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Martijn L. Dijkstra, BA, Matthew J. Eagleton, MD, Roy K

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1 Intraoperative C-arm cone-beam computed tomography in fenestrated/branched aortic endografting 
Martijn L. Dijkstra, BA, Matthew J. Eagleton, MD, Roy K. Greenberg, MD, Tara Mastracci, MD, Adrian Hernandez, MD, PhD  Journal of Vascular Surgery  Volume 53, Issue 3, Pages (March 2011) DOI: /j.jvs Copyright © 2011 Society for Vascular Surgery Terms and Conditions

2 Fig 1 Images depicting the fusion of the cone-beam computed tomography (CBCT) performed prior to stent graft introduction. The colored images represent those of the preoperative multidetector computed tomography (MDCT), while the gray-scale images are the ones obtained from the CBCT. The images are aligned in multiple planes including (A) axial, (B) anterior, and lateral (not shown). Once the scans are registered, or fused, with each other, the images from the MDCT can be overlaid on the live fluoroscopic image. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

3 Fig 2 Example of an image that has been fused with the live fluoroscopy-obtained image. The images obtained on cone-beam computed tomography (CBCT) are fused with those of the preoperative multidetector computed tomography (MDCT). The baseline aortic morphology (A) can then be depicted on the live fluoroscopy. The overlay image can either be the image of the aorta (as seen in Fig 3, panel A) or a computer-generated outline of the aorta (B). Note the location of the branches and the ostia of these branches, which are represented by circles (arrows). The image is fused with a three-dimensional (3D) orientation, and as the C-arm arc rotates, the orientation of the fused image will change accordingly. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

4 Fig 3 Image obtained from intraoperative fluoroscopy with multidetector computed tomography (MDCT) images of the aorta (color) overlaid on the fluoroscopy image (A). The yellow circles represent the ostia of the visceral vessels. These are used to direct catheters and wires into the target vessels during the placement of a fenestrated endograft. Note the catheter (arrow) and wire (double arrow) that are within the highlighted left renal artery. B, Alternatively, a computer-generated graphic image of the aorta can be displayed on the live fluoroscopy image. Both the actual image and computer-generated image are linked in a three-dimensional (3D) setting and will rotate with revolution of the C-arm. Again, note the catheters and wires that are present in the visceral vessels. Notice that the catheter and wire in the left renal artery do not follow the exact path of the vessel. This represents one of the potential limitations of this technology in that while it can accommodate for rotation of the C-arm, it cannot account for the in vivo movement of the arterial tree. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

5 Fig 4 Demonstration of endoleaks identified on cone-beam computed tomography (CBCT) and follow-up multidetector computed tomography (MDCT). A, CBCT image identifying the presence of a type II endoleak immediately following fenestrated/branched endovascular aneurysm repair (FEVAR). The arrow demonstrates a patent lumbar branch that provides continued flow into the aortic sac. Images demonstrating CBCT identification of type III endoleaks (B, C, and D). B, demonstrates type III endoleak arising from the left renal artery (arrows). Axial reconstructions (C) demonstrate continued flow in the aneurysm sac. Note the ability to calculate HU within the aneurysm sac and within the aortic graft itself. Alternate fields of view (D), similar to that obtained with MDCT (E), can demonstrate the origin of an endoleak that is difficult to identify on conventional angiography. Note the arrow demonstrating the origin of the type III endoleak arising from the superior mesenteric artery (SMA) branch (arrow). E, For comparison, MDCT axial cross-section image of a type III endoleak arising from a SMA branch following FEVAR. Note that there is better visualization of the soft tissues in the MDCT compared with CBCT. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

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