE), the Signal to Noise Ratio (SNR) in the resultant image. If the
EERD is too low, the image will suffer from increased noise; if too high, the patient dose will be
unnecessarily high, although the image quality (SNR2) will be improved. There are no regulations governing the EERD and the measured values obtained from a survey conducted byAmerican Association of Physicists in Medicine (AAPM) Task Group 11 revealed a very wide
range of values, ranging from 0.18 microgray per second (µGy/s) [20 microroentgen per second(µR/s)] to 9.1 µGy/s (1043 µR/s) for fluoroscopy systems in clinical use.9 To provide a logicaland reasonable guide to the selection of an appropriate value for the EERD, Phillip Rauch has
proposed a simple rule of thumb, which he calls the “30-30-30 Rule.”10 This rule, and its name,has its basis in legacy XRII/Television fluoroscopy systems that operated in the continuous
mode.† Recalling that standard National Television System Committee (NTSC)11 video operates
at 30 video frames per second (fps), Rauch created the rule by applying the value of 30 to thediameter of the input to the XRII, in units of centimeters (cm), and to the XRII input exposure†

Since the 30-30-30 rule has its basis in the operation of legacy fluoroscopy equipment and since a critical component of the rule is the value of EERD equal to 30 µR/s, the conversion to SI units is not shown in this part of the
discussion.

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FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

rate (in units of µR/s). That is, for XRII-based continuous fluoroscopy at 30 video fps, with a30-cm diameter FOV, the starting point for setting the EERD should be a nominal 30 µR/s.
This is not a hard and fast rule, and the actual EERD can be allowed to vary from the 30 µR/s
nominal value, depending on the noise tolerance of the interventionalist and the nature of theexamination. For conventional XRII-based fluoroscopy systems without additional spectral beam
shaping, acceptable values for the starting point would be in the range from 20 µR/s
[175 nanograys per second (nGy/s)] to 90 µR/s (788 nGy/s) [i.e., 0.67 to 3 times the 30 µR/s
(263 nGy/s) guideline], with the higher values only applied when the imaging task demands lessnoise. During fluoroscopy, flat-panel detectors will demand from 2 to 4 times the EERD
required of a conventional image intensifier due to size of the pixels and the electronic noise
arising in the active matrix readout array. 12,13,14 Because of this limitation and associatedincreased dose, flat-panel detectors should not be utilized without incorporation of aggressive
spectral filtration. During single-frame or serial acquisition imaging, which utilizes a muchhigher detector input dose per frame, the flat-panel detector can operate at a slightly lower
EERD than that of an image intensifier.
III.B. Nominal Patient Skin Entrance Exposure Rate
Discussions of SEER would normally be accompanied by a discussion of the fluoroscopic
image quality.15,16 However, owing to the complexity of the imaging control logic (e.g., as manyas 60 parameters are controlled in order to ensure optimization of image quality17), a suitable
imaging phantom would need to be defined that would be capable of assessing image quality
with any commercially available imager and without bias. The phantom would have to be clinically relevant, yet it must not adversely affect the operation of the control logic. Although thetask group considered the possibility that the NEMA-SCAI phantom,18 could be suitable for thispurpose, it was clear that some effort would be needed to ensure that the phantom provides a fair
and accurate assessment. Ultimately, it was decided by TG-125 to recommend that assessmentof image quality be removed from the original charge and to focus only on the operation of the
ABC/ADRIQ control logic. On the other hand, it must be recognized that for fluoroscopic imaging the control parameters that influence radiation output, differential absorption, and patient
dose are also the same parameters that influence the subsequent image quality.19 Therefore thisreport will continue to utilize the terminology ADRIQ when describing the control logic in modern interventional angiographic systems and, where relevant, will describe the influence of controlled parameters on image quality.
The patient SEER depends on the generator operating curve, especially the way the kVpchanges with increased attenuation. It also depends on the spectral filtration, the source-to-skindistance, the patient table attenuation, the table pad attenuation,20 the grid bucky factor, thepatient size, and the path length of the x-ray beam through the patient. Motz and Danos,21 andlater Zamenhof,22 were able to demonstrate that the image information content per SEER, i.e.,
the ratio of the SNR2 divided by the SEER, could be optimized by finding an appropriate combination of filtration and kVp. Onnasch et al.23 further demonstrated that the contrast-to-noise
ratio was independent of the filter thickness. Thus, thicker spectral filters could be utilized toreduce SEER, while lower kVp could be utilized to improve image contrast. This approach,along with the appropriate selection of detector input exposure per image frame, will result in5

AAPM REPORT NO. 125

the desired improvement in image quality while at the same time reducing the patient skin dose.
This concept was the principle behind the design and operation of modern ABC/ADRIQ control
logic.
Contrary to popular belief, the SEER does not depend on the EERD, as demonstrated in
Figure 4. In this figure the experimentally derived values of kVp and mA that would deliver an
EERD of 788 nGy/s with 20 cm water as the attenuator are shown. Likewise, the values of kVp
and mA that produce a SEER of 22 milligrays per minute (mGy/min) and those that produce a
SEER of 44 mGy/min were also plotted. The circles identify the points where the SEER plots
cross the EERD plot. At these two points the dose delivered to the detector were identical, but
the SEER value differed by a factor of 2×.
This figure could also be used to illustrate one of the main principles that govern the utilization of beam spectral shaping in modern ABC/ADRIQ systems. In a simple field experiment
we could acquire and plot a similar set of data by manually manipulating the x-ray generator
parameters while adding filtration and monitoring the EERD and the SEER. Direct your attention to the lower circled crossing point in Figure 4. The SEER was a higher value than that corresponding to the other circled crossing points due mainly to the lower kVp. On the other hand,
the lower kV would result in an increased image contrast at this operating point. If we now add

Figure 4. Experimental determination of the kVp and mA required to keep the EERD at 788 nGy/s with 20 cm
water attenuator, and also the requirements to keep the SEER at 22 mGy/min and at 44 mGy/min.The circles indicate the values of kVp and mA that will provide exactly the same EERD but with patient doses differing by a factorof 2×. (Adapted from reference 49.)

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FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

filtration to the x-ray beam, without allowing the kVp and mA to change, then clearly the EERD
will drop below the desired setting due to both spectral and intensity changes to the radiation
reaching the detector. If we next keep the kVp constant but adjust the mA to deliver the sameabsorbed energy fluence per pixel at the detector input, the net result will be the same average
detector output signal, but with a lower SEER due to the spectral absorption effects of the filter.
If the measured new value of SEER was not as low as desired, we can add an additional increment of filtration and repeat the above procedure until we reach either the desired SEER or thegenerator power limit. In the latter case, where the combination of water thickness, filtration,kVp, and generator power limit does not permit achievement of the EERD, then we would need
to use a higher kVp for that combination of settings. By doing this procedure using a number ofdifferent water thicknesses, we can create a generator control curve that will, for any given waterequivalence, maintain the detector absorbed energy fluence per pixel using the values of spectral filtration and kVp determined during the experiment, and without exceeding the x-ray tube
power limit. The net result should be the same or reduced SEER while maintaining acceptable
image noise, and with equal or better image quality due to the lower kVp. This report will illustrate the manner in which various manufacturers have created combinations of spectral filtrationand generator control curves to optimize their imaging systems. For the clinical medical physicist, having the knowledge and understanding of all of the parameters that impact patient dose isimportant since these factors are multiplicative, not additive.24
III.C. Maximum Patient Skin Entrance Exposure Rate
III.C.1. Regulatory Limits
The U.S. Food and Drug Administration (FDA), in Title 21CFR(1020.32),25 has establishedregulatory limits on the maximum Air Kerma Rate (AKR) produced by fluoroscopy imaging
equipment. The nominal limits are 88 mGy/min (10 R/min) for normal ABC/ADRIQ operationand 176 mGy/min (20 R/min) if an optional “high-level” control mode is provided. The limits
must be measured under scatter-free conditions and are determined at a specifically definedmeasurement point which depends on the type of equipment. It should be noted that exceptions
to these limits are allowed, based on the equipment manufacture date, on whether images arerecorded, and on the source–to–image receptor distance (SID). The reader should consult theregulations to determine the limits associated with a specific piece of equipment.
III.C.2. Measurement Point †(i) If the source is below the x-ray table, the AKR shall be measured at 1 cm above thetabletop or cradle.
(ii) If the source is above the x-ray table, the AKR shall be measured at 30 cm above thetabletop with the end of the beam-limiting device or spacer positioned as closely as
possible to the point of measurement.

†

Adapted from reference 25.

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AAPM REPORT NO. 125(iii) In a C-arm type of fluoroscope, the AKR shall be measured at 30 cm from the input
surface of the fluoroscopic imaging assembly, with the source positioned at any available SID, provided that the end of the beam-limiting device or spacer is no closer than
30 cm from the input surface of the fluoroscopic imaging assembly.
(iv) In a C-arm type of fluoroscope having an SID less than 45 cm, the AKR shall be measured at the minimum SSD.
(v) In a lateral type of fluoroscope, the AKR shall be measured at a point 15 cm from thecenterline of the x-ray table and in the direction of the x-ray source with the end of thebeam-limiting device or spacer positioned as closely as possible to the point of measurement. If the tabletop is movable, it shall be positioned as closely as possible to thelateral x-ray source, with the end of the beam-limiting device or spacer no closer than
15 cm to the centerline of the x-ray table.
III.C.3. SID Output Compensation
A lesser-known feature of fluoroscopy systems, the SID output compensation, will be briefly
described. As the SID is varied, this control circuit adjusts the maximum radiation output, determined at the FDA-specified measurement point, in accordance with the x-ray tube load limits
and the regulatory maximum exposure rate requirements. In particular, the SID compensation
circuit is designed to automatically adjust the maximum kVp and mA values such that the maximum radiation dose rate at the specified measurement point is maintained at the regulatory
limit, irrespective of the SID. Since the tabletop height (and thus the patient skin entrance point)
is not necessarily raised or lowered in conjunction with changes in the position of the image
receptor, the maximum fluoroscopic output at the location of the patient’s skin may “appear” toexceed the regulatory limits. In fact, since the maximum output is measured at the location
defined by the FDA, the compensation adjustments will ensure that the limits at that location
are not exceeded. On the other hand, if a large SID is utilized while the patient’s skin entry pointis close to the x-ray source, the actual maximum SEER can be an order of magnitude higher
than that specified by the FDA. If the SID output compensation is not properly calibrated there
may be some SID settings where the maximum exposure rate will exceed the 88 mGy/min or
176 mGy/min values. It is therefore important for the clinical medical physicist to be aware ofthis potential for increased skin dose and to educate both administrators26 and users27 regarding
the potential for skin injury and the means to avoid this hazard.
III.C.4. Critical Lead Thickness and Automatic Shutoff of Fluoroscopy
When determining the maximum dose rate at the FDA-specified measurement point, it isimportant to consider that for some fluoroscopy systems the use of a lead sheet as a beam stop
may inhibit the achievement of the desired maximum generator settings. This will occur whenthe manufacturer has incorporated a threshold value of detector signal that must be achieved. If
the minimum signal is not reached, the system will cease the fluoroscopic exposure and indicate
an error via a message on the image display monitor or on the operator’s control screen. For such
systems when the lead beam stop is too thick the generator, under ABC/ADRIQ control, will not

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FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

reach the combination of kVp, mA, and PW that produces the maximum output. For such systems there will be a critical lead thickness (CLT) below which the minimum threshold detector
signal is reached, but above which the signal is insufficient. When the beam stop is set to the
CLT, the brightness of the displayed fluoroscopy image might still be maintained by the television Automatic Gain Control (AGC). Beyond the point where the video signal gain has reachedthe maximum value, the system will achieve only a fraction of the desired display brightness.
When the beam stop is thinner than the CLT, the system logic will operate normally, but thegenerator’s settings will be less than the maximum allowed. Attenuators such as aluminum (Al),copper (Cu), or lead (Pb) sheets traditionally employed by medical physicists to determine themaximum output of fluoroscopy systems might be either too thin to reach the CLT or too thickso that the fluoroscopy system is turned off, preventing the measurement of the maximum radiation output.
Measurement of the maximum output must therefore be carried out with care, and the appropriate thickness of attenuator is essential. The CLT equivalent for materials other than lead could
correspond to a total of 15 to 16 inches of PMMA plastic plates, or more than 14 mm of Cu. The
use of PMMA or other thick attenuators, however, is not recommended for this measurement
since the conditions for maximum entrance exposure rate require that no scattered radiation reachthe radiation dosimeter. A suitable approach would be to have several thicknesses of lead sheet
available ranging from 0.25 mm to 2 mm. Alternatively, the use of lead-aprons or lead-equivalent
aprons can be effectively utilized to achieve the maximum output operating condition.
III.D. Scattered Radiation
As previously mentioned, the use of spectral beam shaping will serve to reduce the SEER.
An added bonus is that although the scatter fraction increases due to beam hardening, the actual
scatter intensity is reduced.28 Thus, there is a dose reduction benefit to the personnel conducting
the interventional procedure as well as that for the patient.

IV. Spectral Filtration
The value in using spectral filters made of Al (Z=13) or Cu (Z=29) as a means of reducing
patient dose was recognized and documented in the early 1950s,29,30 and today spectral shaping
filters may be found on typical radiographic equipment as well as conventional fluoroscopy systems.31–35 In addition to Al and Cu, many other elements have also been investigated such as•

Titanium (Z=22), Niobium (Z=41), Tin (Z=50), Samarium (Z=62), Erbium (Z=68),
Tungsten (Z=74), Gold (Z=79), and Uranium (Z=92)36•

Samarium (Z=62), Gadolinium (Z=64), and Erbium (Z=68)37•

Tin (Z=50), Lanthanum (Z=57), Gadolinium (Z=64), Erbium (Z=68), and Lutecium(Z=71)38•

Erbium (Z=68) and Samarium (Z=62)39•

Hafnium (Z=72)40
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AAPM REPORT NO. 125•

Tantalum (Z=73)41,42•

Niobium (Z=41)43•

Samarium (Z=62), Gadolinium (Z=64), Holmium (Z=67), Ytterbium (Z=70), andTungsten (Z=74).44

Although the list of potential filter materials is large, Nickoloff 45 showed that for elements withatomic number less than 42, equivalent x-ray spectra can be obtained by substituting Cu of
appropriate thickness. He also showed that Cu was more efficient than Al, where the efficiency
was defined as the percentage of photons in the unfiltered x-ray beam that pass though the material when the amount of filtration was adjusted such that the average photon energy was thesame.
The incorporation by manufacturers of spectral shaping filters into the equipment design
began as interventional angiography procedures became widely practiced in the United States inthe early 1990s.46–48 All equipment investigated by the task group utilized combinations of Al
and Cu filtration. Two manufacturers make use of at least one high atomic number filter material in addition to utilizing combinations of Cu and Al. Shimadzu used a combination of gold(Au) and Al, and Toshiba used tantalum (Ta).
It is clearly evident from the experimental studies of the various spectral filters cited abovethat the widespread use of spectral shaping filters has contributed to a reduction in patient skindose. Furthermore, the application of specialized x-ray generator control curves, along withimprovements in noise reduction techniques and image processing algorithms, have been instrumental in maintaining an acceptable level of image quality whenever spectral shaping filters are
utilized.49
There are two general approaches to the implementation of spectral beam filtration in fluoroscopy. For lack of established terminology, the first approach shall be called the “Traditional
Method”; the second shall be called the “Program-Switched Method.” The program-switchedmethod can then be further divided into two distinct methods. In this report the first of these isreferred to as the “Anatomical Program Based Filter Selection,” and the second shall be called
the “Seissl Method” after the Siemens engineer Johann Seissl, who patented the original schemeof using automatically varying thicknesses of Cu filtration† in 1997.50
IV.A. Traditional Method of Filter Selection
The traditional method utilizes combinations of filter materials which are fixed in the collimator, cannot be varied by the user, and do not change with the anatomical program selected.
The traditional method has been utilized in legacy fluoroscopic systems for many decades and iscommonly employed today in mobile vascular C-arms utilized in the surgical suite, and in many
fixed, non-vascular fluoroscopy systems.

†

J. Seissl, personal communications on “Comprehensive application of copper filters for cardiovascular angiography systems” and Siemens Medical Systems internal memorandums (1999).

10FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

IV.B. Program-Switched Method of Filter Selection
IV.B.1. Anatomical Program–Based Filter Selection
The Program-Switched Method is an automated form of the traditional method in that predetermined combinations of added spectral filtration can be automatically switched under program control. With this method the type of filter material and/or the thickness is determined via
user selection of an anatomically or procedurally based exposure program. The filter selected
can also be dependent on the SID, or it can be linked to one of the fluoroscopy exposure rate
control settings. Two or more fluoroscopy exposure rate control settings (fluoroscopy dosemodes) are generally provided. These are often selectable by the user on the tableside control
module. These selections correspond to predefined values of fluoroscopy pulse rate, EERD,
x-ray generator control curve, and spectral filtration. Once a fluoroscopy mode is selected, thespectral filtration is set and is independent of the variations in patient attenuation. During fluoroscopic operation the ABC/ADRIQ varies the generator parameters in response to the demand
for more or less signal from the detector, but the filter remains fixed. Each of the user-selectable
fluoroscopy modes may have a different combination of pulse rate, EERD, generator control
curve, and spectral filtration for each anatomical or procedural program. In addition, the system
could be programmed to automatically change the filtration with change in SID.
IV.B.2. Seissl Method of Filter Selection
With the Seissl method, the ABC/ADRIQ plays an active role in the selection of one or morefilters under a predetermined scheme. These actively selected filters are in addition to the nominal 2.5 mm Al total filtration which is required by regulatory agencies such as the FDA. Whilethe exact scheme for determining which filters are selected is proprietary in nature, the task
group has developed an experimental procedure to investigate just how the filters and otherexposure parameters are varied. The procedure had been previously employed by Lin51 to investigate the operation logic of a Siemens automatic dose control, and was subsequently modified
by the task group for application with the various equipment designs studied. Fukuda et al.52 also
investigated the spectral shaping filter–equipped angiographic equipment. However, their focus
was on skin dose evaluation as influenced by the variance of effective energy, and no discussion
was given on the operational logic of automatic brightness (dose) control.
IV.C. Display of Filtration Utilized
Since the amount of spectral filtration is under program control, it is important to know how
much filtration is in the beam for a given patient, protocol, beam geometry, and dose setting.
Manufacturers initially did not provide a means for the user to know the type and amount of spectral filtration,53 but today it is a requirement of the standards set forth by the FDA.54 Figure 5
shows the various means of displaying the spectral filtration and other parameters by the manufacturers that were included in the study. Note that for these examples PW was displayed on theoperator’s control console only on the Siemens unit. For the GE Innova® 2100, PW indication wasavailable on the image display monitor, but was not provided on any display by Shimadzu orPhilips.
11

AAPM REPORT NO. 125

Figure 5. Display of the spectral filtration setting and other parameters on the operator’s control modules of theimaging equipment included in this study. As evident from these images, there is no consistency in the way imaging
parameters are displayed by the manufacturers.

12

FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

V. The Automatic Brightness/Automatic Dose Rate Control
Before presenting the results obtained for the installed clinical systems evaluated by the task
group, some background information on fluoroscopy systems in general should be reviewed.
Much of this will consist of materials present in all medical physics textbooks but will also
include some lesser-known features such as the currently utilized maximum radiation output
compensation with change in SID.
V.A. Types of Automatic Control
Fluoroscopic x-ray systems make use of a set of rules (algorithms) that control the system’s
response to dynamic changes in imaging conditions. Usually these control algorithms maintainthe absorbed energy fluence per pixel at the imaging detector’s x-ray capture layer, resulting ina reasonably constant average signal level from the detector. The above statement is true for agiven detector FOV. In general, manufacturers will change the nominal input exposure rate to thedetector whenever the FOV is changed. The absorbed energy fluence per pixel is maintained bycontrolling the exposure parameters of the x-ray generator such that a constant, pre-defined
detector signal level is achieved.
One of three methods are commonly employed: (1) a change in kVp with a fixed mA, (2) achange in mA with fixed kVp, or (3) a change in the kVp and the mA simultaneously. For somesystems the exposure PW was varied adjunct to these three methods. The control of generator
exposure factors to maintain a constant image receptor output signal is often called the Automatic
Brightness Control (ABC), or Automatic Dose Rate Control (ADRC) mode of operation.
V.B. Automatic Gain Control
In all cases, it is either the light emitted from the output phosphor of the image intensifier,or the signal from the flat-panel detector that is utilized as the input signal for the ABC/ADRC.
Since the x-ray generator response to a call for changes in technique can be relatively slow, AGC
is utilized as an adjunct to the ABC/ADRC in order to compensate for changes in the signal
strength at the input to the video chain.55 In addition, the size of the aperture in the optical system transmitting the light from the output phosphor to the video camera can also be utilized asa means of maintaining a constant video signal level. In most cases a combination of
ABC/ADRC control logic, AGC, and optical aperture modulation will be employed as a meansof maintaining a reasonably constant video signal. The two most commonly employed methodsof AGC, optical sampling and video sampling, will be further described below.
V.B.1. Optical Sampling AGC
The first method uses either an optical guide connected to a photomultiplier tube or, morecommon today, a solid-state photodiode array to sample the emitted light intensity. In the case of
the photomultiplier, the detection window of the optics is adjusted to subtend a circle defining apercentage the output phosphor area. When a photodiode array is utilized, several pre-defined
regions, either circular or rectangular, can be independently selected as the signal sensing
region. In this way the signal can be sampled from either a central percentage area of the image
or from one or more defined regions of the image.
13

AAPM REPORT NO. 125

V.B.2. Video Sampling AGC
The second method utilizes the video signal from the video camera for the ABC/ADRIQ
input. In this case either the peak or the mean video signal within a selected region of interest(window) of the video image may be employed. This window is electronically selected and thus
can be modified by the fluoroscopist to sample the video signal from a specific area of interest.
Both methods produce a signal that can be fed into the “Voltage Comparator,” shown in
Figure 6. The ABC/ADRIQ algorithm compares the input signal to the reference voltage. The
reference voltage is established via a defined calibration procedure whereby a specific thicknessof Cu is placed in the x-ray beam path and the EERD is monitored with a radiation dosimeter.
As the reference voltage is varied, the generator parameters adjust and the EERD changes untila specified EERD is established under the calibration conditions. The target EERD will dependon the noise tolerance for the imaging task, the FOV selected, and the fluoroscopy pulse rate.
Although the reference value is established using a dosimeter to measure the EERD, the
ABC/ADRIQ does not necessarily maintain a constant EERD but rather reasonably constantabsorbed energy fluence per pixel at the detector input. Because of the dependence of the detector absorption efficiency and energy conversion efficiency on the spectral energy distribution of
the radiation, the established EERD using the Cu attenuator will not be the EERD achieved during patient imaging. It is rather a reference or calibration value achieved under specificallydefined measurement conditions.
During clinical operation of the imaging system the reference values could, in some circumstances, be modified dynamically by the ABC/ADRIQ control logic. For example, to maintain image contrast for cases where the radiation attenuation is large, the system could be
programmed to reduce the reference voltage in lieu of increasing the kVp beyond an established
upper limit.

VI. Block Diagram of ABC/ADRIQ Circuit
This section describes the inner workings of ABC/ADRIQ circuitry so that the functions of
the control logic may be fully appreciated. Depicted in Figure 6 is the overall schematic block
diagram of a complete ABC/ADRIQ installed in typical angiographic imaging equipment.56 In
this figure an XRII system is used to demonstrate the functions of various controllers and subsystems. However, the entire box on the upper left corner of Figure 6 may be replaced by a flatpanel image receptor and its associated control logic/circuits. The descriptions given for an
XRII-equipped system would still be valid for a flat-panel image receptor system with appropriate modifications. This is an artificially synthesized block diagram for the purpose of describing
the ABC/ADRIQ. Some features may be preset while others are end-user selectable. The entire
system could be illustrated by a simplified version as shown in Figure 7.

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FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

Figure 6. Typical schematic block diagram description of ABC/ADRIQ logic. (Adapted from reference 56.)

15

AAPM REPORT NO. 125

Figure 7. Flow diagrams for traditional ABC control logic (left), and modern ABC/ADRIQ control logic (right).

In the system depicted in Figure 7, the chart on the right shows imaging parameters that
may be end-user selectable or preprogrammed in the control logic. In most modern fluoroscopic
systems, these preprogrammed selections are referred to as “organ programs,” and can be represented as shown. These imaging parameters may be preset to an initial start-up condition. For
the fluoroscopy mode the initial settings might be pulsed fluoroscopy at 30 pulses per second(pps), 68 kVp, 10.5 mArms, and 7.5 ms PW; for the acquisition mode the initial settings could
specify a cine frame rate of 30 fps, a digital subtraction angiography (DSA) frame rate of 4 fps,
a digital serial acquisition frame rate of 2 fps, the small focal spot size, and a maximum run
time of 10 seconds. The starting acquisition tube potential, tube current, and PW would also beestablished by the control logic of the ABC/ADRIQ, with these three parameters usually being
derived from the previous fluoroscopy segment. These initial conditions are then dynamicallymodified as required to compensate for patient attenuation during the acquisition. In addition,
Controller Block B of Figure 6 serves to ensure that any change in exposure parameters does not
result in settings that would exceed the design limits of the x-ray generator or the x-ray tube, northat the combination of generator parameters would result in radiation exposure rates that would
exceed the regulatory limits. Included in Controller Block B are (1) an anode heat calculator
which computes the anode heat accumulation and heat dissipation with incoming information of16

FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

tube potential, current, and exposure time, (2) the anode heat sensor which is incorporated into
the x-ray tube housing assembly to monitor the anode heat buildup, (3) the x-ray tube heat loading characteristic table, (4) the generator power and duty cycle characteristics, and (5) various
look-up tables and operational logic associated with radiological imaging parameters and theirinfluence on the desired image quality. The level of sophistication of a given imaging system is
to a large extent determined by what is in Controller Block B and the extent of the programmed
operational logic.
To understand the simplest possible ABC/ADRIQ design for the fluoroscopy mode, one cantreat most of the diagram on the right side of Figure 6 as a black box and concentrate on theController Block A for description and explanation. We can start by assuming that fluoroscopy
has just been initiated and the pickup module, typically a photodiode array and signal preamplifier, begins to create a voltage proportional to that of the output phosphor brightness. This
voltage is then fed into a voltage comparator shown just above the Controller Block A in the diagram. What happens next is dependent on the system design. In the case of the diagram shownin Controller Block A, it is based on a “kVp-primary” ABC/ADRIQ in which the tube potentialfunctions as the primary control parameter. The following steps describe what the ABC/ADRIQ
circuit is designed to do:(1) As described previously, the initial pulsed fluoroscopy condition was set at 30 pps, 68
kVp, 10.5 mArms, and 7.5 ms PW. The actual mA generated during each x-ray pulse
would be determined by dividing the mArms by the PW in seconds and then by thepulse rate. For the conditions described above, the actual mA would be (10.5 mArms /0.0075 s / 30 pps) = 46.7 mA actual.
(2) The initial radiation passing through the patient and absorbed in the input phosphor of
the XRII will generate a signal in the photodiode array.
(3) The signal from the photodiode array is compared against the preset reference voltage.
This reference voltage is established via a calibration procedure and corresponds to a specified EERD obtained using the measurement conditions specified by the manufacturer.
(4) If the incoming signal to the Controller Block A differs from that determined by thereference voltage, the kVp control module would send a signal to the generator in order
to appropriately adjust the tube potential.
(5) At the same time, this signal is fed to Controller Block B where various look-up tables
are consulted by the ABC/ADRIQ. The function of the look-up tables is to ensure that
the ABC/ADRIQ follows a pre-determined x-ray control curve or trajectory.57(6) As the tube potential is being adjusted, the tube current and PW may also be changedin accordance with the selected trajectory, the x-ray tube anode heat storage characteristics, and the x-ray generator capabilities.
(7) New x-ray generator settings are then established (e.g., 72 kVp, 20 mArms, and 7.8 ms
PW). These new settings then produce a photodiode signal that is equal to the reference
voltage utilized by the voltage comparator, and a stable condition is achieved.

17

AAPM REPORT NO. 125(8) The ABC/ADRIQ trajectories are designed to prioritize which parameters are modified
and by how much they are allowed to change. Preference is generally given to keeping
the kVp and PW constant, if possible, and therefore it is the tube current that willchange first, followed by a change in PW (up to an established limit), and finally achange in kVp. The amount of spectral filtration can also change under program control as previously discussed.
(9) At this moment, if a cine acquisition run, DSA run, or digital serial run is initiated via
the acquisition foot pedal, digital images would be acquired at the programmed frame
rate, and the same ABC/ADRIQ system will serve to stabilize the detector output signal during the run. For each of these cases a different, calibrated reference voltage
would be utilized and the radiation delivered to the detector per image frame would bemuch higher than that utilized for fluoroscopy. One might assume that logically all
image frames would be recorded during acquisition and thus available for review via
playback of the run. Unfortunately, this is not always the case, as for some equipment
the user can choose a different image capture rate that is less than the x-ray exposure
frame rate.
The operation of the imaging system described in (9) above is called “acquisition mode” to distinguish it from “fluoroscopy mode.” In modern interventional angiography systems it can sometimes be difficult to discern from the program selection which mode is being utilized, since bothproduce short duration, pulsed exposures at a predetermined pulse rate. As stated above, theacquisition mode delivers a greater detector input dose per frame, but this distinction can generally not be determined by the operator. Also with modern equipment both fluoroscopy andacquisition frames can be stored for review during subsequent playback so storage/review is nota reliable means of distinguishing the two modes. One vendor simply labels the acquisition modeon its vascular C-arms with the word “Pulsed,” which can easily be mistakenly interpreted tomean “Pulsed Fluoroscopy.” The acquisition mode will not be described further in this report.
The complexity of acquisition mode operation logic deserves a separate investigation and isbeyond the scope of the current charge placed upon this task group.
While there are some boxes drawn in the diagram of Figure 6 that were not included in theabove description, it is assumed that for a trained medical physicist, these components will beself explanatory. However, interested readers are invited to consult the references58–60 listed at theend of this report if they desire a more in-depth description of these components. As previously
mentioned, the functions of a flat-panel image receptor are designed to replace all of the functions of the image intensifier, optical distributor, video camera, and film cameras.61 For flatpanel detectors the signal input to the ABC/ADRIQ is derived from sampling a pre-defined
region of the detector. Two or more regions of different size, shape, and location are typicallyprovided and are often user selectable either singly or in combination. Aside from the manner inwhich the signal is derived, for fluoroscopy imagers that utilize flat-panel detectors, the description given above for the operation of the ABC/ADRIQ control logic is valid without substantialchanges.

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FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

VII. Task Group Field Evaluation of ABC/ADRIQ
VII.A. Angiography Systems InvestigatedWhen TG-125 was established, it was intended to include most new angiography equipment
available on the commercial market and from manufacturers known to the task group at thetime. Due to the proprietary nature of the control logic design, none of the manufacturers werewilling to share the explicit information on the generator control (trajectory) curves being utilized in their respective systems. In addition, the equipment available to the task group members
was limited to (in alphabetical order) GE Healthcare (4 units), Philips Medical Systems (5units), Shimadzu Medical USA (1 unit), and Siemens Medical Systems (12 units). The numbersin the parentheses correspond to the number of imaging systems evaluated. All equipment investigated was manufactured within the 3-year period from 2006 to 2008.
After preliminary analysis of the data collected, one representative system from each of thefour manufacturers was selected to be included in this report. All of the selected systems utilized
the most recent software version available at the time. The technical hardware parameters andinformation pertinent to this study are listed in Table 1. For consistency, the cardiac “coronary”
angiogram program was selected for the data collection and the default settings were employedwith the exception of the FOV. The selection of FOV for the flat-panel imagers tested was basedon the de facto standard image intensifier size of 23 cm (9 inches), which have been installed inmost cardiovascular angiography laboratories in the past decade. Although none of the systems
used for data acquisition had a 23-cm FOV selection available, the one that was closest to 23 cm
was chosen for the evaluation.
Although a wide variety of schemes for adjustment of the system operating conditions areavailable, a practical comparison of fluoroscopic systems can be made only for a finite set ofTable 1. Technical Hardware Parameters
Manufacturer
Model

GE
Innova 2100

PhilipsAllura Xper

Siemens
Axiom Artis dFC

Shimadzu
BRANSIST

Spectral Shaping Filter

Variable

0.1 mm Cu+ 1 mm Al

Variable

Variable

Field of View (cm)

20

25

22

23

Focal Spot Sizes (mm)0.3/0.6/1.0

0.5/0.8

0.3/0.6/1.0

0.5/0.8

Default Pulse Rate (pps)

15

15

15

10

Fluoroscopy Curve Label

Cardio IQ Plus

Fluoro Flavoure

70kV10RAF3kW

HLC H2

Fluoro Level Control

NormalDose Button II

NormalVia Program

Focal Length, f0 (cm)

100

100

105

100

Ratio, r

15: 1

13:1

15:1

10:1

Line Density, N(lines/cm)

80

70

80

44

Grid

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AAPM REPORT NO. 125

clearly defined algorithms. A representative set of control algorithms was chosen and the associated control logic was then investigated utilizing the methods described below.
VII.B. Experimental Arrangements
Depicted in Figure 8 is the experimental setup for the evaluation of fluoroscopic ABC/ADRIQ control logic of an angiography system. The SID was set to 120 cm or to the maximum
SID available on the system being investigated. The tabletop–to–image receptor distance (TID)
was kept at 40 to 43 cm (15.75 to 16.5 in.) so that there would be sufficient space to accommodate the ionization chamber and a total nominal phantom thickness of 38 to 41 cm (15 to16 in.).
Due to the differences in the geometry of different systems, SID, TID, and maximum attenuator
thickness had to be varied to some extent. A PMMA plastic phantom was employed to simulate
the patient attenuation and varied from zero cm (zero in.) to 41 cm (16 in.) in increments of
2.54 cm (1 in.). As will be shown, in order to capture the discontinuity points of imaging parameters when the spectral shaping filter thickness was changed, increments of 0.635 cm (0.25 in.)were introduced to pinpoint the PMMA thickness where the ABC/ADRIQ produces a change inspectral filtration. The fluoroscopic imaging parameters kVp, mA, PW, Spectral Shaping Filter,
and PAKR were recorded as a function of the attenuator thickness. Upon completion of the dataacquisition, the fluoroscopic imaging parameters were plotted against the PMMA thickness. The
graphs thus obtained reveal how the imaging system responded to changes in PMMA thickness,and thus how it would operate under clinical conditions. The SID of 120 cm may seem to be
excessive, but considering that the C-arm positioner is frequently placed in a compounded angle,
the SID of 120 cm is not necessarily unusual. It is important to note that no attempt was madeto eliminate the effects of backscatter on the PAKR measurements. The support blocks shown in
Figure 8 were utilized solely to support the PMMA in a position just slightly above the ioniza-

Figure 8. The experimental setup for the evaluation of fluoroscopic ABC/ADRIQ control logic of an angiographysystem.

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FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

tion chamber. The table mattress was removed. The reported PAKR will therefore not necessarily reflect that for a patient of equivalent thickness of PMMA due to the effects of table padattenuation and backscatter. The focus of these measurements was on the operational logic of theimager, and was not intended specifically for patient dosimetry. Nevertheless the task groupbelieves that the relative comparison of the reported PAKR values for different manufacturers is
valid, since the geometry utilized was as identical as could be achieved in practice. Details of
the measurement procedure utilized by the task group are provided in the appendix.
VII.C. Evaluation of Results
The generator control curves (kVp versus mA) for the four representative systems tested areshown in Figure 9. A single imaging system can have many such control curves, and these cantake on different shapes based on the intended study application or anatomical protocol. For systems A and B on the left side of Figure 9, the spectral beam filtration switches automatically as
the PMMA thickness is varied. For systems C and D on the right, the filtration associated withthe selected program remains in place regardless of the beam attenuation. These functions are

Figure 9. Generator control curves for the four representative units tested. A. GE Innova® 2100; B. Siemens dFC;
C. Philips Allura Xper; and D. Shimadzu BRANSIST. The x-ray generator will follow the respective curve whenever
the ABC/ADRIQ system demands more or less radiation in order to maintain a constant output signal from thedetector. Many different control curves may be utilized, depending on the type of examination, focal spot size, andother factors.

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AAPM REPORT NO. 125

described in more detail below for two angiography systems that utilize the Seissl method andfor two systems that utilize the Program-Switched Method.
VII.C.1. Systems Using the Seissl Filter Method
Depicted in Figure 10 are the measurement results for the two systems, GE Innova® 2100
(left column) and Siemens Axiom Artis dFC (right column), that utilize the Seissl filter method.
The graphs at the top of Figure 10, designated “A”, show the tube potential and Cu filter thickness as functions of PMMA phantom thickness. Similarly, the middle graphs, “B”, show thetube current and PW as functions of the PMMA thickness. The bottom graphs, “C”, show the
PAKR and the power loading versus the thickness of PMMA.
Let us follow the imaging parameter curves as the phantom thickness is increased in orderto understand the operation of the control logic. Looking at charts A in both columns of Figure 10,

Figure 10. Various imaging parameters as a function of phantom thickness. Left: GE Innova® 2100. Right: Siemens
Axiom dFC. A: Tube potential and Cu filter thickness; B: PW and tube current; and C: PAKR and Average Power.
Td is the calculated thickness of PMMA that doubles the PAKR.

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FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

it can be seen that the two vendors have slightly different approaches with regard to how the kVpchanges with attenuator thickness. Below 2 in. PMMA neither vendor allows the kVp to drop as
the attenuator thickness decreases. However, between 3 in. and 8 in. GE allows the kVp to
increase whereas Siemens holds the kVp relatively constant. For both vendors the filter changes
only in incremental steps, but each vendor uses a slightly different number of steps and minimum filter thickness. In general, the minimum thickness of spectral filtration will be factory set,but there may be means provided for service to program the minimum thickness desired for specific applications such as electrophysiology (EP) or pediatric studies. To further understand themanner in which the ABC/ADRIQ logic functions, we shall examine the GE Innova® 2100
curves more closely. As seen from the graphs in the left column of Figure 10, the GE Innova®
2100 ABC/ADRIQ logic operates as follows:(1) Initial Conditions (No attenuator)
a. Filter 0.9 mm Cu.
b. Tube Potential 60 kVp.
c. Tube Current 3 mArms.
d. PW 6 ms.
(2) PMMA thickness 0–2 in.
a. Filter remains constant at 0.9 mm Cu.
b. Tube Potential remains constant at 60 kVp.
c. Tube Current increases from 3 mArms to 9 mArms.
d. PW remains constant at 6 ms.
(3) PMMA thickness 2–3 in.
a. Filter remains constant at 0.9 mm Cu.
b. Tube Potential gradually increases from 60 to 63 kVp.
c. Tube Current remains constant at 9 mArms.
d. PW remains constant at 6 ms.
(4) PMMA thickness 3–5 in.
a. Filter drops to and remains constant at 0.6 mm Cu.
b. Tube Potential gradually increases from 63 to 67 kVp.
c. Tube Current remains constant at 9 mArms.
d. PW remains constant at 6 ms.
(5) PMMA thickness 5–7.5 in.
a. Filter remains constant at 0.6 mm Cu.
b. Tube Potential gradually increases from 67 to 75 kVp.
c. Tube Current rapidly increases from 9 to 20 mArms.
d. PW rapidly increases from 6 to 12.5 ms.
(6) PMMA thickness 7.5–9.5 in.
a. Filter drops to and remains constant at 0.3 mm Cu.
b. Tube Potential gradually increases from 75 to 81 kVp.
c. Tube Current drops back to 9 mArms, then rapidly increases from 9 to 20 mArms.
d. PW drops back to 6 ms, then rapidly increases from 6 to 12.5 ms.
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AAPM REPORT NO. 125(7) PMMA thickness 9.5–10.5 in.
a. Filter drops to and remains constant at 0.2 mm Cu.
b. Tube Potential gradually increases from 81 to 91 kVp.
c. Tube Current drops to 18 mArms, then rapidly increases from 18 to 20 mArms.
d. PW drops to 11.5 ms, then rapidly increases from 11.5 to 12.5 ms.
(8) PMMA thickness 10.5–14 in.
a. Filter drops to and remains constant at 0.1 mm Cu.
b. Tube Potential gradually increases from 91 to 120 kVp.
c. Tube Current drops to 18 mA rms, then rapidly increases from 18 to 20 mA rms,
followed by a rapid decrease from 20 to 13 mArms.
d. PW drops to 11.5 ms, then rapidly increases from 11.5 to 16 ms (at 12 in. PMMA),
then remains constant at 16 ms between 12 and 14 in. PMMA.
(9) PMMA thickness >14 in.
a. Filter remains constant at 0.1 mm Cu.
b. Tube Potential remains constant at 120 kVp.
c. Tube Current remains constant at 13 mArms.
d. PW remains constant at 16 ms.
Further analysis of how the imaging parameters changed as the PMMA thickness increased
revealed additional insights into the operation of the control logic. As already stated, the kVp
was never allowed to drop below 60 kVp, even when the PMMA thickness approached zero.
This condition, along with the fact that the maximum spectral filtration was present for PMMA
thicknesses below 3 in., should serve to greatly lower the skin dose during neonatal fluoroscopy
as compared to that which would have occurred with systems using only minimum allowed filtration and having generator control curves that continued to lower the kVp as the attenuator
thickness was reduced.
It was also interesting to note that, at least up to 11 inches PMMA, the PAKR increases
exponentially with increase in PMMA thickness, and without any sudden discontinuities, even at
the PMMA thicknesses where the filter was abruptly changed. The result is a linear relationshipbetween the PAKR and the PMMA thickness when plotted on a semi-logarithmic graph asshown in graphs C of Figure 10. This relationship allows calculation of the incremental PMMA
thickness, Td, that would double the PAKR. Note that above 12 in. of PMMA the PAKR remains
constant due to the regulatory limits imposed by the FDA. The values for the PAKR limit shownon the graphs do not match the limits imposed by the FDA due to the fact that (1) the measurement geometry used by the task group did not conform to the FDA-defined measurement geometry, and (2) the presence of scattered radiation from the PMMA.
Regarding PW, it is evident from the graphs that for PMMA thicknesses from 0 to 11 in.,the PW was allowed to vary only in the range from 6 to 12.5 ms, and for PMMA thicknesses of
12 in. or more, the PW was held constant at 16 ms. It can be assumed that the lower limit to the
PW was imposed in order to keep the power requirements within the ratings of the x-ray generator and the x-ray tube, and the upper limit to the PW was imposed as a means of preserving
temporal resolution.

24

FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMSIn the same manner as used above to describe the operational logic of the GE Innova ®
2100, the ABC/ADRIQ logic of the Siemens Axiom dFC can be discerned. The principal difference between these two systems is the fact that for the Siemens imager the changes in kVp,
mA, and PW correlate much more closely to the associated filter thickness changes. The similarity of these two manufacturers in the ABC/ADRIQ logic designs can be attributed to the factthat both manufacturers utilize the same collimator assembly manufactured by Siemens.
Observed differences are due primarily to the engineering design (e.g., GE reduced the added
filtration to 0.1 mm Cu filter for some fluoroscopy modes, whereas Siemens did not allow lessthan 0.2 mm Cu during fluoroscopy), the capabilities of the generator, and the specifications of
the x-ray tube. It should be noted that in graphs B of Fgure 10 the values of tube current are
root-mean-square (mArms) values. This is also the case for the display of mA on the GE control
console. However, Siemens displays the average of the tube current present during each x-ray
pulse. Thus for the Siemens chart the per-pulse average mA value recorded from the display
console is converted to the time average value of mArms.
VII.C.2. Systems Using the Programmable Filter Method
VII.C.2(i). Philips Allura Xper System

The Philips Allura Xper system employs the design concept associated with the programswitched filter method. Once a clinical program is selected at the control console and the fluoroscopy dose level at the examination tableside controller is selected, a particular filter isswitched into the x-ray beam path. Thus the type and thickness of filtration is determined by the
program selected and no variation is permissible via the ABC/ADRIQ control as the patient
attenuation is varied. The filter arrangement for the unit investigated was set to 0.1 mm Cu plus
1.0 mm Al. This filtration is in addition to the nominal 2.5 mm Al total filtration that is requiredby regulatory requirements.
Figure 11 shows graphs of the test data for the Philips Allura Xper and the Shimadzu
BRANSIST. Graphs A are for the fluoroscopic Tube Potential (kVp), graphs B are for the PW
and Tube Current (mArms), and graphs C are for the PAKR and average power loading. For these
two systems the spectral shaping filter is fixed, as mentioned previously. Neither of these systems
displays the PW to the operator. However, for the Philips Allura Xper system the PW data werecollected by attaching a dual-trace storage oscilloscope at the mA-test point in the generator cabinet. Normally, the kVp-test point would be accessed for measurement of tube potential as well
as for PW information. However, the specific model of generator utilized by the system does nothave a kVp-test point.
With a fixed filter there are no sudden changes in primary beam intensity that would otherwise be caused by the changing spectral shaping filter. Therefore the PAKR will exponentially
increase as the tube potential and the tube current simultaneously increase with phantom thickness. This increase in PAKR occurs up to the thickness that produces either the maximum
allowed PAKR, or the maximum power load for the system.

25

AAPM REPORT NO. 125

Figure 11. Various imaging parameters as a function of phantom thickness. Left: Philips Allura Xper; Right:
Shimadzu BRANSIST. A: Tube potential; B: PW and tube current; C: PAKR and Average Power. Neither Philips nor
Shimadzu indicated the PW.The Philips PW data were obtained via a storage oscilloscope.Td is the calculated thickness of PMMA that doubles the PAKR.
VII.C.2(ii). Shimadzu BRANSIST Cardiovascular

The Shimadzu BRANSIST is a dedicated cardiovascular imaging system with a directcapture flat-panel detector. The BRANSIST utilizes four composite filters, all located on a
motorized disc inside the collimator. Selection of filtration is via program control. A specific filter is assigned to each user-selectable program and is also assigned according to the SID. Thatis, for SID values less than or equal to 96 cm, a given filter is associated with each anatomical
program, and for each dose mode in that program. For SID values equal to or greater than
97 cm, the filter could be the same or could change according to the factory program (see Table 2
and Table 3). In addition to the programmed selection of spectral filtration, Shimadzu provides
the user with the ability to manually select filter #4 and, when this filter is manually selected, it
remains in the beam independent of the SID. The filtration did not change with patient size and26

FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

Table 2. Shimadzu BRANSIST Filters and Their Programmed Utilization

Thickness Fluoro
Filter Material
(mm)
Mode

#1

Al
Cu

2
0.1

X

HVL
Acq (mm Al atMode
80 kVp)

X

4.99

#2

Al
Au

1
0.01

X

X

3.83

#3

Al
Cu

1.5
0.3

X

NA

5.9

#4

Al
Cu

1.5
0.6

X

NA

7.5

Filter Utilization
Whenever the SID is less than orequal to 96 cm, filter #1 is utilized
for all 10 pps/H fluoro modes
and selected 15 pps fluoro modes.
It is also used for all OneShot
Acquisition at any SID.
Whenever the SID exceeds 96 cm,
filter #2 replaces the above-listed
filter #1 settings for fluoro.
Filter #2 is the only one utilized
for all radiographic modes, except
when the “P” (upper left buttonon the collimator control box) is
selected, or for Single Shot as
described above.
Filter #3 is utilized for selected
15 pps fluoro modes and, whenutilized, it is in place for all SID
settings.
Filter #4 is used for all Head andPeri fluoro protocols except the
10 pps/H. It is also utilized forselected Cardiac and Ablation
fluoro protocols.
It is not utilized for any Abdomen
fluoro protocols.

therefore would be classified as the program-control method. Figure 12 shows the measured
PAKR and EERD as a function of PMMA attenuator thickness for the Shimadzu BRANSIST. It
should be noted that the EERD would not normally be measured with PMMA, but since thismaterial is often used to simulate patient attenuation, it is instructive to see how the PAKR and
EERD varies with changes in PMMA thickness. An exponential fit to the straightline portion of
the PAKR plot reveals that the x-ray spectra was slightly harder with the 15 pps program (Td =1.72 in. acrylic) versus the 30 pps program (Td = 1.64 in. acrylic), which uses a different generator control curve. Note also that the PAKR was much lower for the 30 pps program. This result
was not expected and led to investigation of the exposure rate values for all of the selectable programs (Figure 13). The different x-ray control curves utilized by Shimadzu, along with the factory-set dose program, gave rise to the unexpected result that the 30 pps protocol produces alower PAKR than that obtained with the 15 pps protocol. Of particular concern was that the27

AAPM REPORT NO. 125

Table 3. Shimadzu BRANSIST Filter Changeover Program28

FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

Figure 12. Shimadzu BRANSIST PAKR and detector entrance AKR versus PMMA thickness. Left: Fluoroscopy at
15 pps. Right: Fluoroscopy at 30 pps.Td is the calculated thickness of PMMA that doubles the PAKR.

Figure 13. PAKR measurements with two different SID settings. Data acquired using 20 cm PMMA, with the 23-cm
FOV, and for all Shimadzu BRANSIST protocol settings. Note that for all 10 pps/H settings the dose rates are greaterthan for any of the 15 pps settings; and that the 15 pps/H settings deliver a greater dose rate than the 30 pps/H settings.

29

AAPM REPORT NO. 125

highest PAKR occurred when the 10 pps/H setting was selected. Of equal concern was theobservation that in general the 15 pps/H PAKR values were greater than those for the 30 pps/H
settings. This is contradictory to the normal understanding (and de facto standard) that lower
fluoroscopy pulse rates result in lower patient dose rates. For this machine, and with the exception of the ablation modes, the lowest selectable pulse rates produce the highest patient dose
rates. Furthermore, it was revealed that the 10 pps/H mode was the default setting selected automatically on start-up of the system. Since most radiation safety programs teach that lower pulse
rates produce lower patient doses, the user must be cognizant that the Shimadzu BRANSIST
does not conform to this norm.
VII.C.2(iii). Toshiba Infinix CF-i and Infinix VF-i

Toshiba manufactures 10 different types of gantry systems, and with these systems there are
two collimator models employed. The angiography systems Infinix CF-i and Infinix VF-i employ
collimators BLA-800C and BLA-900A, respectively. The BLA-800C system was equipped withthe following filters: 0.2 mm Cu, 0.3 mm Cu, and 1.8 mm Al; while the BLA-900A included:
0.2 mm Cu, 0.3 mm Cu, 0.5 mm Cu, and 1.8 mm Al. 62 The ABC/ADRIQ control logic of
Toshiba cardiovascular equipment is believed to function in a manner similar to the Philips
angiographic equipment. However TG-125 was unable to gain access to a Toshiba angiographysystem to conduct a comprehensive evaluation. Hence, no additional data can be provided.
VII.C.2(iv). Hitachi Medical Systems

Hitachi Medical Systems was unable to provide potential angiography sites for TG-125 toperform evaluation and, therefore, no data are presented here.

VIII. Problem with Lack of Appropriate Standard
Beam Qualities
In the process of collecting data for the TG-125 report, a lack of appropriate standard beam
qualities for highly filtered fluoroscopic beams has been recognized. This problem is being
pointed out in this report so that positive actions may be taken by appropriate organizations andauthorities to remedy the situation. Specifically, there is a lack of standard beam qualities available for calibration of ionization chambers for the beam quality (spectra) being employed inclinical fluoroscopy systems designed for angiographic imaging.
VIII.A. Measured Fluoroscopic X-Ray Beam Quality
Depicted in Figure 14 is the fluoroscopic radiation beam quality, in terms of HVL, obtained
from the Siemens angiography equipment. The HVL data were obtained under the service modethat allowed manual selection of kVp and mA at a fixed exposure time of 100 ms. In this mode,
there was no ABC/ADRIQ intervention. As seen in Figure 14, the combination of thickest Cu filters (0.6, 0.9 mm Cu) with low tube potentials (60 to 75 kVp) yielded beam quality in the rangeof 6 to 9 mm Al HVL. Calibration of ionization chambers for this beam quality cannot be foundin any national calibration laboratories.
30

FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

Figure 14. Typical radiation beam quality (HVL) for angiography systems utilizing various thicknesses of Cu spectralbeam filtration.

VIII.B. The Beam Quality Available for Calibration
The instrumentation utilized for measuring fluoroscopic air kerma and AKR include airequivalent ionization chambers and energy-compensated solid-state detectors. The calibration ofsuch instruments should be ultimately traceable to the National Institute of Standards andTechnology (NIST),63 or equivalent national calibration standards. International ElectrotechnicalCommission (IEC) publication 61267 (ed. 2.0, 2005), “Medical Diagnostic X-ray Equipment Radiation Conditions for Use in the Determination of Characteristics”64 describes the set of calibration beams available in most national laboratories and are reproduced here in Table 4 andTable 5 with permission from the IEC.
VIII.C. The Mismatch of Beam Quality for Dosimetry
Most diagnostic instruments used for measuring patient/phantom skin dose are calibratedusing the RQR† series of beams. Instruments used for measuring image-receptor input dose are†

RQR: Radiation Qualities in Radiation beams emerging from the x-ray tube assembly.

31

AAPM REPORT NO. 125

Table 4. Characterization of Standard Radiation Qualities RQR 2 to RQR 10

Standard
Radiation
Quality

X-Ray Tube
Voltage(kVp)

Homogeneity
Coefficients

Nominal FirstHVL in Thickness
of Aluminum
(mm)

RQR 2

40

0.81

1.42

RQR 3

50

0.76

1.78

RQR 4

60

0.74

2.19

RQR 5

70

0.71

2.58

RQR 6

80

0.69

3.01

RQR 7

90

0.68

3.48

RQR 8

100

0.68

3.97

RQR 9

120

0.68

5.00

RQR 10

150

0.72

6.57

IEC 61267 ed. 2.0 Copyright © 2005 IEC Geneva, Switzerland

Table 5. Characterization of Standard Radiation Qualities RQA 2 to RQA 10

Standard
Radiation
Quality

X-Ray Tube
Voltage(kVp)

Added Filter
Thickness of
Aluminum(mm)

Nominal FirstHVL in Thickness
of Aluminum
(mm)

RQA 2

40

4

2.2

RQA 3

50

10

3.8

RQA 4

60

16

5.4

RQA 5

70

21

6.8

RQA 6

80

26

8.2

RQA 7

90

30

9.2

RQA 8

100

34

10.1

RQA 9

120

40

11.6

RQA 10

150

45

13.3

IEC 61267 ed. 2.0 Copyright © 2005 IEC Geneva, Switzerland

32

FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

typically calibrated using the RQA† series of beams. According to the IEC, the RQR series was
obtained by changing the voltage applied to a tungsten (W) target x-ray tube filtered with a few
millimeters of Al. The RQA series was obtained by adding the specified additional Al at eachbeam quality. As shown in Table 4, in each series the HVL increases with x-ray tube voltage.
Modern interventional fluoroscopic equipment incorporate beam filters with an atomic
number equal to or higher than that of Al, with Cu being the most common. The systems
described in this report were all filtered with combinations of Cu and Al, with two systems alsoutilizing a high atomic number material. As described elsewhere in this report, the filter may
either be programmed to the selected anatomical protocol and fluoroscopic dose setting, or
determined under dynamic control of the ABC/ADRIQ. Typically, systems of the latter typereduce the thickness of spectral filters as the patient/phantom thickness is increased. This wasevident in the graphs A of Figure 10. Representative data for the kVp and filter thickness combinations selected during fluoroscopy and acquisition are shown in the bar graphs of Figure 15.
The thickness of Cu filters (mm Cu) inserted by the ABC/ADRIQ for each phantom size isshown on the right ordinate. Notice that the tube potential increases while the Cu filter thickness
decreases as the PMMA phantom thickness increases.

Figure 15. Sample of the relationships between phantom thickness, x-ray tube potential, and Cu filtration for atypical modern angiography system.

†

RQA: Radiation Qualities based on a phantom made up of an Aluminum added filter.

33

AAPM REPORT NO. 125

Currently, the national laboratories are in the process of developing a set of calibration
beams suitable for interventional fluoroscopic systems. Until these beams are available, the medical physics community needs to take appropriate care in the selection of dose instruments toavoid having the measurements made on such systems confounded by spectral effects.

IX. Limitations of the Report
For the reasons listed below, the information contained in this report will have limitations
as to its accuracy and its application to any specific angiographic system.
(1) The development and progress of angiography imaging technology is so fast that the
information presented in this report might become obsolete within the next 3 to 5 years.
(2) The data collected and the analysis provided are based on newly manufactured equipment having the latest software versions as of February 2008. While newer versions ofsoftware have been implemented since that date, the basic operations remain the sameto this date (February 2012).
(3) This report should be reviewed as a “snapshot” of equipment design and functionality
for angiography systems available on the commercial market and accessible by TG-125
during the time period that the information and data were obtained.
(4) While image quality optimization was part of the initial charge, the task group members believe that this subject was sufficiently extensive that it deserves to be addressed
separately, perhaps by a new task group.
Although there were more than 20 angiography systems investigated by this task group, thedata presented in this report were derived from just four systems: one each from GE Healthcare,
Philips Healthcare, Shimadzu Medical Systems USA, and Siemens Medical Solutions, all ofwhich were installed in the institutions of the task group members. While it is difficult to predict
the technology of the future, it is believed that the use of thick spectral filtration and the programmed control of multiple imaging parameters will continue to be utilized by the manufacturers of interventional angiography systems for many years to come.

X. Conclusion and Discussion
Two of the three original charges assigned to TG-125, namely;(1) Explore and investigate the functionality of fluoroscopic automatic brightness (dose)
control logic (ABC/ADRIQ) in modern angiography systems, and(2) Describe the manner in which imaging parameters are programmed to work withchanging spectral filter thickness
have been accomplished. It is hoped that the information provided in this report will enhance thepracticing medical physicists’ working knowledge, and will thus facilitate their ability to meet
the National Council on Radiation Protection and Measurements (NCRP) recommendation that34

FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS“Interventionalists and qualified physicists should participate in the process for purchase andconfiguration of new fluoroscopes and fluoroscopy facilities.”65
It should be clear that the beam quality of modern cardiovascular angiography imaging systems can be quite different from traditional fluoroscopy equipment. On the other hand, newinstallations of traditional fluoroscopy equipment designed for upper-lower gastrointestinal
examinations, endoscopy, gastroenterology, and pain management have been found to also
employ added spectral filtration to reduce patient exposure, or PAK.66 The work of TG-125 hasrevealed a lack of standardization of radiation measurement instrument calibration at the beam
qualities being employed in modern image-guided interventional equipment. Additional work isneeded in order to understand the impact of beam quality on radiation measurement accuracy
and to determine if a new beam quality standard should be made available by calibration laboratories for radiation detectors used to measure fluoroscopic dose.
Since the power train (x-ray generator control, transformer, and exposure switching mechanism) of traditional fluoroscopy equipment is generally lower in power ratings than that of fluoroscopy systems designed for angiography applications, the radiation transparency and the
maximum patient thickness that can be properly imaged would be lower for the traditional
equipment.
No explicit image quality evaluation was included in this report, and no attempt was madeto validate whether the tested programs were appropriate for the intended clinical procedures.
Although it has been shown that the use of thick spectral filters is particularly beneficial for
pediatric fluoroscopy,67–69 where radiation sensitivity is a major concern,70 there was no attempt
made to determine if the equipment under study provided special programs for pediatricpatients. Likewise, there was no attempt to determine if the use of increased spectral filtration
could benefit the morbidly obese patient for which the potential for serious skin injury is a major
concern.71–73
Finally, the work of TG-125 was limited to the fluoroscopic operation of the imaging
equipment and did not include the acquisition modes (e.g., digital cine, digital angiography,
DSA, etc.). Although the acquisition modes often utilize the same signal measurement and generator control logic as that for the fluoroscopic operation, there is generally greater user control
over the selection of the EERD, spectral filtration, generator parameters, and image processing.
Thus the acquisition mode of operation would be an important topic for additional study andevaluation.

XI. Acknowledgments and Disclaimer
Members of TG-125 sincerely appreciate valuable discussions provided by the engineers
and scientists from (in alphabetical order) GE Healthcare, Hitachi Medical Systems, Philips
Healthcare, Shimadzu Medical Systems, Siemens Healthcare, and Toshiba Medical Systems.
Despite trade restrictions, the information provided by various individuals was very useful andassistance provided in looking into the hardware connection points and test points has ensured
the accuracy of the imaging parameters being measured.

35

AAPM REPORT NO. 125

The authors appreciate and thank the IEC for permission to reproduce information from its
international standard IEC 61267 ed. 2.0 (2005). All such excerpts are copyrighted by the IEC,
Geneva, Switzerland. All rights reserved. Further information on the IEC is available fromwww.iec.ch. IEC has no responsibility for the placement and context in which the excerpts andtheir contents are reproduced by the authors, nor is IEC in any way responsible for the othercontent or accuracy therein.

36

FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMS

Acronyms and Abbreviations in TG-125 Report

AAPM
ABC
ADRC
ADRIQ
AGC
AKR
Al
Au
CLT
cm
Cu
DQE
DSA
EERD
EP
FDA
FOV
fps
HU/sec
HVL
IEC
kVp
mA
lGy/s
lR/s
mGy/minms
NCRP
NEMA-SCAI
nGy/s
NIST
NTSC
PAK
PAKR
Pb
Pixel
PMMA

American Association of Physicists in Medicine
Automatic Brightness Control
Automatic Dose Rate Control
Automatic Dose Rate and Image Quality
Automatic Gain Control
Air Kerma Rate
AluminumGold
Critical lead thickness
Centimeter
Copper
Detective quantum efficiency
Digital subtraction angiography
Entrance exposure rate to the detector
Electrophysiology
U.S. Food and Drug Administration
Field of view
Frames per second
Heat Units per second
Half-value layer
International Electrotechnical Commission
Kilovolts peak
Milliampere
Microgray per second
Microroentgen per second
Milligray per minuteMillisecond
National Council on Radiation Protection and Measurements
National Electrical Manufacturers Association – Society for Cardiac
Angiography
Nanogray per second
National Institute of Standards and Technology
National Television System Committee
Patient Air Kerma
Patient Air Kerma Rate
Lead
Picture element
Polymethylmethacrylate
37

AAPM REPORT NO. 125

pps
PW
r
rms
RQA
RQR
R/min
SEER
SI
SID
SNR
Td
TG
TID
XRII
Z

Pulses per second
Pulse width
Grid ratio
Root mean square
Radiation Qualities based on a phantom made up of an Aluminum added filter
Radiation Qualities in Radiation beams emerging from the x-ray tube assembly
Roentgen per minute
Skin Entrance Exposure Rate
International System of Units
Source–to–image receptor distance
Signal-to-noise ratio
PMMA thickness to double the PAKR
Task Group
Tabletop–to–image receptor distance
X-ray image intensifier
Atomic number

38

FLUOROSCOPIC ABC/ADRC IN CARDIOVASCULAR AND ANGIOGRAPHY SYSTEMSAppendix
TG-125 Data Collection Methodology

1. Position the C-arm in a vertical x-ray beam position, with the image receptor at the top position, x-ray tube beneath the table.
2. Position the dosimeter chamber on the tabletop, centered in the FOV.
3. Place a support block on each side of the ionization chamber for the purpose of supporting
the PMMA sheets above the dosimeter.
4. Set the SID of the system to 120 cm (or maximum SID).
5. Position the tabletop vertically such that the dosimeter chamber is at the IEC reference point(15 cm below isocenter) as shown in Figure 8.
6. When collecting data, always initiate and stop a short “test” fluoroscopy exposure after achange in attenuator thickness and before collecting data. This step ensures that filter
changeover will occur, if necessary, following a change in attenuator thickness.
7. If a filter change is detected following increased PMMA in the beam, remove the last 1-in.
thick slab and increase the PMMA by four ¼-inch increments to determine more precisely
the thickness and exposure factors associated with the filter changeover. Repeat step 6 witheach increment of PMMA.
8. During fluoroscopy allow the parameters to stabilize, and then record the PMMA thickness,
kVp, mA, PW, filter selected, and PAKR.
9. Plot the results as shown in Figure 9 and Figure 10 in order to characterize the generator
power curve and the ABC/ADRIQ operational logic of the system.

39

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