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Maqsood HA, Jawed HA, Kumar H, Bansal R, Shahid B, Nazir A, Rustam Z, Aized MT, Scemesky EA, Lepidi S, Bertoglio L, D'Oria M. Advanced Imaging Techniques for Complex Endovascular Aortic Repair: Pre-Operative, Intra-Operative and Post-Operative Advancements. Ann Vasc Surg 2024:S0890-5096(24)00288-7. [PMID: 38942370 DOI: 10.1016/j.avsg.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/02/2024] [Accepted: 06/07/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVES Endovascular aortic repair requires extensive preoperative, intraoperative, and postoperative imaging for planning, surveillance, and detection of endo-leaks. There have been many advancements in imaging modalities to achieve this purpose. This review discussed different imaging modalities used at different stages of treatment of complex endovascular aortic repair. METHODS We conducted a literature review of all the imaging modalities utilized in endovascular aortic repair by searching various databases. RESULTS Pre-operative techniques include analysis of images obtained via modified central line using analysis software and intravascular ultrasound. Fusion imaging, CO2 angiography, intravascular ultrasound, and Fiber Optic RealShape technology have been crucial in obtaining real-time imaging for the detection of endo-leaks during operative procedures. Conventional imaging modalities like CT Angiography and MR Angiography are still employed for post-operative surveillance along with computational fluid dynamics and contrast-enhanced ultrasound. The advancements in artificial intelligence have been the breakthrough in developing robust imaging applications. CONCLUSIONS This review explains the advantages, disadvantages, and side-effect profile of the abovementioned imaging modalities.
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Affiliation(s)
| | | | | | - Radha Bansal
- Government Medical College and Hospital, Chandigarh, India
| | | | | | - Zainab Rustam
- Wilmer Eye Institute, John Hopkins Medicine, Baltimore, MD, USA
| | - Majid Toseef Aized
- Ascension St. Mary's Hospital, Vascular Health clinics, Saginaw, Michigan, USA
| | | | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, University Hospital of Trieste ASUGI, Italy
| | - Luca Bertoglio
- Department of Vascular Surgery, Brescia University School of Medicine, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, University Hospital of Trieste ASUGI, Italy
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2
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Zhao L, Liu J, Cai X, Yang W, Wang J. Image fusion guidance for left subclavian artery in situ fenestration during thoracic endovascular repair. J Cardiothorac Surg 2024; 19:104. [PMID: 38388911 PMCID: PMC10885385 DOI: 10.1186/s13019-024-02561-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVES To evaluate the feasibility and clinical benefit of utilizing image fusion for thoracic endovascular repair (TEVAR) with in situ fenestration (ISF-TEVAR). MATERIALS AND METHODS Between January 2020 and December 2020, we prospectively collected 18 consecutive cases with complex thoracic aortic lesions who underwent image fusion guided ISF-TEVAR. As a control group, 18 patients were collected from historical medical records from June 2019 to December 2019. The fusion group involved the use of 3D fusion of CTA and fluoroscopic images for real-time 3D guidance, and the control group involved the use of only regular fluoroscopic images for guidance. The total contrast medium volume, hand-injected contrast medium volume, overall operative time, radiation dose and fluoroscopy time were compared between the two groups. Accuracy was measured based on preoperative CTA and intraoperative digital subtraction angiography. RESULTS 3D fusion imaging guidance was successfully implemented in all patients in the fusion group. Hand-injected contrast medium volume and overall operative time were significantly lower in the fusion group than in the control group (p = .028 and p = .011). Compared with the control group, the fusion group showed a significant reduction in time and radiation dose-area product (DAP) for fluoroscopy (p = .004 and p = .010). No significant differences in total radiation dose (DAP) or total contrast medium volume were observed (p = .079 and p = .443). Full accuracy was achieved in 8 cases (44%), with a mean deviation of 2.61 mm ± 3.1 (range 0.0-8.4 mm). CONCLUSIONS 3D image fusion for ISF-TEVAR was associated with a significant reduction in hand-injected contrast medium, time and radiation exposure for fluoroscopy and overall operative time. The image fusion guidance showed potential clinical benefits towards improved treatment safety and accuracy for complex thoracic endovascular interventions.
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Affiliation(s)
- Liang Zhao
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, P. R. China
| | - Jidong Liu
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, P. R. China
| | - Xiaoshu Cai
- Advanced Therapies, Siemens Healthineers Ltd, Shanghai, China
| | - Wengang Yang
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, P. R. China
| | - Ji Wang
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, P. R. China.
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Holzer RJ, Bergersen L, Thomson J, Aboulhosn J, Aggarwal V, Akagi T, Alwi M, Armstrong AK, Bacha E, Benson L, Bökenkamp R, Carminati M, Dalvi B, DiNardo J, Fagan T, Fetterly K, Ing FF, Kenny D, Kim D, Kish E, O'Byrne M, O'Donnell C, Pan X, Paolillo J, Pedra C, Peirone A, Singh HS, Søndergaard L, Hijazi ZM. PICS/AEPC/APPCS/CSANZ/SCAI/SOLACI: Expert Consensus Statement on Cardiac Catheterization for Pediatric Patients and Adults With Congenital Heart Disease. JACC Cardiovasc Interv 2024; 17:115-216. [PMID: 38099915 DOI: 10.1016/j.jcin.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Ralf J Holzer
- UC Davis Children's Hospital, Sacramento, California.
| | | | - John Thomson
- Johns Hopkins Children's Center, Baltimore, Maryland
| | - Jamil Aboulhosn
- UCLA Adult Congenital Heart Disease Center, Los Angeles, California
| | - Varun Aggarwal
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | | | - Mazeni Alwi
- Institut Jantung Negara, Kuala Lumpur, Malaysia
| | | | - Emile Bacha
- NewYork-Presbyterian Hospital, New York, New York
| | - Lee Benson
- Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | | | - Thomas Fagan
- Children's Hospital of Michigan, Detroit, Michigan
| | | | - Frank F Ing
- UC Davis Children's Hospital, Sacramento, California
| | | | - Dennis Kim
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Emily Kish
- Rainbow Babies Children's Hospital, Cleveland, Ohio
| | - Michael O'Byrne
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Xiangbin Pan
- Cardiovascular Institute, Fu Wai, Beijing, China
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Tsitsiou Y, Velan B, Ross R, Lakshminarayan R, Rogers A, Hamady M. National UK Survey of Radiation Doses During Endovascular Aortic Interventions. Cardiovasc Intervent Radiol 2024; 47:92-100. [PMID: 37968425 PMCID: PMC10770209 DOI: 10.1007/s00270-023-03592-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/11/2023] [Indexed: 11/17/2023]
Abstract
PURPOSE Endovascular aortic repair (EAR) interventions, endovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR), are associated with significant radiation exposures. We aimed to investigate the radiation doses from real-world practice and propose diagnostic reference level (DRL) for the UK. MATERIALS AND METHODS Radiation data and essential demographics were retrospectively collected from 24 vascular and interventional radiology centres in the UK for all patients undergoing EAR-standard EVAR or complex, branched/fenestrated (BEVAR/FEVAR), and TEVAR-between 2018 and 2021. The data set was further categorised according to X-ray unit type, either fixed or mobile. The proposed national DRL is the 75th percentile of the collective medians for procedure KAP (kerma area product), cumulative air kerma (CAK), fluoroscopy KAP and CAK. RESULTS Data from 3712 endovascular aortic procedures were collected, including 2062 cases were standard EVAR, 906 cases of BEVAR/FEVAR and 509 cases of TEVAR. The majority of endovascular procedures (3477/3712) were performed on fixed X-ray units. The proposed DRL for KAP was 162 Gy cm2, 175 Gy cm2 and 266 Gy cm2 for standard EVAR, TEVAR and BEVAR/FEVAR, respectively. CONCLUSION The development of DRLs is pertinent to EAR procedures as the first step to optimise the radiation risks to patients and staff while maintaining the highest patient care and paving the way for steps to reduce radiation exposures.
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Affiliation(s)
- Yvonne Tsitsiou
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK.
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Bar Velan
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK
| | - Rebecca Ross
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK
| | | | - Andy Rogers
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mohamad Hamady
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed St, London, W2 1NY, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Patel RJ, Lee AM, Hallsten J, Lane JS, Barleben AR, Malas MB. Use of surgical augmented intelligence maps can reduce radiation and improve safety in the endovascular treatment of complex aortic aneurysms. J Vasc Surg 2023; 77:982-990.e2. [PMID: 36581011 DOI: 10.1016/j.jvs.2022.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The introduction of endovascular procedures has revolutionized the management of complex aortic aneurysms. Although repair has traditionally required longer operative times and increased radiation exposure compared with simple endovascular aneurysm repair, the recent introduction of three-dimensional technology has become an invaluable operative adjunct. Surgical augmented intelligence (AI) is a rapidly evolving tool initiated at our institution in June 2019. In our study, we sought to determine whether this technology improved patient and operator safety. METHODS A retrospective review of patients who had undergone endovascular repair of complex aortic aneurysms (pararenal, juxtarenal, or thoracoabdominal), type B dissection, or infrarenal (endoleak, coil placement, or renal angiography with or without intervention) at a tertiary care center from August 2015 to November 2021 was performed. Patients were stratified according to the findings from intelligent maps, which are patient-specific AI tools used in the operating room in conjunction with real-time fluoroscopic images. The primary outcomes included operative time, radiation exposure, fluoroscopy time, and contrast use. The secondary outcomes included 30-day postoperative complications and long-term follow-up. Linear regression models were used to evaluate the association between AI use and the main outcomes. RESULTS During the 6-year period, 116 patients were included in the present study, with no significant differences in the baseline characteristics. Of the 116 patients, 76 (65.5%) had undergone procedures using AI and 40 (34.5%) had undergone procedures without AI software. The intraoperative outcomes revealed a significant decrease in radiation exposure (AI group, 1955 mGy; vs non-AI group, 3755 mGy; P = .004), a significant decrease in the fluoroscopy time (AI group, 55.6 minutes; vs non-AI group, 86.9 minutes; P = .007), a decrease in the operative time (AI group, 255 minutes; vs non-AI group, 284 minutes; P = .294), and a significant decrease in contrast use (AI group, 123 mL; vs non-AI group, 199 mL; P < .0001). No differences were found in the 30-day and long-term outcomes. CONCLUSIONS The results from the present study have demonstrated that the use of AI technology combined with intraoperative imaging can significantly facilitate complex endovascular aneurysm repair by decreasing the operative time, radiation exposure, fluoroscopy time, and contrast use. Overall, evolving technology such as AI has improved radiation safety for both the patient and the entire operating room team.
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Affiliation(s)
- Rohini J Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Arielle M Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - John Hallsten
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - John S Lane
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Andrew R Barleben
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA.
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Modarai B, Haulon S, Ainsbury E, Böckler D, Vano-Carruana E, Dawson J, Farber M, Van Herzeele I, Hertault A, van Herwaarden J, Patel A, Wanhainen A, Weiss S, Esvs Guidelines Committee, Bastos Gonçalves F, Björck M, Chakfé N, de Borst GJ, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kakkos SK, Koncar IB, Kolh P, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Document Reviewers, Bacher K, Brountzos E, Fanelli F, Fidalgo Domingos LA, Gargiulo M, Mani K, Mastracci TM, Maurel B, Morgan RA, Schneider P. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Radiation Safety. Eur J Vasc Endovasc Surg 2023; 65:171-222. [PMID: 36130680 DOI: 10.1016/j.ejvs.2022.09.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/15/2022] [Indexed: 01/24/2023]
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Katsarou M, Chinnadurai P, Bismuth J, Reardon MJ. Multimodality imaging and image guidance techniques for endovascular ascending aortic repair. JTCVS Tech 2022; 15:9-17. [PMID: 36276668 PMCID: PMC9579853 DOI: 10.1016/j.xjtc.2022.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 11/26/2022] Open
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8
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Klaassen J, Vijn LJ, Hazenberg CEVB, van Herwaarden JA. New tools to reduce radiation exposure during aortic endovascular procedures. Expert Rev Cardiovasc Ther 2022; 20:567-580. [PMID: 35726665 DOI: 10.1080/14779072.2022.2092096] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The evolution of endovascular surgery over the past 30 years has made it possible to treat increasingly complex vascular pathologies with an endovascular method. Although this generally speeds up the patient's recovery, the risks of health problems caused by long-term exposure to radioactive radiation increase. This warrants the demand for radiation-reducing tools to reduce radiation exposure during these procedures. AREAS COVERED For this systematic review Pubmed, Embase and Cochrane library databases were searched on 28 December 2021 to provide an overview of tools that are currently used or have the potential to contribute to reducing radiation exposure during endovascular aortic procedures. In addition, an overview is presented of radiation characteristics of clinical studies comparing a (potential) radiation-reducing device with conventional fluoroscopy use. EXPERT OPINION Radiation-reducing instruments such as fiber optic shape sensing or electromagnetic tracking devices offer the possibility to further reduce or even eliminate the use of radiation during endovascular procedures. In an era of increasing endovascular interventional complexity and awareness of the health risks of long-term radiation exposure, the use of these technologies could have a major impact on an ongoing challenge to move toward radiation-free endovascular surgery.
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Affiliation(s)
- Jurre Klaassen
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Linde J Vijn
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Xodo A, D’Oria M, Mendes B, Bertoglio L, Mani K, Gargiulo M, Budtz-Lilly J, Antonello M, Veraldi GF, Pilon F, Milite D, Calvagna C, Griselli F, Taglialavoro J, Bassini S, Wanhainen A, Lindstrom D, Gallitto E, Mezzetto L, Mastrorilli D, Lepidi S, DeMartino R. Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes. J Pers Med 2022; 12:jpm12071018. [PMID: 35887518 PMCID: PMC9317732 DOI: 10.3390/jpm12071018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Mario D’Oria
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
- Correspondence: ; Tel.: +39-0403994645
| | - Bernardo Mendes
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” San Raffaele University, 58-20132 Milan, Italy;
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Mauro Gargiulo
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Jacob Budtz-Lilly
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Aarhus University Hospital, 161-8200 Aarhus, Denmark;
| | - Michele Antonello
- Vascular and Endovascular Surgery, University Hospital of Padova, DSCTV-University of Padova, 35128 Padova, Italy;
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Fabio Pilon
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Domenico Milite
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Cristiano Calvagna
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Filippo Griselli
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Jacopo Taglialavoro
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Silvia Bassini
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - David Lindstrom
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Enrico Gallitto
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Sandro Lepidi
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Randall DeMartino
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
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Spenkelink IM, Heidkamp J, Fütterer JJ, Rovers MM. Image-guided procedures in the hybrid operating room: A systematic scoping review. PLoS One 2022; 17:e0266341. [PMID: 35363811 PMCID: PMC8975112 DOI: 10.1371/journal.pone.0266341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 03/19/2022] [Indexed: 11/18/2022] Open
Abstract
Background The shift from open to minimally invasive procedures with growing complexity has increased the demand for advanced intraoperative medical technologies. The hybrid operating room (OR) combines the functionality of a standard OR with fixed advanced imaging systems to facilitate minimally invasive image-guided procedures. Objective This systematic scoping review provides an overview of the use of the hybrid OR over the years, and reports on the encountered advantages and challenges. Methods We conducted a systematic search in PubMed, Embase, Web of Science, and Cochrane library databases for studies that described procedures being performed with the aid of 3D imaging in the hybrid OR. Results The search identified 123 studies that described 44 distinct procedures, divided over nine clinical disciplines. The number of studies increased from two in 2010 to 15 in the first five months of 2020. Ninety-nine (80%) of the studies described how 3D imaging was performed in the hybrid OR; 95 (96%) used cone-beam CT; four (4%) used multi-detector CT. Advantages and challenges of the hybrid OR were described in 94 (76%) and 34 (35%) studies, respectively. The most frequently reported advantage of using a hybrid OR is the achievement of more accurate treatment results, whereas elongation of the procedure time is the most important challenge, followed by an increase in radiation dose. Conclusion In conclusion, the growing number of clinical disciplines that uses the hybrid OR shows its wide functionality. To optimize its use, future comparative studies should be conducted to investigate which procedures really benefit from being performed in the hybrid OR.
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Affiliation(s)
- Ilse M. Spenkelink
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail:
| | - Jan Heidkamp
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jurgen J. Fütterer
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M. Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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11
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Sieren MM, Jäckle S, Eixmann T, Schulz-Hildebrandt H, Matysiak F, Preuss M, García-Vázquez V, Stahlberg E, Kleemann M, Barkhausen J, Goltz J, Horn M. Radiation-free Thoracic Endovascular Aneurysm Repair with Fiberoptic and Electromagnetic Guidance:A Phantom Study. J Vasc Interv Radiol 2021; 33:384-391.e7. [PMID: 34958860 DOI: 10.1016/j.jvir.2021.12.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the feasibility and accuracy of a radiation-free implantation of a thoracic aortic stent-graft employing fiberoptic and electromagnetic tracking in an anthropomorphic phantom. MATERIALS AND METHODS An anthropomorphic phantom was manufactured based on computed tomography angiography (CTA) data from a patient. An aortic stent-graft application system was equipped with a fiber Bragg gratings fiber and three electromagnetic sensors. The stent-graft was navigated in the phantom by three interventionalists using the tracking data generated by both technologies. One implantation procedure was performed. The technical success of the procedure was evaluated using digital subtraction angiography and pre- and post-interventional CTA. Tracking accuracy was determined at various anatomical landmarks based on separately acquired fluoroscopic images. The mean/maximum errors were measured for the stent-graft application system and the tip/end of the stent-graft. RESULTS The procedure resulted in technical success with a mean error below 3 mm for the entire application system and <2 mm for the position of the tip of the stent-graft. Navigation/implantation and handling of the device were rated sufficiently accurate and on a par with comparable, routinely used stent-graft application systems. CONCLUSION Our study demonstrates successful stent-graft implantation during a thoracic endovascular aortic repair procedure employing advanced guidance techniques and avoiding fluoroscopic imaging. This is an essential step in facilitating the implantation of stent-grafts and reducing the health risks associated with ionizing radiation during endovascular procedures.
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Affiliation(s)
- Malte Maria Sieren
- Department of Radiology and Nuclear Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany.
| | - Sonja Jäckle
- Fraunhofer Institute for Digital Medicine MEVIS, Maria-Goeppert Straße 2, 23562 Lübeck, Germany
| | - Tim Eixmann
- Medical Laser Center Lübeck, Peter-Monnik-Weg 4, 23562 Lübeck, Germany
| | | | - Florian Matysiak
- Department of Vascular Surgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Mark Preuss
- Department of Vascular Surgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Verónica García-Vázquez
- Institute for Robotics and Cognitive Systems, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany, Lübeck, Germany
| | - Erik Stahlberg
- Department of Radiology and Nuclear Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Markus Kleemann
- Department of Vascular Surgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Jörg Barkhausen
- Department of Radiology and Nuclear Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Jan Goltz
- Department of Radiology and Neuroradiology, Sana Hospital, Kronsforder Allee 71-73, 23560 Lübeck, Germany
| | - Marco Horn
- Department of Vascular Surgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
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12
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Klein A, Guild J, Xi Y, Chamseddin K, Shih M, Siah M, Timaran C, Kirkwood M. Use of a 2 Dimensional Vessel Navigator Roadmap Decreases Patient Radiation Dose Compared to Standard 3D Mapping for Fenestrated Endovascular Aneurysm Repair. Ann Vasc Surg 2021; 80:250-255. [PMID: 34748947 DOI: 10.1016/j.avsg.2021.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/24/2021] [Accepted: 08/24/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE For fenestrated endovascular aneurysm repair (FEVAR), the implementation of the VesselNavigator (Philips Healthcare, Best, The Netherlands) to provide a 3-dimensional vessel roadmap has been shown to reduce patient radiation exposure. Unfortunately, FEVAR radiation doses remain substantial despite utilization of this technology. Traditionally, registration of the live fluoroscopy with the pre-operative CTA is performed via the acquisition of a low-dose cone-beam CT scan. However, this registration can also be accomplished with the acquisition of 2D X-rays using the c-arm in 2 different projection angles. We hypothesized that the 2D image acquisition for vessel roadmap development would result in a significant reduction in patient radiation dose in comparison to the 3D CT registration without compromising image quality or increasing procedural length. METHODS This single-center, retrospective study included FEVARs performed from January 2015 to May 2019. For patient data, the cumulative reference air kerma (RAK) was presented as geometric mean and standard deviation. A general linear model with log-normal distribution was used to test the difference in patient RAK between 2D X-ray and 3D CT VesselNavigator registration after adjusting for BMI and the number of vessel fenestrations (1 to 2 vs. 3 to 4). Fluoroscopy time was recorded and used as a surrogate for case complexity. All analyses were done in SAS 9.4 (SAS Institute, Inc., Cary, North Carolina). RESULTS One hundred and sixty four FEVARs were performed on a Philips Allura Xper FD 20 fluoroscopy system equipped with clarity technology. The VesselNavigator registration was completed using 3D CT mapping in 99 cases and 2D X-rays in 65 procedures. On average, utilization of 2D mapping versus 3D mapping for the VesselNavigator resulted in a 20.4% reduction in patient RAK after controlling for BMI and number of vessel fenestrations, P = 0.0135. There was no significant difference in fluoroscopy time between the 2 study groups (P= 0.81) suggesting that image quality was not compromised by the use of 2D mapping leading to the need for additional fluoroscopy. CONCLUSION Acquisition of 2D films rather than a 3D CT scan for VesselNavigator registration allows for a significant reduction in patient radiation dose during FEVAR without increasing the case complexity or compromising image quality.
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Affiliation(s)
- Andrea Klein
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX.
| | - Jeffrey Guild
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Yin Xi
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Khalil Chamseddin
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Michael Shih
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Michael Siah
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Carlos Timaran
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Melissa Kirkwood
- Department of Surgery, Division of Vascular and Endovascular Surgery, UT Southwestern Medical Center, Dallas, TX
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13
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Caradu C, Stenson K, Houmaïda H, Le Ny J, Lalys F, Ducasse E, Gheysens B. EndoNaut two-dimensional fusion imaging with a mobile C-arm for endovascular treatment of occlusive peripheral arterial disease. J Vasc Surg 2021; 75:651-659.e1. [PMID: 34509588 DOI: 10.1016/j.jvs.2021.08.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/13/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endovascular treatment has become the first-line strategy for peripheral arterial disease (PAD). Given the number of procedures required, any technology associated with a reduction in radiation exposure and contrast volume is highly relevant. In the present study, we evaluated whether two-dimensional (2D) fusion imaging could reduce the radiation exposure and contrast volume during endovascular treatment of occlusive PAD. METHODS Our consecutive, retrospective, single-center, nonrandomized comparative trial included patients with PAD at the femoral, popliteal, and/or tibial level, at any clinical stage, if they were candidates for endovascular revascularization. Patients were treated with or without the EndoNaut 2D fusion imaging system (Therenva, Rennes, France) in a nonhybrid room with the same Cios Alpha mobile C-arm (Siemens, Munich, Germany). The indirect dose-area product and contrast medium volume were recorded. RESULTS Between March 2018 and April 2020, 255 patients underwent endovascular femoropopliteal revascularization with (n = 124) or without (n = 131) 2D fusion imaging. The volume of injected contrast medium (34.7 ± 13.8 mL vs 51.3 ± 26.7 mL; P < .001) and dose-area product (8.9 ± 9.9 Gy/cm2 vs 13.5 ± 14.0 Gy/cm2; P = .003) were significantly lower for the 2D fusion imaging group than for the control group. A subgroup analysis of complex (TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease C/D) lesions showed similar results. Stratification of the fusion imaging group into three subgroups, according to the procedure dates, showed no effect of a potential learning curve on the operative parameters. CONCLUSIONS The results from the present study showed a significant reduction in the contrast volume and radiation dose for endovascular treatment of PAD when applying 2D fusion imaging technology. Overall, a reduction of >30% was observed for both operative parameters, without excessive training requirements, highlighting the potential benefits of using 2D fusion imaging when performing endovascular revascularization for PAD.
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Affiliation(s)
- Caroline Caradu
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France.
| | | | - Hassan Houmaïda
- Department of Vascular Surgery, Libourne Hospital, Libourne, France
| | - Julie Le Ny
- Department of Image-Guided Surgical Navigation in Endovascular Procedures, Therenva SAS, Rennes, France
| | - Florent Lalys
- Department of Image-Guided Surgical Navigation in Endovascular Procedures, Therenva SAS, Rennes, France
| | - Eric Ducasse
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Benoit Gheysens
- Department of Vascular Surgery, Libourne Hospital, Libourne, France
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14
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Jäckle S, Lange A, García-Vázquez V, Eixmann T, Matysiak F, Sieren MM, Horn M, Schulz-Hildebrandt H, Hüttmann G, Ernst F, Heldmann S, Pätz T, Preusser T. Instrument localisation for endovascular aneurysm repair: Comparison of two methods based on tracking systems or using imaging. Int J Med Robot 2021; 17:e2327. [PMID: 34480406 DOI: 10.1002/rcs.2327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/23/2021] [Accepted: 08/30/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND In endovascular aneuysm repair (EVAR) procedures, medical instruments are currently navigated with a two-dimensional imaging based guidance requiring X-rays and contrast agent. METHODS Novel approaches for obtaining the three-dimensional instrument positions are introduced. Firstly, a method based on fibre optical shape sensing, one electromagnetic sensor and a preoperative computed tomography (CT) scan is described. Secondly, an approach based on image processing using one 2D fluoroscopic image and a preoperative CT scan is introduced. RESULTS For the tracking based method, average errors from 1.81 to 3.13 mm and maximum errors from 3.21 to 5.46 mm were measured. For the image-based approach, average errors from 3.07 to 6.02 mm and maximum errors from 8.05 to 15.75 mm were measured. CONCLUSION The tracking based method is promising for usage in EVAR procedures. For the image-based approach are applications in smaller vessels more suitable, since its errors increase with the vessel diameter.
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Affiliation(s)
- Sonja Jäckle
- Fraunhofer Institute for Digital Medicine MEVIS, Lübeck, Germany
| | - Annkristin Lange
- Fraunhofer Institute for Digital Medicine MEVIS, Lübeck, Germany
| | | | - Tim Eixmann
- Institute for Biomedical Optics, Universität zu Lübeck, Lübeck, Germany
| | - Florian Matysiak
- Department of Surgery, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Malte Maria Sieren
- Department for Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Marco Horn
- Department of Surgery, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Hinnerk Schulz-Hildebrandt
- Institute for Biomedical Optics, Universität zu Lübeck, Lübeck, Germany.,Medical Laser Center Lübeck GmbH, Lübeck, Germany.,German Center for Lung Research (DZL), Airway Research Center North, Großhansdorf, Germany
| | - Gereon Hüttmann
- Institute for Biomedical Optics, Universität zu Lübeck, Lübeck, Germany.,Medical Laser Center Lübeck GmbH, Lübeck, Germany.,German Center for Lung Research (DZL), Airway Research Center North, Großhansdorf, Germany
| | - Floris Ernst
- Institute for Robotics and Cognitive Systems, Universität zu Lübeck, Lübeck, Germany
| | - Stefan Heldmann
- Fraunhofer Institute for Digital Medicine MEVIS, Lübeck, Germany
| | - Torben Pätz
- Fraunhofer Institute for Digital Medicine MEVIS, Bremen, Germany
| | - Tobias Preusser
- Fraunhofer Institute for Digital Medicine MEVIS, Bremen, Germany.,Jacobs University, Bremen, Germany
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15
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Jansen MM, van der Stelt M, Smorenburg SPM, Slump CH, van Herwaarden JA, Hazenberg CEVB. Target vessel displacement during fenestrated and branched endovascular aortic repair and its implications for the role of traditional computed tomography angiography roadmaps. Quant Imaging Med Surg 2021; 11:3945-3955. [PMID: 34476180 DOI: 10.21037/qims-20-1077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 03/15/2021] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Marloes M Jansen
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Cornelis H Slump
- Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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16
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West K, Al-Nimer S, Goel VR, Yanof JH, Hanlon AT, Weunski CJ, Kattar J, Farivar BS. Three-Dimensional Holographic Guidance, Navigation, and Control (3D-GNC) for Endograft Positioning in Porcine Aorta: Feasibility Comparison With 2-Dimensional X-Ray Fluoroscopy. J Endovasc Ther 2021; 28:796-803. [PMID: 34142900 DOI: 10.1177/15266028211025026] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Intraprocedural deployment of endovascular devices during complex aortic repair with 2-dimensional (2D) x-ray fluoroscopic guidance poses challenges in terms of accurate delivery system positioning and increased risk of x-ray radiation exposure with prolonged fluoroscopy times, particularly in unfavorable anatomy. The objective of this study was to assess feasibility of using an augmented reality (AR) system to position and orient a modified aortic endograft delivery system in comparison with standard fluoroscopy. MATERIALS AND METHODS The 3-dimensional guidance, navigation, and control (3D-GNC) prototype system was developed for eventual integration with the Intra-Operative Positioning System (IOPS, Centerline Biomedical, Cleveland, OH) to project spatially registered 3D holographic representations of the subject-specific aorta for intraoperative guidance and coupled with an electromagnetically (EM) tracked delivery system for intravascular navigation. Numerical feedback for controlling the endograft landing zone distance and ostial alignment was holographically projected on the operative field. Visualization of the holograms was provided via a commercially available AR headset. A Zenith Spiral-Z AAA limb stent-graft was modified with a scallop, 6 degree-of-freedom EM sensor for tracking, and radiopaque markers for fluoroscopic visualization. In vivo, 10 interventionalists independently positioned and oriented the delivery system to the ostia of renal or visceral branch vessels in anesthetized swine via open femoral artery access using 3D-GNC and standard fluoroscopic guidance. Procedure time, fluoroscopy time, cumulative air kerma, and contrast material volume were recorded for each technique. Positioning and orientation accuracy was determined by measuring the target landing-zone distance error (δLZE) and the scallop-ostium angular alignment error (θSOE) using contrast-enhanced cone beam computed tomography imaging after each positioning for each technique. Mean, standard deviation, and standard error are reported for the performance variables, and Student's t tests were used to evaluate statistically significant differences in performance mean values of 3D-GNC and fluoroscopy. RESULTS Technical success for the use of 3D-GNC to orient and position the endovascular device at each renal-visceral branch ostium was 100%. 3D-GNC resulted in 56% decrease in procedure time in comparison with standard fluoroscopic guidance (p<0.001). The 3D-GNC system was used without fluoroscopy or contrast-dye administration. Positioning accuracy was comparable for both techniques (p=0.86), while overall orientation accuracy was improved with the 3D-GNC system by 41.5% (p=0.008). CONCLUSIONS The holographic 3D-GNC system demonstrated improved accuracy of aortic stent-graft positioning with significant reductions in fluoroscopy time, contrast-dye administration, and procedure time.
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Affiliation(s)
- Karl West
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Sara Al-Nimer
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | | | - Jeffrey H Yanof
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Aydan T Hanlon
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Crew J Weunski
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Jackie Kattar
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Behzad S Farivar
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA, USA
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17
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Sieren MM, Schareck C, Kaschwich M, Horn M, Matysiak F, Stahlberg E, Wegner F, Oechtering TH, Barkhausen J, Goltz J. Accuracy of registration techniques and vascular imaging modalities in fusion imaging for aortic endovascular interventions: a phantom study. CVIR Endovasc 2021; 4:51. [PMID: 34125287 PMCID: PMC8200901 DOI: 10.1186/s42155-021-00234-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/17/2021] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- M M Sieren
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.
| | - C Schareck
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - M Kaschwich
- Department for Vascular Surgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - M Horn
- Department for Vascular Surgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - F Matysiak
- Department for Vascular Surgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - E Stahlberg
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - F Wegner
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - T H Oechtering
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - J Barkhausen
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - J Goltz
- Department for Radiology and Neuroradiology, Sana Hospital, Lübeck, Germany
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18
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Use of three-dimensional-three-dimensional digital subtraction angiography spin fusion protocol for complex aortoiliac endovascular interventions. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:339-342. [PMID: 34041424 PMCID: PMC8144108 DOI: 10.1016/j.jvscit.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 03/26/2021] [Indexed: 11/22/2022]
Abstract
Complex endovascular aortic interventions in patients with excessive tortuosity or difficult gantry angles can be challenging. Although fusion imaging can help navigate these issues, it is based on preoperative imaging studies, which becomes skewed after introduction of stiff wires and large devices into the aorta. The subtraction spin protocol performs two cone-beam computed tomography scans to create a subtracted image of the contrast-filled vessels after wire and device placement to accommodate vessel distortion. We have reported a complex fenestrated endovascular aneurysm repair case with a highly angulated neck to highlight the advantages of the subtraction spin protocol in anatomically hostile endovascular repairs.
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19
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De Beaufort LM, Nasr B, Corvec TL, Brisard L, Guyomarc'h B, Fellah I, Postaire B, Chaillou P, Clough RE, Maurel B. Automated Image Fusion Guidance during Endovascular Aorto-Iliac Procedures: A Randomized Controlled Pilot Study. Ann Vasc Surg 2021; 75:86-93. [PMID: 33823257 DOI: 10.1016/j.avsg.2021.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The benefits of imaging guidance using a new fully automated fusion process (CYDAR) have been demonstrated during endovascular aortic aneurysm repair, but little is known about its use during aorto-iliac occlusive disease endovascular revascularization. The aim of this study was to evaluate the influence of CYDAR image fusion guidance during endovascular treatment of symptomatic aorto-iliac occlusive lesions, compared with control patients treated using standard 2D fluoroscopy alone. METHODS This is a single-center randomized controlled pilot study that recruited patients undergoing aorto-iliac endovascular revascularization. RESULTS Between January 2019 and February 2020, 37 patients with symptomatic aorto-iliac lesions were enrolled: 18 were assigned to the fusion group and 19 to the control group. Patients and lesions characteristics were well balanced between both study groups. The technical success of the procedure was 100% in the Fusion group and 94% in the control group. All radiation-related parameters were lower in the fusion compared to the control group, including: median DAP 18.5 Gy.cm2 vs. 21.8 Gy.cm2; Air Kerma 0.10 Gy vs. 0.12 Gy; fluoroscopy dose 4.2 Gy.cm2 vs. 5.1 Gy.cm2; and number of DSA 7.5 vs. 8. The volume of iodinated contrast used was higher in the fusion group: 41 mL vs. 30 mL. The total procedure time was the same in both groups:60 min vs. 60 min. CONCLUSIONS The results of this pilot study suggest the use of fusion imaging in endovascular treatment of aorto-iliac disease results in reduction in radiation-related measured parameters with no change in procedure time and higher doses of iodinated contrast used. These results need to be further investigated in a larger, adequately powered study.
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Affiliation(s)
| | - Bahaa Nasr
- CHU Nantes, l'institut du thorax, service de chirurgie cardio-vasculaire, Nantes, France
| | - Tom Le Corvec
- CHU Nantes, l'institut du thorax, service de chirurgie cardio-vasculaire, Nantes, France
| | - Laurent Brisard
- CHU Nantes, département d'anesthésie réanimation, Nantes, France
| | | | - Imen Fellah
- CHU Nantes, l'institut du thorax, INSERM, CNRS, UNIV Nantes, Nantes, France
| | - Boris Postaire
- CHU Nantes, l'institut du thorax, service de chirurgie cardio-vasculaire, Nantes, France
| | - Philippe Chaillou
- CHU Nantes, l'institut du thorax, service de chirurgie cardio-vasculaire, Nantes, France
| | - Rachel E Clough
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London
| | - Blandine Maurel
- CHU Nantes, l'institut du thorax, service de chirurgie cardio-vasculaire, Nantes, France; Université de Nantes, Nantes, France.
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20
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Tinelli G, Bonnet M, Hertault A, Sica S, Di Tanna GL, Bianchini A, Fabre D, Sobocinski J, Haulon S. Impact of Hybrid Operating Rooms on Long-Term Clinical Outcomes Following Fenestrated and Branched Endovascular Aortic Repair. J Endovasc Ther 2021; 28:415-424. [PMID: 33660577 DOI: 10.1177/1526602821996725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Evaluate the impact of hybrid operating room (HOR) guidance on the long-term clinical outcomes following fenestrated and branched endovascular repair (F-BEVAR) for complex aortic aneurysms. MATERIALS AND METHODS Prospectively collected registry data were retrospectively analyzed to compare the procedural, short- and long-term outcomes of consecutive F-BEVAR performed from January 2010 to December 2014 under standard mobile C-arm versus hybrid room guidance in a high-volume aortic center. RESULTS A total of 262 consecutive patients, including 133 patients treated with a mobile C-arm equipped operating room and 129 with a HOR guidance, were enrolled in this study. Patient radiation exposure and contrast media volume were significantly reduced in the HOR group. Short-term clinical outcomes were improved despite higher case complexity in the HOR group, with no statistical significance. At a median follow-up of 63.3 months (Q1 33.4, Q3 75.9) in the C-arm group, and 44.9 months (Q1 25.1, Q3 53.5, p=0.53) in the HOR group, there was no statistically significant difference in terms of target vessel occlusion and limb occlusion. When the endograft involved 3 or more fenestrations and/or branches (complex F-BEVAR), graft instability (36% vs 25%, p=0.035), reintervention on target vessels (20% vs 11%, p=0.019) and total reintervention rates (24% vs 15%, p=0.032) were significantly reduced in the HOR group. The multivariable Cox regression analysis did not show statistically significant differences for long-term death and aortic-related death between the 2 groups. CONCLUSION Our study suggests that better long-term clinical outcomes could be observed when performing complex F-BEVAR in the latest generation HOR.
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Affiliation(s)
- Giovanni Tinelli
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
| | | | - Adrien Hertault
- Vascular and Endovascular Surgery Department, Valenciennes General Hospital, Valenciennes, France
| | - Simona Sica
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Gian Luca Di Tanna
- Statistics Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Aurélia Bianchini
- Vascular and Endovascular Surgery Department, Valenciennes General Hospital, Valenciennes, France
| | - Dominique Fabre
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, INSERM UMR_S 999, Université Paris Saclay, France
| | | | - Stéphan Haulon
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, INSERM UMR_S 999, Université Paris Saclay, France
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Doelare SAN, Smorenburg SPM, van Schaik TG, Blankensteijn JD, Wisselink W, Nederhoed JH, Lely RJ, Hoksbergen AWJ, Yeung KK. Image Fusion During Standard and Complex Endovascular Aortic Repair, to Fuse or Not to Fuse? A Meta-analysis and Additional Data From a Single-Center Retrospective Cohort. J Endovasc Ther 2020; 28:78-92. [PMID: 32964768 PMCID: PMC7816548 DOI: 10.1177/1526602820960444] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE To determine if image fusion will reduce contrast volume, radiation dose, and fluoroscopy and procedure times in standard and complex (fenestrated/branched) endovascular aneurysm repair (EVAR). MATERIALS AND METHODS A search of the PubMed, Embase, and Cochrane databases was performed in December 2019 to identify articles describing results of standard and complex EVAR procedures using image fusion compared with a control group. Study selection, data extraction, and assessment of the methodological quality of the included publications were performed by 2 reviewers working independently. Primary outcomes of the pooled analysis were contrast volume, fluoroscopy time, radiation dose, and procedure time. Eleven articles were identified comprising 1547 patients. Data on 140 patients satisfying the study inclusion criteria were added from the authors' center. Mean differences (MDs) are presented with the 95% confidence interval (CI). RESULTS For standard EVAR, contrast volume and procedure time showed a significant reduction with an MD of -29 mL (95% CI -40.5 to -18.5, p<0.001) and -11 minutes (95% CI -21.0 to -1.8, p<0.01), respectively. For complex EVAR, significant reductions in favor of image fusion were found for contrast volume (MD -79 mL, 95% CI -105.7 to -52.4, p<0.001), fluoroscopy time (MD -14 minutes, 95% CI -24.2 to -3.5, p<0.001), and procedure time (MD -52 minutes, 95% CI -75.7 to -27.9, p<0.001). CONCLUSION The results of this meta-analysis confirm that image fusion significantly reduces contrast volume, fluoroscopy time, and procedure time in complex EVAR but only contrast volume and procedure time for standard EVAR. Though a reduction was suggested, the radiation dose was not significantly affected by the use of fusion imaging in either standard or complex EVAR.
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Affiliation(s)
- Sabrina A N Doelare
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Stefan P M Smorenburg
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Theodorus G van Schaik
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Jan D Blankensteijn
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Willem Wisselink
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Johanna H Nederhoed
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Rutger J Lely
- Department of Radiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Arjan W J Hoksbergen
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Kak Khee Yeung
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands.,Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
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Chow JCK, Boyd SK, Lichti DD, Ronsky JL. Robust Self-Supervised Learning of Deterministic Errors in Single-Plane (Monoplanar) and Dual-Plane (Biplanar) X-Ray Fluoroscopy. IEEE TRANSACTIONS ON MEDICAL IMAGING 2020; 39:2051-2060. [PMID: 31902759 DOI: 10.1109/tmi.2019.2963446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Fluoroscopic imaging that captures X-ray images at video framerates is advantageous for guiding catheter insertions by vascular surgeons and interventional radiologists. Visualizing the dynamical movements non-invasively allows complex surgical procedures to be performed with less trauma to the patient. To improve surgical precision, endovascular procedures can benefit from more accurate fluoroscopy data via calibration. This paper presents a robust self-calibration algorithm suitable for single-plane and dual-plane fluoroscopy. A three-dimensional (3D) target field was imaged by the fluoroscope in a strong geometric network configuration. The unknown 3D positions of targets and the fluoroscope pose were estimated simultaneously by maximizing the likelihood of the Student-t probability distribution function. A smoothed k-nearest-neighbour (kNN) regression is then used to model the deterministic component of the image reprojection error of the robust bundle adjustment. The Maximum Likelihood Estimation step and the kNN regression step are then repeated iteratively until convergence. Four different error modeling schemes were compared while varying the quantity of training images. It was found that using a smoothed kNN regression can automatically model the systematic errors in fluoroscopy with similar accuracy as a human expert using a small training dataset. When all training images were used, the 3D mapping error was reduced from 0.61-0.83 mm to 0.04 mm post-calibration (94.2-95.7% improvement), and the 2D reprojection error was reduced from 1.17-1.31 to 0.20-0.21 pixels (83.2-83.8% improvement). When using biplanar fluoroscopy, the 3D measurement accuracy of the system improved from 0.60 mm to 0.32 mm (47.2% improvement).
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Varkevisser RR, O'Donnell TF, Swerdlow NJ, Liang P, Li C, Ultee KH, Patel VI, Scali ST, Verhagen HJ, Schermerhorn ML. Factors associated with in-hospital complications and long-term implications of these complications in elderly patients undergoing endovascular aneurysm repair. J Vasc Surg 2020; 71:470-480.e1. [DOI: 10.1016/j.jvs.2019.03.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/26/2019] [Indexed: 12/21/2022]
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Lange A, Heldmann S. Multilevel 2D-3D Intensity-Based Image Registration. BIOMEDICAL IMAGE REGISTRATION 2020. [PMCID: PMC7279926 DOI: 10.1007/978-3-030-50120-4_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
2D-3D image registration is an important task for computer-aided minimally invasive vascular therapies. A crucial component for practical image registration is the use of multilevel strategies to avoid local optima and to speed-up runtime. However, due to the different dimensionalities of the 2D fixed and 3D moving image, the setup of multilevel strategies is not straightforward. In this work, we propose an intensity-driven 2D-3D multiresolution registration approach using the normalized gradient fields (NGF) distance measure. We discuss and empirically analyze the impact on the choice of 2D and 3D image resolutions. Furthermore, we show that our approach produces results that are comparable or superior to other state-of-the-art methods.
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25
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Fusion Imaging to Guide Thoracic Endovascular Aortic Repair (TEVAR): A Randomized Comparison of Two Methods, 2D/3D Versus 3D/3D Image Fusion. Cardiovasc Intervent Radiol 2019; 42:1522-1529. [PMID: 31482337 DOI: 10.1007/s00270-019-02303-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare the accuracy of two-dimensional (2D) versus three-dimensional (3D) image fusion for thoracic endovascular aortic repair (TEVAR) image guidance. MATERIALS AND METHODS Between December 2016 and March 2018, all eligible patients who underwent TEVAR were prospectively included in a single-center study. Image fusion methods (2D/3D or 3D/3D) were randomly assigned to guide each TEVAR and compared in terms of accuracy, dose area product (DAP), volume of contrast medium injected, fluoroscopy time and procedure time. RESULTS Thirty-two patients were prospectively included; 18 underwent 2D/3D and 14 underwent 3D/3D TEVAR. The 3D/3D method allowed more accurate positioning of the aortic mask on top of the fluoroscopic images (proximal landing zone error vector: 1.7 ± 3.3 mm) than was achieved by the 2D/3D method (6.1 ± 6.1 mm; p = 0.03). The 3D/3D image fusion method was associated with significantly lower DAP than the 2D/3D method (50.5 ± 30.1 Gy cm2 for 3D/3D vs. 99.5 ± 79.1 Gy cm2 for 2D/3D; p = 0.03). The volume of contrast medium injected was significantly lower for the 3D/3D method than for the 2D/3D method (50.6 ± 22.9 ml vs. 98.4 ± 47.9 ml; p = 0.002). CONCLUSION Higher image fusion accuracy and lower contrast volume and irradiation dose were observed for 3D/3D image fusion than for 2D/3D during TEVAR. LEVEL OF EVIDENCE II, Randomized trial.
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Lalys F, Barré A, Kafi M, Benziane M, Saudreau B, Dupont C, Kaladji A. Identification of Parameters Influencing the Vascular Structure Displacement in Fusion Imaging during Endovascular Aneurysm Repair. J Vasc Interv Radiol 2019; 30:1386-1392. [PMID: 31155497 DOI: 10.1016/j.jvir.2019.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 10/26/2022] Open
Abstract
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.
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Affiliation(s)
| | - Alexandre Barré
- Department of Cardiothoracic and Vascular Surgery, University Hospital Rennes, Rennes, France
| | - Moundji Kafi
- Department of Cardiothoracic and Vascular Surgery, University Hospital Rennes, Rennes, France
| | | | - Blandine Saudreau
- Department of Cardiothoracic and Vascular Surgery, University Hospital Rennes, Rennes, France
| | - Claire Dupont
- University Rennes 1, Signal and Image Processing Laboratory, INSERM, Rennes, France
| | - Adrien Kaladji
- University Rennes 1, Signal and Image Processing Laboratory, INSERM, Rennes, France; Department of Cardiothoracic and Vascular Surgery, University Hospital Rennes, Rennes, France
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Schulz CJ, Böckler D, Krisam J, Geisbüsch P. Two-dimensional-three-dimensional registration for fusion imaging is noninferior to three-dimensional- three-dimensional registration in infrarenal endovascular aneurysm repair. J Vasc Surg 2019; 70:2005-2013. [PMID: 31147123 DOI: 10.1016/j.jvs.2019.02.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/11/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Fusion imaging is a tool for intraoperative three-dimensional (3D) guidance in endovascular aneurysm repair (EVAR). In many aortic centers, the registration for location is based on an intraoperative 3D dataset acquired by means of cone-beam computed tomography (3D-3D registration). Another registration method is based on two two-dimensional (2D) images (lateral and posteroanterior) acquired with the use of intraoperative fluoroscopy for registration with a computed tomographic angiogram (2D-3D registration). The aim of the present study was to compare 2D-3D registration with 3D-3D registration regarding noninferiority in accuracy and to describe radiation exposure and ease of use of both modalities. METHODS From December 2014 to September 2015, 50 sequentially enrolled patients received EVAR with the use of fusion imaging using 2D-3D registration. No adjustments were made until the first angiography with inserted stent graft. The deviation of fusion imaging to the actual position of the lower renal artery compared with digital subtraction angiography was measured. A historic cohort of 101 patients treated with EVAR and fusion imaging with 3D-3D registration (3D-3D cohort) served as the control group for this study. RESULTS Craniocaudal deviation did not differ significantly (4.6 ± 4.4 mm in the 2D-3D cohort vs 3.6 ± 3.9 mm in the 3D-3D cohort; P = .17). The difference of the means was 1.05 mm with a 95% confidence interval of -2.45 to 0.34 and a P value for the noninferiority test of .0249, indicating that 2D-3D registration was noninferior in terms of a margin of δ = 2.5 mm. 2D-3D registration was significantly faster with significantly less additional radiation necessary: 0.45 ± 0.28 vs 45.7 ± 9.1 Gy·cm2 in the 3D-3D cohort (P < .001); 2.3 ± 1.3 vs 5.3 ± 4.3 minutes in the 3D-3D cohort (P < .001). CONCLUSIONS Fusion imaging during EVAR with the use of 2D-3D registration is feasible in routine EVAR. Our findings of two consecutive cohorts with the same clinical, hardware, and software setup used for the procedures underscore that the accuracy of 2D-3D registration is noninferior to that of a 3D-3D registration workflow, with advantages in terms of radiation exposure, intraoperative time demand, and ease of use.
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Affiliation(s)
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University of Heidelberg, Heidelberg, Germany
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Philipp Geisbüsch
- Department of Vascular and Endovascular Surgery, University of Heidelberg, Heidelberg, Germany.
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Swerdlow NJ, Jones DW, Pothof AB, O'Donnell TF, Liang P, Li C, Wyers MC, Schermerhorn ML. Three-dimensional image fusion is associated with lower radiation exposure and shorter time to carotid cannulation during carotid artery stenting. J Vasc Surg 2019; 69:1111-1120. [DOI: 10.1016/j.jvs.2018.07.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/09/2018] [Indexed: 12/12/2022]
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Nypan E, Tangen GA, Manstad-Hulaas F, Brekken R. Vessel-based rigid registration for endovascular therapy of the abdominal aorta. MINIM INVASIV THER 2019; 28:127-133. [PMID: 30810444 DOI: 10.1080/13645706.2019.1575240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Combining electromagnetic tracking of instruments with preoperatively acquired images can provide detailed visualization for intraoperative guidance and reduce the need for fluoroscopy and contrast. In this study, we investigated the accuracy of a vessel-based registration method designed for matching preoperative image and electromagnetically tracked positions for endovascular therapy. MATERIAL AND METHODS An open-source registration method was used to match the centerline extracted from computed tomography (CT) to electromagnetically tracked positions within a vascular phantom representing the abdominal aorta with bifurcations. The target registration error (TRE) was calculated for 11 fiducials distributed over the phantom. Median and intra-quartile range (IQR) for 30 registrations was reported. TRE < 5 mm was claimed sufficient for endovascular navigation, evaluated using the Wilcoxon signed-rank test. TRE was also compared to a 3D-3D registration method based on intraoperative cone-beam CT, using the Mann-Whitney U-test. RESULTS The TRE was 3.75 (IQR: 3.48-3.99) mm for the centerline registration algorithm and 3.21 (IQR: 1.50-3.57) mm for the 3D-3D method (p < .001). For both methods, the TRE was significantly < 5 mm (p < .001). CONCLUSION The centerline registration method was feasible, with an accuracy sufficient for navigation in endovascular therapy. The centerline method avoids additional image acquisition for registration purpose only.
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Affiliation(s)
- Erik Nypan
- a Department of Circulation and Medical Imaging Faculty of Medicine and Health Sciences , Norwegian University of Science and Technology (NTNU) , Trondheim , Norway.,b Norwegian National Advisory Unit on Ultrasound and Image-guided Therapy , St. Olavs Hospital , Trondheim , Norway
| | - Geir Arne Tangen
- a Department of Circulation and Medical Imaging Faculty of Medicine and Health Sciences , Norwegian University of Science and Technology (NTNU) , Trondheim , Norway.,b Norwegian National Advisory Unit on Ultrasound and Image-guided Therapy , St. Olavs Hospital , Trondheim , Norway.,c Department of Health Research - Medical Technology , SINTEF , Trondheim , Norway
| | - Frode Manstad-Hulaas
- a Department of Circulation and Medical Imaging Faculty of Medicine and Health Sciences , Norwegian University of Science and Technology (NTNU) , Trondheim , Norway.,b Norwegian National Advisory Unit on Ultrasound and Image-guided Therapy , St. Olavs Hospital , Trondheim , Norway.,d Department of Radiology , St. Olavs Hospital , Trondheim , Norway
| | - Reidar Brekken
- b Norwegian National Advisory Unit on Ultrasound and Image-guided Therapy , St. Olavs Hospital , Trondheim , Norway.,c Department of Health Research - Medical Technology , SINTEF , Trondheim , Norway
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Affiliation(s)
- Nicholas J. Swerdlow
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Winona W. Wu
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L. Schermerhorn
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Goudeketting SR, Heinen SGH, de Haan MW, Sailer AM, van den Heuvel DAF, van Strijen MJ, de Vries JPPM. Fluoroscopy with MRA fusion image guidance in endovascular iliac artery interventions: study protocol for a randomized controlled trial (3DMR-Iliac-roadmapping study). Trials 2018; 19:603. [PMID: 30382900 PMCID: PMC6211411 DOI: 10.1186/s13063-018-2981-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 10/13/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Endovascular iliac artery interventions rely on the use of two-dimensional digital subtraction angiographies with an iodinated contrast agent and ionizing radiation. The amount of iodinated contrast agent should be limited because of its potentially nephrotoxic effects. Three-dimensional (3D) image fusion requires registration of a preprocedural magnetic resonance angiogram (MRA) or computed tomography (CT) angiogram to a perprocedurally acquired cone-beam CT or two fluoroscopic orthogonal projections. After registration, the 3D angiography images can be overlaid on the fluoroscopy screen and will follow table and C-arm movements. This study will assess the added value of the 3D image fusion technique in iliac artery interventions regarding the amount of the iodinated contrast agent administered. METHODS/DESIGN The study cohort will comprise 106 patients (> 18 years) with symptomatic common and/or external iliac artery stenoses or occlusions and a recent (< 6 months) diagnostic MRA from the pelvis through the lower extremities, for which an endovascular intervention is indicated. Patients will be randomized into the control or study group (i.e. treatment without or with 3D image fusion guidance). The primary endpoint is the amount of administered iodinated contrast agent (mL). Secondary outcomes are technical success of the procedure, defined as < 30% residual stenosis over the treated lesion, fluoroscopy time, and radiation dose as dose area product (mGycm2). Patient participation in the study will be completed after hospital discharge. DISCUSSION This study is a randomized controlled multicenter trial to provide evidence on the effect of the 3D image fusion technique on the amount of administered iodinated contrast during endovascular common and/or external iliac artery interventions. TRIAL REGISTRATION Nederlands Trial Register, NTR5008 . Registered on 16 December 2014.
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Affiliation(s)
- Seline R. Goudeketting
- Department of Vascular Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Stefan G. H. Heinen
- Department of Vascular Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Michiel W. de Haan
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Anna M. Sailer
- Department of Radiology, Stanford University School of Medicine, Stanford, CA USA
| | | | | | - Jean-Paul P. M. de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Jones DW, Stangenberg L, Swerdlow NJ, Alef M, Lo R, Shuja F, Schermerhorn ML. Image Fusion and 3-Dimensional Roadmapping in Endovascular Surgery. Ann Vasc Surg 2018; 52:302-311. [DOI: 10.1016/j.avsg.2018.03.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 11/30/2022]
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Hertault A, Rhee R, Antoniou GA, Adam D, Tonda H, Rousseau H, Bianchini A, Haulon S. Radiation Dose Reduction During EVAR: Results from a Prospective Multicentre Study (The REVAR Study). Eur J Vasc Endovasc Surg 2018; 56:426-433. [DOI: 10.1016/j.ejvs.2018.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/01/2018] [Indexed: 10/14/2022]
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Alas, ALARA! Why the (con)fusion? Eur J Vasc Endovasc Surg 2018; 56:434. [PMID: 29921532 DOI: 10.1016/j.ejvs.2018.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 11/21/2022]
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A hybrid image fusion system for endovascular interventions of peripheral artery disease. Int J Comput Assist Radiol Surg 2018; 13:997-1007. [DOI: 10.1007/s11548-018-1731-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 03/07/2018] [Indexed: 11/25/2022]
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Computed tomography angiography-fluoroscopy image fusion allows visceral vessel cannulation without angiography during fenestrated endovascular aneurysm repair. J Vasc Surg 2018; 68:2-11. [PMID: 29395427 DOI: 10.1016/j.jvs.2017.11.062] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/02/2017] [Indexed: 11/21/2022]
Abstract
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.
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Touma J, Kobeiter H, Majewski M, Tacher V, Desgranges P. Triple In Situ Antegrade Laser Fenestration of Aortic Stent-Graft Extension Using Fusion Imaging for Urgent Treatment of Symptomatic Abdominal Aneurysm with Type 1 Endoleak. Cardiovasc Intervent Radiol 2017; 41:513-517. [DOI: 10.1007/s00270-017-1837-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 10/31/2017] [Indexed: 11/30/2022]
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