Stereotactic endovascular aortic navigation with a novel ultrasonic-based three- dimensional localization system Jay C. Mung, PhD, ShihYau Grace Huang,

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Stereotactic endovascular aortic navigation with a novel ultrasonic-based three- dimensional localization system Jay C. Mung, PhD, ShihYau Grace Huang, MD, John M. Moos, MD, Jesse T. Yen, PhD, Fred A. Weaver, MD, MMM Journal of Vascular Surgery Volume 57, Issue 6, Pages 1637-1644 (June 2013) DOI: 10.1016/j.jvs.2012.09.078 Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 1 Volume rendering of aorta obtained from computed tomography (CT) angiography. Blue line indicates aorta centerline. Arrows and insets indicate position and orientation of corresponding virtual endoluminal views at: Top left, Superior right renal artery; right, inferior left renal artery; bottom left, illiac bifurfaction. Journal of Vascular Surgery 2013 57, 1637-1644DOI: (10.1016/j.jvs.2012.09.078) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 2 A, Wooden bed with custom-fit Alpha Cradle immobilizer (blue bag) and ultrasound sensors in place. B, Volume rendering computed tomography (CT) image of swine positioned within custom immobilizer. Immobilizer is present but not visible in rendered image settings. Sensors were removed to prevent artifacts during image acquisition. Journal of Vascular Surgery 2013 57, 1637-1644DOI: (10.1016/j.jvs.2012.09.078) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 3 Target positions were identified by endoluminally advancing the ultrasonic-based localization system (ULS) catheter to the predetermined target positions on the intraoperative three-dimensional (3D) computed tomography (CT) display using the ULS. The shaft of the ULS catheter was then marked at the junction of the catheter and the external vascular access sheath, providing the physical length from the external vascular access sheath to the target position. The ULS catheter was then removed, and the length to the target position was then transferred to the stent delivery catheter. Inset, Photograph of ULS catheter transmitter. Journal of Vascular Surgery 2013 57, 1637-1644DOI: (10.1016/j.jvs.2012.09.078) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 4 Screen shots from cine fluoroscopy demonstrating catheter movement with time stamps in seconds for each frame. Red x indicates fluoroscopy-derived positioning used for comparison study. Pigtail catheter markings indicate 1-cm spacing. Final frame shows contrast angiography run. Journal of Vascular Surgery 2013 57, 1637-1644DOI: (10.1016/j.jvs.2012.09.078) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 5 A, Thin solid black trace represents ultrasonic-based localization system (ULS) position data. Thick dashed red trace represents temporally and spatially registered fluoroscopy-derived position data, both plotted against time. Only position along principal axis of motion is shown for clarity (orthogonal axis omitted). B, Magnitude of error between ULS data and fluoroscopy-derived coordinates. Journal of Vascular Surgery 2013 57, 1637-1644DOI: (10.1016/j.jvs.2012.09.078) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 6 Three-dimensional (3D) volume rendering of computed tomography (CT) image showing swine abdomen with relevant anatomy labeled. Aorta centerline is shown in red. Ultrasonic-based localization system (ULS)-tracked coordinates are shown in green and black. Nipplelike structures are electrocardiograph leads attached as fiducial landmarks. L, Left; R, right; SMA, superior mesenteric artery. Journal of Vascular Surgery 2013 57, 1637-1644DOI: (10.1016/j.jvs.2012.09.078) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 7 Distribution of distances between tracked points and aorta centerline. Mean distance to centerline was 3.3 mm. Aorta radius in vicinity of tracking was 6 mm, suggesting that the tool appears inside the aorta 98% of the time. Journal of Vascular Surgery 2013 57, 1637-1644DOI: (10.1016/j.jvs.2012.09.078) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 8 A, Necropsy exposing abdominal aorta with stent in situ and ruler indicating stent landing zone. B, Partially dissected abdominal aorta exposing stent. Inf, Inferior; L, left; R, right; Sup, superior. Journal of Vascular Surgery 2013 57, 1637-1644DOI: (10.1016/j.jvs.2012.09.078) Copyright © 2013 Society for Vascular Surgery Terms and Conditions