CREATION OF AN OPTIMAL ANGIO SUITE A. CHATZIOANNOU

DEPARTMENT LAYOUT Large lead lined doors to allow admission of bed with ancillary equipment Ceiling 3,5 -4 m with additional space above to allow mechanical access Total 65 m2 not including the X ray control

MAIN FEATURES Dirty utility space adjoining the examination space Scrub sink with hot and cold water Surveillance X ray control (10 m 2 ) Storage space, apron rack and shelves for all equipment Surgical ceiling mounted lights Patient preparation space/room Fluoroscopy unit

Fluoroscopy history Popular Science: July 1939

Fluoroscopy unit Motion features C or U arm which can rotate in axial and sagittal planes Angles of rotation must be displayed on the monitor Ability to vary source detector distance Combination of fluoroscopy arm and table movement should make imaging of the whole body possible Manual override and locking should be possible

Support at least 140 kg of weight Support at least 140 kg of weight Tilting capability both in craniocaudal and lateral direction Tilting capability both in craniocaudal and lateral direction Ability to move away from C-arm in case of emergency Ability to move away from C-arm in case of emergency Additional ( foot and hand) controls to use by the radiographer Additional ( foot and hand) controls to use by the radiographer Fluoroscopy unit Table features

Fluoroscopy unit Imaging features Image intensifier with large field of view (FOV) Image intensifier with large field of view (FOV) Digital subtraction and acquisition (DSA) Digital subtraction and acquisition (DSA) Pulsed fluoroscopy for dose reduction Pulsed fluoroscopy for dose reduction Variety of frame rates Variety of frame rates Various collimators Various collimators Filters to reduce skin dose Filters to reduce skin dose Road mapping and land marking Road mapping and land marking Last image hold and frame grab Last image hold and frame grab

The image quality mainly depends on the flat panel (image intensifier) and the processing system The image quality mainly depends on the flat panel (image intensifier) and the processing system Image quality of fixed systems >> quality of mobile systems (difference in focal spot and tissue penetration) Image quality of fixed systems >> quality of mobile systems (difference in focal spot and tissue penetration) Fluoroscopy unit Image quality

Fluoroscopy unit Image quality – Image Intensifier The image intensifier determines the Field of View (FOV). FOV is of great importance especially in aortic interventions. It depends on the size of the image intensifier. The image intensifier should have: - large FOV ( cm) - three modes of magnification -spatial resolution at least 2.5 line pairs/mm in the 36-cm FOV, 3.3 line pairs/mm in the 23- cm FOV, and 4.6 line pairs/mm in the 15-cm FOV - contrast ratio at least 20:1 - automatic brightness control

Fluoroscopy unit Image quality – Processing system 1024x1024 image matrix (ability to display compressed images on a 512x512 matrix) Display at least five frames per second in the 1024x1024 mode. Road-mapping (helpful during percutaneous transluminal angioplasty, with or without stent placement, and during passage of guidewires through tortuous vessels) Measurement of vessel diameter Digital Subtraction and Acquisition

Overheating is rare in modern equipment due to the presence of excellent cooling systems (oil and water based) Overheating is rare in modern equipment due to the presence of excellent cooling systems (oil and water based) Fluoroscopy unit Heat capacity

Fluoroscopy unit Radiation exposure It varies greatly between different procedures It is dependent on multiple factors. One factor is the fluoroscopy unit itself. Radiation exposure is higher using portable C- arms than fixed systems

Don’t forget

Important issues of a modern angiosuite Important issues of a modern angiosuite Sterility issues Sterility issues Ability to convert Ability to convert Anaesthesia Anaesthesia Ergonomics Ergonomics Personnel Personnel

Angiographic and interventional procedures should be performed in strictly aseptic conditions Angiographic and interventional procedures should be performed in strictly aseptic conditions Primary and secondary operators should wear sterile gowns and gloves as well as surgical caps and masks. Primary and secondary operators should wear sterile gowns and gloves as well as surgical caps and masks. Sterile, impervious barriers should be available to Sterile, impervious barriers should be available to cover any part of the equipment that may contaminate the field cover any part of the equipment that may contaminate the field Appropriate receptacles for contaminated items should be readily available Appropriate receptacles for contaminated items should be readily available OR sterility > Angiosuite sterility OR sterility > Angiosuite sterility Important issues in a modern angiosuite Sterility issues

Majority of endovascular procedures without major intra-operative complications Majority of endovascular procedures without major intra-operative complications In case of conversion to open surgery, the lack of adequate lightning, suction, surgical and anaesthetic equipment and room for surgical instruments, and the extra personnel can make even small procedures challenging In case of conversion to open surgery, the lack of adequate lightning, suction, surgical and anaesthetic equipment and room for surgical instruments, and the extra personnel can make even small procedures challenging Important issues in a modern angiosuite Ability to convert

Although endovascular procedures are minimally invasive,adequate monitoring of the cardiopulmonary system is essential in certain procedures (eg carotid stenting) Although endovascular procedures are minimally invasive,adequate monitoring of the cardiopulmonary system is essential in certain procedures (eg carotid stenting) The presence of an anesthesiologist, a specialized nurse and all anesthetic equipment seem to be of major importance The presence of an anesthesiologist, a specialized nurse and all anesthetic equipment seem to be of major importance Important issues in a modern angiosuite Anesthesia

Poor ergonomics is one of the major drawbacks of mobile systems Poor ergonomics is one of the major drawbacks of mobile systems Ideally, a monitor should be placed just below eye level (10-15 degrees angle) Ideally, a monitor should be placed just below eye level (10-15 degrees angle) Monitors on bothsides of the table Monitors on bothsides of the table Ceiling-fixed monitors perform a great range of positions,without claiming space on the floor. Adjustment of the position of these monitors is easier Ceiling-fixed monitors perform a great range of positions,without claiming space on the floor. Adjustment of the position of these monitors is easier Important issues in a modern angiosuite Ergonomics

Important issues in a modern angiosuite Personnel Specially trained personnel Physicians should spend enough time doing procedures to fulfill the obligations of the angio suite and should perform a sufficient number of procedures to maintain proficiency and competence. All personnel should have knowledge about catheter techniques and the various materials that are used such as sheaths, guide wires, catheters and stent- grafts All personnel should have knowledge about radiation safety measures