Medical Societies Call for ‘ALARA+’ Safety Standard to Reduce Radiation and Injury Risks in Fluoroscopy Labs

Teams delivering minimally invasive care face radiation exposure and orthopedic injuries that could be reduced through new policies and modern technology

WASHINGTON—Nine leading medical societies are calling for new safety standards in fluoroscopy laboratories, often called cath labs, where clinicians performing minimally invasive procedures face radiation exposure and orthopedic injuries from heavy protective equipment. A report published simultaneously today in JSCAI, Heart Rhythm, JVIR, and JVS–Vascular Insights details an enhanced safety framework known as ALARA+, or “As Low and As Light as Reasonably Achievable.”

“How we think about safety was long guided by the old ALARA, or ‘as low as reasonably achievable.’ But that approach is no longer enough,” said Robert F. Riley, MD, MS, FSCAI, Chair of the Summit on Radiation and Orthopedic Risks in Fluoroscopic Labs, convened during the 2025 SCAI Scientific Sessions. “Traditional ALARA principles focused primarily on minimizing radiation exposure, but they did not fully account for the orthopedic strain caused by wearing heavy radiation protection during long procedures. The new framework, ALARA+, calls for protection strategies that are ‘as low and as light as reasonably achievable.’ It reflects a more complete view of safety by reducing radiation exposure while eliminating the orthopedic strain clinicians and staff experience from wearing heavy lead protection. This multisociety effort is a call to redesign fluoroscopy laboratories so safety is built into the environment, the equipment, and the standard of care.

Developed through a multisociety effort, the “ALARA+: Summit on Radiation and Orthopedic Risks in Fluoroscopic Laboratories” addresses the dual occupational hazards associated with fluoroscopic procedures: radiation exposure and the orthopedic strain caused by traditional protective equipment. The report endorsed by the Society for Cardiovascular Angiography and Interventions (SCAI), American College of Cardiology (ACC), Alliance for Cardiovascular Professionals (ACVP), American Society of Echocardiography (ASE), Heart Rhythm Society (HRS), Society of Interventional Radiology (SIR), Society of NeuroInterventional Surgery (SNIS), Society of Vascular and Interventional Neurology (SVIN), and the Society for Vascular Surgery (SVS).

Fluoroscopy is widely used to perform minimally invasive procedures that treat conditions such as heart attack, stroke, and vascular disease. Using real-time X-ray imaging, clinicians guide catheters and other devices through blood vessels to diagnose and treat disease without open surgery. While these procedures improve patient outcomes and shorten recovery times, they carry long-term occupational risks for the teams performing them, as they receive thousands of low-but-repeated radiation doses over the course of their career. To reduce exposure, clinicians often wear heavy lead or lead-equivalent protective garments that can weigh 15 to 20 pounds. However, the strain of wearing them during long procedures contributes to chronic neck, back, and joint injuries.

“These occupational harms affect every member of the procedural team and the healthcare system as a whole, carrying major financial and human costs,” said Summit Co-Chair Arnold H. Seto, MD, MPA, FSCAI. “Across fluoroscopy laboratories, clinicians and staff face both cumulative radiation exposure and the physical burden of heavy protective equipment. Over time, that means years of strain from protective gear and nonergonomic lab setups. The consequences are real. People develop chronic pain, require surgery, and some are left with severe spinal conditions that limit or even end their procedural careers. Maintaining a skilled workforce in these labs, which is already in limited supply, is essential to ensuring patients have access to these lifesaving procedures. As demand for minimally invasive procedures continues to grow, protecting and retaining experienced teams will be critical to preserving and expanding access to care.”

A 2025 Occupational Health Hazards report from SCAI found that roughly two-thirds of interventional cardiologists report musculoskeletal pain related to working in the catheterization laboratory or wearing radiation protection equipment. These risks affect the entire procedural team, including physicians, nurses, technologists, and imaging specialists. Trainees may accumulate higher exposure near the radiation source while developing procedural skills. Concerns about radiation exposure during pregnancy and the physical burden of protective lead are often cited as discouraging many women from entering or remaining in fluoroscopy-based specialties.

To address these risks, the multisociety report calls for several actions to improve safety in fluoroscopy laboratories, including:

· Accelerating adoption of modern radiation protection technologies such as suspended shielding systems and robotic positioning tools that reduce exposure without requiring clinicians to wear heavy lead garments
· Redesigning fluoroscopy laboratory environments with improved ergonomics, including optimized monitor placement and workflow that reduces physical strain
· Expanding real-time radiation monitoring so clinicians receive immediate feedback and can reduce exposure during procedures
· Strengthening education and training in radiation safety and exposure reduction for physicians, trainees, nurses, and technologists
· Implementing institutional policies that prioritize occupational safety and provide access to modern protection technologies
· Supporting regulatory and accreditation standards that promote safer fluoroscopy laboratory environments

“This multisociety effort to address radiation and injury risks not only protects today’s physicians and staff, but future generations planning to join the field”, said SNIS President Guilherme Dabus, MD. “They come to work every day with the goal of to providing the best patient care. It is our duty to make sure their environment is safe with the lowest occupational risk possible. We are looking forward to seeing the long-term benefits of new policies.”

DOI: https://doi.org/10.1016/j.jscai.2025.104166

Article URL when live: https://www.jscai.org/article/S2772-9303(25)01612-6/fulltext