Evaluation of Automated 2D-3D Image Overlay System Utilizing Subtraction of Bone Marrow Image for EVAR: Feasibility Study

Augmented Reality in Vascular and Endovascular Surgery: Scoping Review

Background

Technological advances have transformed vascular intervention in recent decades. In particular, improvements in imaging and data processing have allowed for the development of increasingly complex endovascular and hybrid interventions. Augmented reality (AR) is a subject of growing interest in surgery, with the potential to improve clinicians’ understanding of 3D anatomy and aid in the processing of real-time information. This study hopes to elucidate the potential impact of AR technology in the rapidly evolving fields of vascular and endovascular surgery.

Objective

The aim of this review is to summarize the fundamental concepts of AR technologies and conduct a scoping review of the impact of AR and mixed reality in vascular and endovascular surgery.

Methods

A systematic search of MEDLINE, Scopus, and Embase was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies written in English from inception until January 8, 2021, were included in the search. Combinations of the following keywords were used in the systematic search string: (“augmented reality” OR “hololens” OR “image overlay” OR “daqri” OR “magic leap” OR “immersive reality” OR “extended reality” OR “mixed reality” OR “head mounted display”) AND (“vascular surgery” OR “endovascular”). Studies were selected through a blinded process between 2 investigators (JE and AS) and assessed using data quality tools.

Results

AR technologies have had a number of applications in vascular and endovascular surgery. Most studies (22/32, 69%) used 3D imaging of computed tomography angiogram–derived images of vascular anatomy to augment clinicians’ anatomical understanding during procedures. A wide range of AR technologies were used, with heads up fusion imaging and AR head-mounted displays being the most commonly applied clinically. AR applications included guiding open, robotic, and endovascular surgery while minimizing dissection, improving procedural times, and reducing radiation and contrast exposure.

Conclusions

AR has shown promising developments in the field of vascular and endovascular surgery, with potential benefits to surgeons and patients alike. These include reductions in patient risk and operating times as well as in contrast and radiation exposure for radiological interventions. Further technological advances are required to overcome current limitations, including processing capacity and vascular deformation by instrumentation.

Efficacy of Fusion Imaging in Endovascular Revascularization of the Superficial Femoral Artery

BACKGROUND

The demand for endovascular revascularization (ER) to treat peripheral artery disease (PAD) has steadily increased. However, ER comes at the cost of increased contrast and radiation exposure, particularly in more complex cases. Fusion imaging is a new technology that may address these issues. The purpose of this study was to evaluate the efficacy of fusion imaging in ER of the superficial femoral artery (SFA).

METHODS

Patients with PAD undergoing ER of the SFA from February 2016 to July 2020 were retrospectively evaluated. A group of patients treated using fusion imaging was compared with a control group treated without fusion imaging. The primary end points were the contrast dose, fluoroscopy time, radiation dose, and operative time.

RESULTS

A total of 51 patients (fusion group, n = 26; control group, n = 25) underwent ER during the study period. Significantly lower iodinated contrast doses were observed in the fusion than in the control group (56.1 ± 23.7 vs. 87.9 ± 44.9 mL; P = 0.003), as well as significantly shorter fluoroscopy times (21.2 ± 11.1 vs. 44.9 ± 31.4 min; P = 0.001), lower radiation exposure (29.9 ± 8.9 vs. 122.2 ± 223.1 mGy; P = 0.04), and shorter operative times (88.3 ± 32.1 vs. 126.1 ± 66.8 min; P = 0.013).

CONCLUSIONS

The use of fusion imaging technology during ER of the SFA can significantly reduce the contrast dose, fluoroscopy time, radiation dose, and operative time.

Target vessel displacement during fenestrated and branched endovascular aortic repair and its implications for the role of traditional computed tomography angiography roadmaps

Background

This retrospective study quantifies target vessel displacement during fenestrated and branched endovascular aneurysm repair due to the introduction of stiff guidewires and stent graft delivery systems. The effect that intraoperative vessel displacement has on the usability of computed tomography angiography (CTA) roadmaps is also addressed.

Methods

Patients that underwent fenestrated or branched EVAR were included in this retrospective study. Two imaging datasets were collected from each patient: (I) preoperative CTA and (II) intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) acquired after the insertion of the stiff guidewire and stent graft delivery system. After image registration, the 3D coordinates of the ostium of the celiac artery, superior mesenteric artery, right renal artery and left renal artery were recorded in both the CTA and the ceCBCT dataset by two observers. The three-dimensional displacement of the ostia of the target vessels was calculated by subtracting the coordinates of CTA and ceCBCT from one another. Additionally, the tortuosity index and the maximum angulation of the aorta were calculated.

Results

In total 20 patients and 77 target vessels were included in this study. The ostium of the celiac, superior mesenteric, right renal and left renal artery underwent non-uniform three-dimensional displacement with mean absolute displacement of 8.2, 7.7, 8.2 and 6.2 mm, respectively. The average displacement of all different target vessels together was 7.8 mm. A moderate correlation between vessel displacement and the maximum angulation of the aortoiliac segment was found (Spearman's ρ=0.45, P<0.05).

Conclusions

The introduction of stiff endovascular devices during fenestrated or branched EVAR causes significant, non-uniform displacement of the ostium of the visceral and renal target vessels. Consequently, preoperative CTA roadmaps based on bone registration are suboptimal to guide target vessel catheterization during these procedures.

Accuracy of registration techniques and vascular imaging modalities in fusion imaging for aortic endovascular interventions: a phantom study

Background

This study aimed to assess the error of different registration techniques and imaging modalities for fusion imaging of the aorta in a standardized setting using a anthropomorphic body phantom.

Materials and methods

A phantom with the 3D printed vasculature of a patient suffering from an infrarenal aortic aneurysm was constructed. Pulsatile flow was generated via an external pump. CTA/MRA of the phantom was performed, and a virtual 3D vascular model was computed. Subsequently, fusion imaging was performed employing 3D-3D and 2D-3D registration techniques. Accuracy of the registration was evaluated from 7 right/left anterior oblique c-arm angulations using the agreement of centerlines and landmarks between the phantom vessels and the virtual 3D virtual vascular model. Differences between imaging modalities were assessed in a head-to-head comparison based on centerline deviation. Statistics included the comparison of means ± standard deviations, student’s t-test, Bland-Altman analysis, and intraclass correlation coefficient for intra- and inter-reader analysis.

Results

3D-3D registration was superior to 2D-3D registration, with the highest mean centerline deviation being 1.67 ± 0.24 mm compared to 4.47 ± 0.92 mm. The highest absolute deviation was 3.25 mm for 3D-3D and 6.25 mm for 2D-3D registration. Differences for all angulations between registration techniques reached statistical significance. A decrease in registration accuracy was observed for c-arm angulations beyond 30° right anterior oblique/left anterior oblique. All landmarks (100%) were correctly positioned using 3D-3D registration compared to 81% using 2D-3D registration. Differences in accuracy between CT and MRI were acceptably small. Intra- and inter-reader reliability was excellent.

Conclusion

In the realm of registration techniques, the 3D-3D method proved more accurate than did the 2D-3D method. Based on our data, the use of 2D-3D registration for interventions with high registration quality requirements (e.g., fenestrated aortic repair procedures) cannot be fully recommended. Regarding imaging modalities, CTA and MRA can be used equivalently.

Three cases of fusion imaging in endovascular treatment of occlusive peripheral artery disease

Endovascular treatment of peripheral artery disease has dramatically improved in the past decades; however, occlusive or stenotic lesions of the femoral-popliteal artery segment remain a significant challenge for vascular specialists. Real-time guidance based on vessel visualization might be helpful for successful recanalization. Herein, we present three successful cases of fusion imaging during endovascular treatment of the femoral-popliteal artery segments.

Identification of Parameters Influencing the Vascular Structure Displacement in Fusion Imaging during Endovascular Aneurysm Repair

PURPOSE

To quantify the displacement of the vascular structures after insertion of stiff devices during endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm and to identify potential parameters influencing this displacement.

MATERIALS AND METHODS

A total of 50 patients from a single center undergoing EVAR were prospectively enrolled between January 2016 and December 2017. Fusion imaging was employed using the EndoNaut (Therenva, Rennnes, France) station through a 3-dimensional (3D)/2-dimensional (2D) technology synchronizing the 3D computed tomography scan to the live intraoperative fluoroscopy. The accuracy of the fusion roadmap was evaluated before deployment by conventional digital subtraction angiogram on a single plane (with different C-arm incidences).

RESULTS

The mean displacement error of the ostium of the lowest renal artery was 4.1 ± 2.4 mm (range, 0-11.7 mm), with a left/right displacement of 1.6 ± 1.7 mm (range, 0-6.9 mm) and a craniocaudal displacement of 3.5 ± 2.4 mm (range, 0-11.3 mm). The correction required for the ostium of the lower renal artery was mostly cranial and to the left. Multiple linear regression analysis revealed only the sharpest angle between the aneurysm neck and sac as the factor influencing the accuracy of fusion imaging. All other parameters did not show any correlation.

CONCLUSIONS

This study identified the sources of fusion error after insertion of rigid material during EVAR. As the sharpest angulation between aneurysm neck and sac increases, the overall accuracy of the fusion might be affected.

The 2D-3D Registration Method in Image Fusion Is Accurate and Helps to Reduce the Used Contrast Medium, Radiation, and Procedural Time in Standard EVAR Procedures

OBJECTIVE

This study aimed to evaluate the accuracy and the effectiveness of 2D-3D registration method of image fusion (IF) technology in endovascular aneurysm repair (EVAR).

METHODS

We performed a review of our institutional endovascular aortic database of patients who had undergone EVAR between 2011 and 2015 before and after the installation of a 3D IF computed tomography system in our hybrid operating room.

RESULTS

The accuracy was assessed in 14 endovascular procedures and showed a median registration error of 1.8 mm at the origin of the right renal artery and 1.0 mm at the origin of the left renal artery and a complete visual accuracy in 42% of the cases. EVAR was performed using the intraoperative IF technique with a 2D-3D registration method in 105 patients (group IF), whereas 47 patients done without served as controls. The IF group had a significantly reduced amount of used contrast compared with controls with a median of 58 mL and P < 0.0001. The intraoperative exposition to radiation was similar between the 2 groups with a median dose area product of 2,343.7 cGy cm² in the IF group and 3,219 cGy cm² among the controls (P = 0.457). The radiation dose in the sub group IF (including patients operated by the 2 most experienced surgeons) was lower than that in sub controls (median, 1,087 cG cm² vs. 2,705.3 cG cm², P = 0.012). The procedure time and the time of intraoperative radiation did not differ between the study groups (P = 0.117 and 0.106, respectively), as did not fluoroscopy time in the sub group IF (median, 6.3 min, vs. 9.5 min, P = 0.067), but for the 2 most experienced surgeons, the procedural time was shortened when using IF (P = 0.002).

CONCLUSIONS

The 2D-3D registration method of IF guidance is accurate to delineate the vessels of interest and could help the execution of the EVAR procedures with a significantly reduced amount of contrast medium and also with reduced radiation and shorter procedural duration when surgeons are more familiar with EVAR and IF.

Computed tomography angiography-fluoroscopy image fusion allows visceral vessel cannulation without angiography during fenestrated endovascular aneurysm repair

BACKGROUND

Fenestrated endovascular aneurysm repair (FEVAR) is an evolving technique to treat juxtarenal abdominal aortic aneurysms (AAAs). Catheterization of visceral and renal vessels after the deployment of the fenestrated main body device is often challenging, usually requiring additional fluoroscopy and multiple digital subtraction angiograms. The aim of this study was to assess the clinical utility and accuracy of a computed tomography angiography (CTA)-fluoroscopy image fusion technique in guiding visceral vessel cannulation during FEVAR.

METHODS

Between August 2014 and September 2016, all consecutive patients who underwent FEVAR at our institution using image fusion guidance were included. Preoperative CTA images were fused with intraoperative fluoroscopy after coregistering with non-contrast-enhanced cone beam computed tomography (syngo 3D3D image fusion; Siemens Healthcare, Forchheim, Germany). The ostia of the visceral vessels were electronically marked on CTA images (syngo iGuide Toolbox) and overlaid on live fluoroscopy to guide vessel cannulation after fenestrated device deployment. Clinical utility of image fusion was evaluated by assessing the number of dedicated angiograms required for each visceral or renal vessel cannulation and the use of optimized C-arm angulation. Accuracy of image fusion was evaluated from video recordings by three raters using a binary qualitative assessment scale.

RESULTS

A total of 26 patients (17 men; mean age, 73.8 years) underwent FEVAR during the study period for juxtarenal AAA (17), pararenal AAA (6), and thoracoabdominal aortic aneurysm (3). Video recordings of fluoroscopy from 19 cases were available for review and assessment. A total of 46 vessels were cannulated; 38 of 46 (83%) of these vessels were cannulated without angiography but based only on image fusion guidance: 9 of 11 superior mesenteric artery cannulations and 29 of 35 renal artery cannulations. Binary qualitative assessment showed that 90% (36/40) of the virtual ostia overlaid on live fluoroscopy were accurate. Optimized C-arm angulations were achieved in 35% of vessel cannulations (0/9 for superior mesenteric artery cannulation, 12/25 for renal arteries).

CONCLUSIONS

Preoperative CTA-fluoroscopy image fusion guidance during FEVAR is a valuable and accurate tool that allows visceral and renal vessel cannulation without the need of dedicated angiograms, thus avoiding additional injection of contrast material and radiation exposure. Further refinements, such as accounting for device-induced aortic deformation and automating the image fusion workflow, will bolster this technology toward optimal routine clinical use.

Prospective evaluation of MR overlay on real-time fluoroscopy for percutaneous extremity biopsies of bone lesions visible on MRI but not on CT in children in the interventional radiology suite

Magnetic resonance imaging (MRI) often provides better visualization of bone marrow abnormalities than computed tomography (CT) or fluoroscopy, but bone biopsies are usually performed using conventional CT or, more recently, C-arm CT guidance. Biopsies of bone lesions solely visible on MRI are often challenging to localize and require the operator to review the MRI on a separate console to correlate with MRI anatomical landmarks during the biopsy. The MR overlay technique facilitates such biopsies in the angiographic suite by allowing the pre-procedural 3-D MRI to be overlaid on intraprocedural 2-D fluoroscopy. This study describes our initial experience with the MR overlay technique in the angiography suite during pediatric percutaneous extremity bone biopsies of lesions visible on MRI but not on CT or fluoroscopy and demonstrates its utility in relevant clinical cases.

Real-Time 3D CT Image Guidance for Transjugular Intrahepatic Portosystemic Shunt Creation Using Preoperative CT: A Prospective Feasibility Study of 20 Patients

OBJECTIVE

The purpose of this study is to prospectively evaluate the feasibility and efficacy of real-time 3D CT image guidance during transjugular intrahepatic portosystemic shunt (TIPS) creation.

SUBJECTS AND METHODS

Between October 2013 and December 2013, a total of 20 patients were prospectively enrolled in the present study. Previously acquired portal venous phase CT datasets and intraoperative CT datasets were registered on a dedicated workstation. We accomplished semiautomatic registration for the datasets of 11 of 20 patients (55%), and we performed manual registration for the datasets of the remaining nine patients. The selected volume of interest of the CT image showing the portal vein vasculature was overlaid onto the fluoroscopic display to provide real-time 3D CT image guidance during the procedure.

RESULTS

For all 20 patients, TIPS procedures were successfully performed by the same operator. The mean (± SD) number of needle passes required for portal vein entry was 1.8 ± 1.1 passes (range, 1-5 passes). The mean duration of radiographic fluoroscopy was 3.5 ± 1.1 minutes for portal vein entry and 11.4 ± 2.1 minutes for the whole procedure. The mean radiation dose used for the whole TIPS procedure was 295.5 ± 66.6 Gy · cm². No major technical complications were observed.

CONCLUSION

Real-time 3D guidance with the use of preoperative CT is feasible, safe, and effective for assisting in the creation of TIPS. This approach may result in a shorter procedural time and less radiation exposure. However, future studies are required to compare this method with other mapping techniques.

Meta-analysis of Cumulative Radiation Duration and Dose During EVAR Using Mobile, Fixed, or Fixed/3D Fusion C-Arms

Purpose: To investigate the total fluoroscopy time and radiation exposure dose during endovascular aortic repairs using mobile, fixed, or fixed C-arms with 3-dimensional image fusion (3D-IF). Methods: A systematic search was performed to identify original articles reporting fluoroscopy time (FT) and the kerma area product (KAP) during endovascular aortic repairs. Data were grouped by noncomplex or complex (fenestrated, branched, or chimney) repairs and stratified by type of C-arm. The search identified 27 articles containing 51 study groups (35 noncomplex and 16 complex) that included 3444 patients. Random-effects meta-analysis and meta-regression models were used to calculate the pooled mean estimates of KAP and FT, as well as any effect of equipment or type of intervention. Results are presented with the 95% confidence interval and the statistical heterogeneity ( I2). Results: Within the noncomplex procedure studies, a significant (p<0.001) increase was found in the pooled mean KAP estimate in the fixed C-arm group (181 Gy·cm2, 95% CI 129 to 233; I2=99.7) compared with the mobile C-arm (78 Gy·cm2, 95% CI 59.6 to 97.3; I2=99.6). For complex cases, use of 3D-IF showed a significantly (p<0.001) lower mean KAP (139 Gy·cm2, 95% CI 85 to 191; I2=94%) compared to using fixed C-arms without 3D-IF (487 Gy·cm2, 95% CI 331 to 643; I2=94%). Conclusion: For equivalent fluoroscopy times, the use of a fixed C-arm in noncomplex procedures leads to higher patient radiation doses compared to a mobile C-arm. Complex procedures, which are predominantly performed using fixed C-arms, are associated with the highest radiation dose per intervention. Using fixed C-arms combined with 3D-IF techniques during complex cases might seem an adequate method to compensate for the higher radiation doses measured when a fixed C-arm is used.

Fusion Imaging to Support Endovascular Aneurysm Repair Using 3D-3D Registration

Purpose: To evaluate the feasibility and accuracy of fusion imaging (FI) during endovascular aneurysm repair (EVAR). Methods: FI was performed in 101 consecutive EVAR patients (median age 72 years; 93 men) using automatic registration of the preoperative computed tomography angiography (CTA) with an intraoperative noncontrast cone beam CT (nCBCT; 3D-3D registration). Operative landmarks defined on the CTA were then overlaid in 3 dimensions on fluoroscopy images. Accuracy was measured as the deviation of the position of the lowest renal artery between the FI and angiography. Factors potentially influencing accuracy (α angle, β angle, anesthesia, tortuosity index, neck calcification, neck length, CTA slice thickness, and conventional or sac sealing stent-graft) were analyzed in a multivariate linear regression model. Results: Median procedure time for nCBCT was 3 minutes (range 2–20), with 4 minutes (range 0.4–15) for registration. An automatic registration tool was used successfully in 90 (89%) patients. Median craniocaudal deviation of the FI was 3 mm (range 0–15). Full accuracy (<1-mm deviation) was seen in 23 (23%) patients, 1- to 3-mm deviation in 23 (23%), 4- to 5-mm deviation in 22 (22%), and >5-mm deviation in 33 (33%). Caudal deviation potentially resulting in renal coverage was seen in 9 (9%). Lateral plus craniocaudal deviation was a median 5.8 mm (range 0–22). The position of the lowest renal artery compared to the FI was left and cranial in 62 (61%). Aneurysm morphology (β angle, p=0.04), CTA slice thickness (p=0.02), and the use of 2 stiff guidewires in endovascular aneurysm sealing (p=0.01) influenced the overlay accuracy. Conclusion: Fusion imaging can be integrated into a daily workflow adding little to the procedure time. Craniocaudal accuracy (<5 mm) was achieved in 68% of cases, allowing optimal C-arm and angiographic catheter positioning or cannulation of target vessels in most patients. However, the accuracy of FI does not allow a noncontrast EVAR procedure without confirmation of FI overlay by a minimal contrast injection or vessel cannulation.

A Comparison of Accuracy of Image- versus Hardware-based Tracking Technologies in 3D Fusion in Aortic Endografting

OBJECTIVES

Fusion of three-dimensional (3D) computed tomography and intraoperative two-dimensional imaging in endovascular surgery relies on manual rigid co-registration of bony landmarks and tracking of hardware to provide a 3D overlay (hardware-based tracking, HWT). An alternative technique (image-based tracking, IMT) uses image recognition to register and place the fusion mask. We present preliminary experience with an agnostic fusion technology that uses IMT, with the aim of comparing the accuracy of overlay for this technology with HWT.

METHOD

Data were collected prospectively for 12 patients. All devices were deployed using both IMT and HWT fusion assistance concurrently. Postoperative analysis of both systems was performed by three blinded expert observers, from selected time-points during the procedures, using the displacement of fusion rings, the overlay of vascular markings and the true ostia of renal arteries. The Mean overlay error and the deviation from mean error was derived using image analysis software. Comparison of the mean overlay error was made between IMT and HWT. The validity of the point-picking technique was assessed.

RESULTS

IMT was successful in all of the first 12 cases, whereas technical learning curve challenges thwarted HWT in four cases. When independent operators assessed the degree of accuracy of the overlay, the median error for IMT was 3.9 mm (IQR 2.89-6.24, max 9.5) versus 8.64 mm (IQR 6.1-16.8, max 24.5) for HWT (p = .001). Variance per observer was 0.69 mm(2) and 95% limit of agreement ±1.63.

CONCLUSION

In this preliminary study, the error of magnitude of displacement from the "true anatomy" during image overlay in IMT was less than for HWT. This confirms that ongoing manual re-registration, as recommended by the manufacturer, should be performed for HWT systems to maintain accuracy. The error in position of the fusion markers for IMT was consistent, thus may be considered predictable.

New simple image overlay system using a tablet PC for pinpoint identification of the appropriate site for anastomosis in peripheral arterial reconstruction

PURPOSE

To evaluate the accuracy and utility of a new image overlay system using a tablet PC for patients undergoing peripheral arterial reconstruction.

METHODS

Eleven limbs treated with distal bypass surgery were studied. Three-dimensional images obtained by processing a preoperative contrast-enhanced computed tomography scan were superimposed onto the back-camera images of a tablet PC. We used this system to pinpoint a planned distal anastomotic site preoperatively and to make a precise incision directly above it during surgery. We used a branch artery near the distal anastomotic site as a reference point and the accuracy of the system was validated by comparing its results with the intraoperative findings. The precision of the system was also compared with that of a preoperative ultrasonographic examination.

RESULTS

Both the image overlay system and ultrasonography (US) accurately identified the target branch artery in all except one limb. In that limb, which had a very small reference branch artery, preoperative US wrongly identified another branch, whereas the image overlay system located the target branch with an error of 10 mm.

CONCLUSIONS

Our image overlay system was easy to use and allowed us to precisely identify a target artery preoperatively. Therefore, this system could be helpful for pinpointing the most accurate incision site during surgery.

Early experience with X-ray magnetic resonance fusion for low-flow vascular malformations in the pediatric interventional radiology suite

This technical innovation describes our experience using an X-ray magnetic resonance fusion (XMRF) software program to overlay 3-D MR images on real-time fluoroscopic images during sclerotherapy procedures for vascular malformations at a large pediatric institution. Five cases have been selected to illustrate the application and various clinical utilities of XMRF during sclerotherapy procedures as well as the technical limitations of this technique. The cases demonstrate how to use XMRF in the interventional suite to derive additional information to improve therapeutic confidence with regards to the extent of lesion filling and to guide clinical management in terms of intraprocedural interventional measures.

Feasibility and accuracy of fusion imaging during thoracic endovascular aortic repair

OBJECTIVE

To evaluate accuracy and feasibility of fusion imaging during thoracic endovascular aortic repair (TEVAR).

METHODS

From January 2013 to January 2015 fusion imaging was used in 18 TEVAR procedures. Patients were prospectively enrolled for the survey and informed consent was obtained. Planning of the procedure and computed tomography (CT) angiography (CTA) segmentation with determination of all relevant surgical landmarks that should be displayed on fusion imaging was done using the preoperative CTA data. The registration was done with an intraoperative noncontrast-enhanced cone beam CT and CTA (three-dimensional [3D]-3D registration; n = 15) or with two fluoroscopic images in anteroposterior and lateral projection and the CTA (two-dimensional-3D registration; n = 3). An intraoperative digital subtraction angiography was performed to adjust fusion imaging and to allow accuracy measurement.

RESULTS

Fusion imaging was possible in all included patients. The median dose for noncontrast-enhanced cone beam CT imaging was 28.6 Gy/cm(2) (range, 17.9-43.3) and 0.46 Gy cm(2) for two fluoroscopic images in the two-dimensional-3D group. Full accuracy was achieved in two cases (11%), with a median deviation of 11.7 mm (range, 0.0-37.2). Manual realignment was possible in all cases.

CONCLUSIONS

This early experience shows that fusion imaging is feasible in TEVAR procedures using different registration methods. However, it shows a significant deviation in thoracic procedures because of different sources of error, making confirmation of fusion overlay with a digital subtraction angiography necessary in any case.

Quantification of Respiratory Movement of the Aorta and Side Branches

Purpose: To assess and quantify the magnitude and direction of respiratory movement of the aorta and origins of its side branches. Methods: A quantitative 3-dimensional (3D) subtraction analysis of computed tomography (CT) scans during inspiration and expiration was performed to determine the respiratory geometric movements of the aorta and side branches in 60 patients. During breath-hold expiration and inspiration, 1-mm-thick CT slices of the aorta were acquired in unenhanced and contrast-enhanced scans. The datasets were compared using dedicated multiplanar reformation image subtraction software to determine the change in position of relevant anatomic sections, including the ascending thoracic aorta (AA), the origins of the brachiocephalic artery (BA) and left subclavian artery (LSA), the descending thoracic aorta (DTA) at the level of the tenth thoracic vertebra, as well as the origins of the celiac trunk, superior mesenteric artery, and the renal arteries. Results: Complex movement was visible during inspiration; the regions of interest in the thoracic aorta and side branches moved in the anterior, medial, and caudal directions compared with the expiration state. Mean 3D movement vectors (± standard deviation) were 8.9±3.6 mm (AA), 12.0±4.1 mm (BA), 11.1±3.9 mm (LSA), and 4.9±2.5 mm (DTA). Abdominal side branches moved in the caudal direction 1.3±1.1 mm. There was significantly less movement in the DTA compared to AA (p<0.001). The correlation coefficient between the extent of LSA movement and thoracic excursion was 0.78. Conclusion: The aorta and side branches undergo considerable respiratory movement. The results from this study provide an important contribution to understanding aortic dynamics.

Automatic detection of selective arterial devices for advanced visualization during abdominal aortic aneurysm endovascular repair

Here we address the automatic segmentation of endovascular devices used in the endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) that deform vascular tissues. Using this approach, the vascular structure is automatically reshaped solving the issue of misregistration observed on 2D/3D image fusion for EVAR guidance. The endovascular devices we considered are the graduated pigtail catheter (PC) used for contrast injection and the stent-graft delivery device (DD). The segmentation of the DD was enhanced using an asymmetric Frangi filter. The segmented geometries were then analysed using their specific features to remove artefacts. The radiopaque markers of the PC were enhanced using a fusion of Hessian and newly introduced gradient norm shift filters. Extensive experiments were performed using a database of images taken during 28 AAA-EVAR interventions. This dataset was divided into two parts: the first half was used to optimize parameters and the second to compile performances using optimal values obtained. The radiopaque markers of the PC were detected with a sensitivity of 88.3% and a positive predictive value (PPV) of 96%. The PC can therefore be positioned with a majority of its markers localized while the artefacts were all located inside the vessel lumen. The major parts of the DD, the dilatator tip and the pusher surfaces, were detected accurately with a sensitivity of 85.9% and a PPV of 88.7%. The less visible part of the DD, the stent enclosed within the sheath, was segmented with a sensitivity of 63.4% because the radiopacity of this region is low and uneven. The centreline of the DD in this stent region was alternatively traced within a 0.74 mm mean error. The automatic segmentation of endovascular devices during EVAR is feasible and accurate; it could be useful to perform elastic registration of the vascular lumen during endovascular repair.