Glass-Fiber-based MR-safe Guidewire for MR Imaging-guided Endovascular Interventions: In Vitro and Preclinical in Vivo Feasibility Study

Clinical impact of novel CMR technology on patients with congenital heart disease. A scientific statement of the Association for European Pediatric and Congenital Cardiology (AEPC) and the European Association of Cardiovascular Imaging (EACVI) of the ESC

Cardiovascular magnetic resonance (CMR) imaging is recommended in patients with congenital heart disease (CHD) in clinical practice guidelines as the imaging standard for a large variety of diseases. As CMR is evolving, novel techniques are becoming available. Some of them are already used clinically, whereas others still need further evaluation. In this statement the authors give an overview of relevant new CMR techniques for the assessment of CHD. Studies with reference values for these new techniques are listed in the supplement.

Current State of MRI-Guided Endovascular Arterial Interventions: A Systematic Review of Preclinical and Clinical Studies

BACKGROUND

MRI guidance of arterial endovascular interventions could be beneficial as it does not require radiation exposure, allows intrinsic blood-tissue contrast, and enables three-dimensional and functional imaging, however, clinical applications are still limited.

PURPOSE

To review the current state of MRI-guided arterial endovascular interventions and to identify the most commonly reported challenges.

STUDY TYPE

Systematic review.

POPULATION

Pubmed, Embase, Web of Science, and The Cochrane Library were systematically searched to find relevant articles. The search strategy combined synonyms for vascular pathology, endovascular therapy, and real-time MRI guidance.

FIELD STRENGTH/SEQUENCE

No field strength or sequence restrictions were applied.

ASSESSMENT

Two reviewers independently identified and reviewed the original articles and extracted relevant data.

STATISTICAL TESTS

Results of the included original articles are reported.

RESULTS

A total of 24,809 studies were identified for screening. Eighty-eight studies were assessed for eligibility, after which data were extracted from 43 articles (6 phantom, 33 animal, and 4 human studies). Reported technical success rates for animal and human studies ranged between 42% to 100%, and the average complication rate was 5.8% (animal studies) and 8.8% (human studies). Main identified challenges were related to spatial and temporal resolution as well as safety, design, and scarcity of current MRI-compatible endovascular devices.

DATA CONCLUSION

MRI guidance of endovascular arterial interventions seems feasible, however, included articles included mostly small single-center case series. Several hurdles remain to be overcome before larger trials can be undertaken. Main areas of research should focus on adequate imaging protocols with integrated tracking of dedicated endovascular devices.

MRI-guided endovascular intervention: current methods and future potential

INTRODUCTION

Image-guided endovascular interventions, performed using the insertion and navigation of catheters through the vasculature, have been increasing in number over the years, as minimally invasive procedures continue to replace invasive surgical procedures. Such endovascular interventions are almost exclusively performed under x-ray fluoroscopy, which has the best spatial and temporal resolution of all clinical imaging modalities. Magnetic resonance imaging (MRI) offers unique advantages and could be an attractive alternative to conventional x-ray guidance, but also brings with it distinctive challenges.

AREAS COVERED

In this review, the benefits and limitations of MRI-guided endovascular interventions are addressed, systems and devices for guiding such interventions are summarized, and clinical applications are discussed.

EXPERT OPINION

MRI-guided endovascular interventions are still relatively new to the interventional radiology field, since significant technical hurdles remain to justify significant costs and demonstrate safety, design, and robustness. Clinical applications of MRI-guided interventions are promising but their full potential may not be realized until proper tools designed to function in the MRI environment are available. Translational research and further preclinical studies are needed before MRI-guided interventions will be practical in a clinical interventional setting.

Interventional cardiac MRI using an add-on parallel transmit MR system: In vivo experience in sheep

PURPOSE

We present in vivo testing of a parallel transmit system intended for interventional MR-guided cardiac procedures.

METHODS

The parallel transmit system was connected in-line with a conventional 1.5 Tesla MRI system to transmit and receive on an 8-coil array. The system used a current sensor for real-time feedback to achieve real-time current control by determining coupling and null modes. Experiments were conducted on 4 Charmoise sheep weighing 33.9-45.0 kg with nitinol guidewires placed under X-ray fluoroscopy in the atrium or ventricle of the heart via the femoral vein. Heating tests were done in vivo and post-mortem with a high RF power imaging sequence using the coupling mode. Anatomical imaging was done using a combination of null modes optimized to produce a useable B₁ field in the heart.

RESULTS

Anatomical imaging produced cine images of the heart comparable in quality to imaging with the quad mode (all channels with the same amplitude and phase). Maximum observed temperature increases occurred when insulation was stripped from the wire tip. These were 4.1℃ and 0.4℃ for the coupling mode and null modes, respectively for the in vivo case; increasing to 6.0℃ and 1.3℃, respectively for the ex vivo case, because cooling from blood flow is removed. Heating < 0.1℃ was observed when insulation was not stripped from guidewire tips. In all tests, the parallel transmit system managed to reduce the temperature at the guidewire tip.

CONCLUSION

We have demonstrated the first in vivo usage of an auxiliary parallel transmit system employing active feedback-based current control for interventional MRI with a conventional MRI scanner.

Catheter-based Arterial Input Function Determination for Myocardial Perfusion Measurements

The quantification of myocardial perfusion with contrast agent (CA) tracers requires the precise knowledge of the arterial input function (AIF). In this study a method for MR-guided vascular interventions is evaluated that determines the AIF via an active tracking catheter during targeted CA injection. A phantom experiment with a dialysis filter was conducted to measure the AIF using an active catheter and a dynamic image series as reference. To compensate for dilution and coil sensitivity effects, correction methods were developed for the catheter-based AIF determination. From the dynamic MR measurements in the perfusion phantom quantitative perfusion maps were calculated by a deconvolution of the measured CA concentration with the AIF, and additional flow measurements were used to normalize the perfusion map. The signal-time-curves of the measured AIF using the catheter-based and imaging-based methods agree while the absolute values differ by a scaling factor of about 9. After normalization to the surrounding flow, both perfusion techniques are in excellent agreement. Catheter-based AIF measurements are feasible but require an additional normalization which can be determined from a flow measurement. The technique might enable faster perfusion measurements during cardiovascular interventions.

Improved 3D Catheter Shape Estimation Using Ultrasound Imaging for Endovascular Navigation: A Further Study

OBJECTIVE

Two-dimensional fluoroscopy is the standard guidance imaging method for closed endovascular intervention. However, two-dimensional fluoroscopy lacks depth perception for the intervention catheter and causes radiation exposure for both surgeons and patients. In this paper, we extend our previous study and develop the improved three-dimensional (3D) catheter shape estimation using ultrasound imaging. In addition, we perform further quantitative evaluations of endovascular navigation.

METHOD

First, the catheter tracking accuracy in ultrasound images is improved by adjusting the state vector and adding direction information. Then, the 3D catheter points from the catheter tracking are further optimized based on the 3D catheter shape optimization with a high-quality sample set. Finally, the estimated 3D catheter shapes from ultrasound images are overlaid with preoperative 3D tissue structures for the intuitive endovascular navigation.

RESULTS

the tracking accuracy of the catheter increased by 24.39%, and the accuracy of the catheter shape optimization step also increased by approximately 17.34% compared with our previous study. Furthermore, the overall error of catheter shape estimation was further validated in the catheter intervention experiment of in vitro cardiovascular tissue and in a vivo swine, and the errors were 2.13 mm and 3.37 mm, respectively.

CONCLUSION

Experimental results demonstrate that the improved catheter shape estimation using ultrasound imaging is accurate and appropriate for endovascular navigation.

SIGNIFICANCE

Improved navigation reduces the radiation risk because it decreases use of X-ray imaging. In addition, this navigation method can also provide accurate 3D catheter shape information for endovascular surgery.

Magnetic resonance imaging for pathobiological assessment and interventional treatment of the coronary arteries

X-ray-based fluoroscopy is the standard tool for diagnostics and intervention in coronary artery disease. In recent years, computed tomography has emerged as a non-invasive alternative to coronary angiography offering detection of coronary calcification and imaging of the vessel lumen by the use of iodinated contrast agents. Even though currently available invasive or non-invasive techniques can show the degree of vessel stenosis, they are unable to provide information about biofunctional plaque properties, e.g. plaque inflammation. Furthermore, the use of radiation and the necessity of iodinated contrast agents remain unfavourable prerequisites. Magnetic resonance imaging (MRI) is a radiation-free alternative to X-ray which offers anatomical and functional imaging contrasts fostering the idea of non-invasive biofunctional assessment of the coronary vessel wall. In combination with molecular contrast agents that target-specific epitopes of the vessel wall, MRI might reveal unique plaque properties rendering it, for example, ‘vulnerable and prone to rupture’. Early detection of these lesions may allow for early or prophylactic treatment even before an adverse coronary event occurs. Besides diagnostic imaging, advances in real-time image acquisition and motion compensation now provide grounds for MRI-guided coronary interventions. In this article, we summarize our research on MRI-based molecular imaging in cardiovascular disease and feature our advances towards real-time MRI-based coronary interventions in a porcine model.

Real-time 3T MRI-guided cardiovascular catheterization in a porcine model using a glass-fiber epoxy-based guidewire

PURPOSE

Real-time magnetic resonance imaging (MRI) is a promising alternative to X-ray fluoroscopy for guiding cardiovascular catheterization procedures. Major challenges, however, include the lack of guidewires that are compatible with the MRI environment, not susceptible to radiofrequency-induced heating, and reliably visualized. Preclinical evaluation of new guidewire designs has been conducted at 1.5T. Here we further evaluate the safety (device heating), device visualization, and procedural feasibility of 3T MRI-guided cardiovascular catheterization using a novel MRI-visible glass-fiber epoxy-based guidewire in phantoms and porcine models.

METHODS

To evaluate device safety, guidewire tip heating (GTH) was measured in phantom experiments with different combinations of catheters and guidewires. In vivo cardiovascular catheterization procedures were performed in both healthy (N = 5) and infarcted (N = 5) porcine models under real-time 3T MRI guidance using a glass-fiber epoxy-based guidewire. The times for each procedural step were recorded separately. Guidewire visualization was assessed by measuring the dimensions of the guidewire-induced signal void and contrast-to-noise ratio (CNR) between the guidewire tip signal void and the blood signal in real-time gradient-echo MRI (specific absorption rate [SAR] = 0.04 W/kg).

RESULTS

In the phantom experiments, GTH did not exceed 0.35°C when using the real-time gradient-echo sequence (SAR = 0.04 W/kg), demonstrating the safety of the glass-fiber epoxy-based guidewire at 3T. The catheter was successfully placed in the left ventricle (LV) under real-time MRI for all five healthy subjects and three out of five infarcted subjects. Signal void dimensions and CNR values showed consistent visualization of the glass-fiber epoxy-based guidewire in real-time MRI. The average time (minutes:seconds) for the catheterization procedure in all subjects was 4:32, although the procedure time varied depending on the subject's specific anatomy (standard deviation = 4:41).

CONCLUSIONS

Real-time 3T MRI-guided cardiovascular catheterization using a new MRI-visible glass-fiber epoxy-based guidewire is feasible in terms of visualization and guidewire navigation, and safe in terms of radiofrequency-induced guidewire tip heating.

CT and MRI compatibility of flexible 3D-printed materials for soft actuators and robots used in image-guided interventions

PURPOSE

Three-dimensional (3D) printing allows for the fabrication of medical devices with complex geometries, such as soft actuators and robots that can be used in image-guided interventions. This study investigates flexible and rigid 3D-printing materials in terms of their impact on multimodal medical imaging.

METHODS

The generation of artifacts in clinical computer tomography (CT) and magnetic resonance (MR) imaging was evaluated for six flexible and three rigid materials, each with a cubical and a cylindrical geometry, and for one exemplary flexible fluidic actuator. Additionally, CT Hounsfield units (HU) were quantified for various parameter sets iterating peak voltage, x-ray tube current, slice thickness, and convolution kernel.

RESULTS

We found the image artifacts caused by the materials to be negligible in both CT and MR images. The HU values mainly depended on the elemental composition of the materials and applied peak voltage was ranging between 80 and 140 kVp. Flexible, nonsilicone-based materials were ranged between 51 and 114 HU. The voltage dependency was less than 29 HU. Flexible, silicone-based materials were ranged between 60 and 365 HU. The voltage-dependent influence was as large as 172 HU. Rigid materials ranged between -69 and 132 HU. The voltage-dependent influence was <33 HU.

CONCLUSIONS

All tested materials may be employed for devices placed in the field of view during CT and MR imaging as no significant artifacts were measured. Moreover, the material selection in CT could be based on the desired visibility of the material depending on the application. Given the wide availability of the tested materials, we expect our results to have a positive impact on the development of devices and robots for image-guided interventions.

Real-time magnetic resonance imaging - guided coronary intervention in a porcine model

X-ray fluoroscopy is the gold standard for coronary diagnostics and intervention. Magnetic resonance imaging is a radiation-free alternative to x-ray with excellent soft tissue contrast in arbitrary slice orientation. Here, we assessed real-time MRI-guided coronary interventions from femoral access using newly designed MRI technologies. Six Goettingen minipigs were used to investigate coronary intervention using real-time MRI. Catheters were custom-designed and equipped with an active receive tip-coil to improve visibility and navigation capabilities. Using modified standard clinical 5 F catheters, intubation of the left coronary ostium was successful in all animals. For the purpose of MR-guided coronary interventions, a custom-designed 8 F catheter was used. In spite of the large catheter size, and therefore limited steerability, intubation of the left coronary ostium was successful in 3 of 6 animals within seconds. Thereafter, real-time guided implantation of a non-metallic vascular scaffold into coronary arteries was possible. This study demonstrates that real-time MRI-guided coronary catheterization and intervention via femoral access is possible without the use of any contrast agents or radiation, including placement of non-metallic vascular scaffolds into coronary arteries. Further development, especially in catheter and guidewire technology, will be required to drive forward routine MR-guided coronary interventions as an alternative to x-ray fluoroscopy.

Right heart catheterization using metallic guidewires and low SAR cardiovascular magnetic resonance fluoroscopy at 1.5 Tesla: first in human experience

BACKGROUND

Cardiovascular magnetic resonance (CMR) fluoroscopy allows for simultaneous measurement of cardiac function, flow and chamber pressure during diagnostic heart catheterization. To date, commercial metallic guidewires were considered contraindicated during CMR fluoroscopy due to concerns over radiofrequency (RF)-induced heating. The inability to use metallic guidewires hampers catheter navigation in patients with challenging anatomy. Here we use low specific absorption rate (SAR) imaging from gradient echo spiral acquisitions and a commercial nitinol guidewire for CMR fluoroscopy right heart catheterization in patients.

METHODS

The low-SAR imaging protocol used a reduced flip angle gradient echo acquisition (10° vs 45°) and a longer repetition time (TR) spiral readout (10 ms vs 2.98 ms). Temperature was measured in vitro in the ASTM 2182 gel phantom and post-mortem animal experiments to ensure freedom from heating with the selected guidewire (150 cm × 0.035″ angled-tip nitinol Terumo Glidewire). Seven patients underwent CMR fluoroscopy catheterization. Time to enter each chamber (superior vena cava, main pulmonary artery, and each branch pulmonary artery) was recorded and device visibility and confidence in catheter and guidewire position were scored on a Likert-type scale.

RESULTS

Negligible heating (< 0.07°C) was observed under all in vitro conditions using this guidewire and imaging approach. In patients, chamber entry was successful in 100% of attempts with a guidewire compared to 94% without a guidewire, with failures to reach the branch pulmonary arteries. Time-to-enter each chamber was similar (p=NS) for  the two approaches. The guidewire imparted useful catheter shaft conspicuity and enabled interactive modification of catheter shaft stiffness, however, the guidewire tip visibility was poor.

CONCLUSIONS

Under specific conditions, trained operators can apply low-SAR imaging and using a specific fully-insulated metallic nitinol guidewire (150 cm × 0.035" Terumo Glidewire) to augment clinical CMR fluoroscopy right heart catheterization.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03152773 , registered May 15, 2017.

Radial MRI with variable echo times: reducing the orientation dependency of susceptibility artifacts of an MR-safe guidewire

OBJECTIVES

Guidewires are indispensable tools for intravascular MR-guided interventions. Recently, an MR-safe guidewire made from a glass-fiber/epoxy compound material with embedded iron particles was developed. The size of the induced susceptibility artifact, and thus the guidewire's visibility, depends on its orientation against B ₀. We present a radial acquisition scheme with variable echo times that aims to reduce the artifact's orientation dependency.

MATERIALS AND METHODS

The radial acquisition scheme uses sine-squared modulated echo times depending on the physical direction of the spoke to balance the susceptibility artifact of the guidewire. The acquisition scheme was studied in simulations based on dipole fields and in phantom experiments for different orientations of the guidewire against B ₀. The simulated and measured artifact widths were quantitatively compared.

RESULTS

Compared to acquisitions with non-variable echo times, the proposed acquisition scheme shows a reduced angular variability. For the two main orientations (i.e., parallel and perpendicular to B ₀), the ratio of the artifact widths was reduced from about 2.2 (perpendicular vs. parallel) to about 1.2 with the variable echo time approach.

CONCLUSION

The reduction of the orientation dependency of the guidewire's artifact via sine-squared varying echo times could be verified in simulations and measurements. The more balanced artifact allows for a better overall visibility of the guidewire.