Intraprocedural imaging: Flat panel detectors, rotational angiography, FluoroCT, IVUS, or still the portable C-arm? Matthew J. Eagleton, MD Journal.

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Presentation transcript:

Intraprocedural imaging: Flat panel detectors, rotational angiography, FluoroCT, IVUS, or still the portable C-arm? Matthew J. Eagleton, MD Journal of Vascular Surgery Volume 52, Issue 4, Pages 50S-59S (October 2010) DOI: 10.1016/j.jvs.2010.06.144 Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 1 Schematic representation of the image intensifier. Journal of Vascular Surgery 2010 52, 50S-59SDOI: (10.1016/j.jvs.2010.06.144) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 2 Representation of the effects of spatial distortion with conventional image intensifier (II) system. The image becomes “pin-cushioned.” Note in (A) how the grid has lines that are all parallel/perpendicular to each other. Alternatively, (B) the spatial distortion causes the lines further from the center of the image to become curved, like a pin cushion. Similar distortion is visualized with a conventional II system. Journal of Vascular Surgery 2010 52, 50S-59SDOI: (10.1016/j.jvs.2010.06.144) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 3 Schematic representation of a flat panel detector. Journal of Vascular Surgery 2010 52, 50S-59SDOI: (10.1016/j.jvs.2010.06.144) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 4 Photographs demonstrating (A) a characteristic portable C-arm, (B) a conventional II-television monitor system, and (C) a flat panel detector-based imaging system. Journal of Vascular Surgery 2010 52, 50S-59SDOI: (10.1016/j.jvs.2010.06.144) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 5 Intra-operative DynaCT images obtained following endovascular repair of a branched/fenestrated aortic aneurysm repair. (A) The images obtained are able to be viewed with and without contrast, and in multiple planes similar to a conventional CT. Similarly, (B) 3D reconstructions can be generated based on the data, and (C) segments of the image can be removed and color added to highlight specific aspects of the image. Journal of Vascular Surgery 2010 52, 50S-59SDOI: (10.1016/j.jvs.2010.06.144) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 6 Intra-operative fluoroCT performed at the completion of a fenestrated/branched aortic endograft to treat an aortic aneurysm. (A) In one case, a type II endoleak is identified arising from a lumbar artery (arrow). This endoleak was not treated, and on follow-up CT, it had resolved. In another case (B), a type III endoleak (arrow) arising from the junction of the left renal branch and the fenestrated graft was identified. This was not visualized on completion aortography. The junction underwent a balloon angioplasty with resolution of the endoleak. Journal of Vascular Surgery 2010 52, 50S-59SDOI: (10.1016/j.jvs.2010.06.144) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 7 Images demonstrating the fusion of preoperative MDCT and intra-operative DynaCT. (A) and (B) demonstrate the registration of the preoperative CT (color image) with the intraoperative DynaCT (black and white segment). Registration typically occurs by aligning, in multiple planes, bony landmarks and areas of calcifications within the aorta. Once registered, the preoperative CT image can be displayed on the fluoroscopic monitor (C), or a computer-generated outline of the image can be displayed (D). The fused image will rotate in 3D with movement of the C-arm and alterations in the gantry angle. Alternatively, specific sites can be highlighted on the preoperative CT, such as the origins of the visceral branches as depicted here (E), and only those markings displayed on the fluoroscopy screen (F). As with the entire CT image as described above, the location of these markers will move with repositioning of the C-arm. Journal of Vascular Surgery 2010 52, 50S-59SDOI: (10.1016/j.jvs.2010.06.144) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 8 Image from intra-operative use of fusion of preoperative CT and with the live fluoroscopic image. There is an overlay of the aortic aneurysm with a catheter traversing the aorta and entering the left renal artery (arrow). The catheter was easily advanced to this location based solely on the fusion of the two images. Note how the wire in the renal artery does not exactly follow the course of the projected path (double arrow) due to displacement of the artery by the wire and catheter. Journal of Vascular Surgery 2010 52, 50S-59SDOI: (10.1016/j.jvs.2010.06.144) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 9 Images obtained from IVUS during treatment of a patient with an acute aortic dissection. (A) Demonstrates the most proximal aspect of the dissection with evidence of an intramural hematoma and an entry tear (arrow). (B) and (C) demonstrate the more distal aorta with clear evidence of the dissection flap (arrow) and evidence of expansion of the false lumen (FL) and some compression of the true lumen (TL). IVUS can aid in the treatment of this disease by verifying that the wire is traversing the true lumen, identifying sites of entry tears or fenestrations, and demonstrating true lumen expansion after successful exclusion of flow into the false lumen. Journal of Vascular Surgery 2010 52, 50S-59SDOI: (10.1016/j.jvs.2010.06.144) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 10 The AcuNav probe positioned with the elements as a line to the left, viewing into the left inferior renal artery, as seen on (A) fluoroscopy (arrow) and (B) digital subtraction angiography. (C) Corresponding color Doppler image with AcuNav. The probe is placed close to the aortic wall (arrow). (D) Color Doppler image of the right renal artery with the probe at the opposite wall. Reproduced from Eriksson M-O, Wanahainen A, Nymen R. Intravascular ultrasound with vector phased-array probe (AcuNav) is feasible in endovascular abdominal aortic aneurysm repair. Acta Radiolgica 2009; 50: 870-5. Authorized by the Taylor & Francis Group (http://www.informaworld.com). Journal of Vascular Surgery 2010 52, 50S-59SDOI: (10.1016/j.jvs.2010.06.144) Copyright © 2010 Society for Vascular Surgery Terms and Conditions