Results with intraoperative 3-D angiography

Transcription

1 Results with intraoperative 3-D angiography P. Geisbüsch, C. Schulz, D. Böckler Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie Universitätsklinik Heidelberg Ärztlicher Direktor: Prof. Dr. D.Böckler

2 Disclosure Research grant by Siemens AG Speakers fee (Siemens AG)

3 Contrast enhanced cone beam CT for EVAR evaluation = Completion Dyna CT

4 Dyna CT Aquisition 5s Protocol; 90 LAO RAO

5 Dyna CT Aquisition 5s Protocol; 90 LAO RAO

6 Dyna CT: Volume of Aquisition 24 cm 19 cm Standard EVAR FEVAR 19 cm Iliac Side branch Branched Endografts?

7 DynaCT

8

9 Heidelberg experience EVAR Patients: n=98, prospective patient cohort Intraoperative Postoperative DSA DynaCT Geisbüsch et al J Vasc Surg Submitted for publication

10 Study Objective 1. Detection of endograft related complications: - Endoleaks - Endograft limb stenoses - Endograft limb thrombosis 2. Reduction of reinterventions 3. Radiation exposure (Phantom model) 4. Reduction of contrast agent

11 Detection of endoleaks Endoleak Type DSA (n= / %) DynaCT (n= / %) (n= / %) I 1 (1.0%) 2 (2.0%) 1 (1.0%) II 15 (15.3%) 33 (33.7%) 21 (21.4%) III total (n=98) 16 (16.3%) 35 (35.7%) 22 (22.4%)

12 Endoleak Typ I DSA DynaCT Reintervention Ia Ballooning Ia - (Ia)* Ballooning Ia (dorsal) Ballooning Ia Endostapler (neglected by patient) II II II Distal Stentgraftextension (Typ Ib in CEUS) *treated after DSA and not seen on control-dsa

13 Endoleak Typ I DSA DynaCT Reintervention Ia Ballooning Ia - (Ia)* Ballooning Ia (dorsal) Ballooning Ia Endostapler (neglected by patient) II II II Distal Stentgraftextension (Typ Ib in CEUS) *treated after DSA and not seen on control-dsa

14 Endoleak Typ I DSA DynaCT Reintervention Ia Ballooning Ia - (Ia)* Ballooning Ia (dorsal) Ballooning Ia Endostapler (neglected by patient) II II II Distal Stentgraftextension (Typ Ib in CEUS) *treated after DSA and not seen on control-dsa

15 Endoleak Typ I DSA DynaCT Reintervention Ia Ballooning Ia - (Ia)* Ballooning Ia (dorsal) Ballooning Ia Endostapler (neglected by patient) II II II Distal Stentgraftextension (Typ Ib in CEUS) *treated after DSA and not seen on control-dsa

16 Endoleak Typ II Endoleak Type DSA (n= / %) DynaCT (n= / %) (n= / %) I 1 (1.0%) 2 (2.0%) 1 (1.0%) II 15 (15.3%) 33 (33.7%) 21 (21.4%) III total (n=98) 16 (16.3%) 35 (35.7%) 22 (22.4%)

17 Detection of endoleaks Endoleak Type DSA (n= / %) DynaCT (n= / %) (n= / %) I 1 (1.0%) 2 (2.0%) 1 (1.0%) II 15 (15.3%) 33 (33.7%) 21 (21.4%) III total (n=98) 16 (16.3%) 35 (35.7%) 22 (22.4%)

18 Endograft limb stenosis DSA DynaCT Intraoperative Intervention Reintervention - 1 PTA Stentgraft Implantation - 1 PTA 1 - Stentgraft Implantation

19 Endograft limb thrombosis DSA DynaCT Intraoperative Intervention Reintervention - 1 Thrombectomy Thrombectomy Thrombectomy -

20 Author (Year) Patients Protocol Radiation Dose cdsa Intervention (n= / %) Postoperative Control Method Intraoperative DynaCT Reinterventionen Heidelberg Reinterventions after / CEUS Heidelberg 1 n=98 5s, f 3 40 x 30 cm ± 10.8 Gycm² X 7/98 (7.1%) 2/98 (2.0%) 1 Geisbüsch et al J Vasc Surg submitted for publication, 2 rotation, 3 f=frames, 4 detector size

21 Author (Year) Patients Protocol Radiation Dose Intervention Postoperative Intraoperative DynaCT Control Literatur (Reintervention cdsa (n= cecbct) / %) Method Reinterventions after / CEUS Heidelberg 1 n=98 5s, f 3 40 x 30 cm ± 10.8 Gycm² X 7/98 (7.1%) 2/98 (2.0%) Hertault et al. (2015) Lille n=54 8s, f 30 x 30 cm 7 Gycm² (5.25-8) - 17/54 (31.5%) CEUS 2/54 (3.7%) Törnqvist et al. (2015) Malmö n=51 8s, f 40 x 30 cm 70.6 Gycm² ( ) X 4/59 (6.7%) 3/51 (5.9%) Dijkstra et al. (2011) Cleveland n=19 8s 397f ± Gy - 6/19 (31.5%) n.a. Biasi et al. (2009) St. George s London n=65 8s f 40 x 30 cm - X 5/65 (7.7%) 0/65 1 Geisbüsch et al J Vasc Surg submitted for publication, 2 rotation, 3 f=frames, 4 detector size

22 Author (Year) Patients Protocol Radiation Dose Intervention Postoperative Intraoperative DynaCT Control Literatur (Reintervention cdsa (n= w/o / %) DSA) Method Reinterventions after / CEUS Heidelberg 1 n=98 5s, f 3 40 x 30 cm ± 10.8 Gycm² X 7/98 (7.1%) 2/98 (2.0%) Hertault et al. (2015) Lille n=54 8s, f 30 x 30 cm 7 Gycm² (5.25-8) - 17/54 (31.5%) CEUS 2/54 (3.7%) Törnqvist et al. (2015) Malmö n=51 8s, f 40 x 30 cm 70.6 Gycm² ( ) X 4/59 (6.7%) 3/51 (5.9%) Dijkstra et al. (2011) Cleveland n=19 8s 397f ± Gy - 6/19 (31.5%) n.a. Biasi et al. (2009) St. George s London n=65 8s f 40 x 30 cm - X 5/65 (7.7%) 0/65 1 Geisbüsch et al J Vasc Surg submitted for publication, 2 rotation, 3 f=frames, 4 detector size

23 Author (Year) Patients Protocol Radiation Dose Intervention Postoperative Control Method Intraoperative DynaCT Literatur (Reintervention cdsa (n= / %) ) Reinterventions after / CEUS Heidelberg 1 n=98 5s, f 3 40 x 30 cm ± 10.8 Gycm² X 7/98 (7.1%) 2/98 (2.0%) Hertault et al. (2015) Lille n=54 8s, f 30 x 30 cm 7 Gycm² (5.25-8) - 17/54 (31.5%) CEUS 2/54 (3.7%) Törnqvist et al. (2015) Malmö n=51 8s, f 40 x 30 cm 70.6 Gycm² ( ) X 4/59 (6.7%) 3/51 (5.9%) Dijkstra et al. (2011) Cleveland n=19 8s 397f ± Gy - 6/19 (31.5%) n.a. Biasi et al. (2009) St. George s London n=65 8s f 40 x 30 cm - X 5/65 (7.7%) 0/65 1 Geisbüsch et al J Vasc Surg submitted for publication, 2 rotation, 3 f=frames, 4 detector size

24 Author (Year) Patients Protocol Radiation Dose Intervention Postoperative Control Method Intraoperative DynaCT Literatur (Protokoll) cdsa (n= / %) Reinterventions after / CEUS Heidelberg 1 n=98 5s, f 3 40 x 30 cm ± 10.8 Gycm² X 7/98 (7.1%) 2/98 (2.0%) Hertault et al. (2015) Lille n=54 8s, f 30 x 30 cm 7 Gycm² (5.25-8) - 17/54 (31.5%) CEUS 2/54 (3.7%) Törnqvist et al. (2015) Malmö n=51 8s, f 40 x 30 cm 70.6 Gycm² ( ) X 4/59 (6.7%) 3/51 (5.9%) Dijkstra et al. (2011) Cleveland n=19 8s 397f ± Gy - 6/19 (31.5%) n.a. Biasi et al. (2009) St. George s London n=65 8s f 40 x 30 cm - X 5/65 (7.7%) 0/65 1 Geisbüsch et al J Vasc Surg submitted for publication, 2 rotation, 3 f=frames, 4 detector size

25 Literatur (Protokoll) Author (Year) Patients Protocol Radiation Dose Heidelberg 1 n=98 5s, f 3 40 x 30 cm ± 10.8 Gycm² Hertault et al. (2015) Lille n=54 8s, f 30 x 30 cm 7 Gycm² (5.25-8) Törnqvist et al. (2015) Malmö n=51 8s, f 40 x 30 cm 70.6 Gycm² ( ) 1 Geisbüsch et al J Vasc Surg submitted for publication, 2 rotation, 3 f=frames, 4 detector size

26 Phantom Model: Effective Dose Dyna CT vs RANDO Alderson Phantoms Thermo-Luminescent Dosimeters (TLD) BMI 22 kg/m² + BMI 30 kg/m² Same field of view (FOV) for both modalities Geisbüsch et al J Endovasc Ther. Submitted for publication

27 Phantom Model: Effective Dose Dyna CT vs Single Phase, abdominal FOV Three Phase, Thoracoabdominal FOV DynaCT BMI 22 kg/m² % BMI 30 kg/m² Geisbüsch et al J Endovasc Ther. Submitted for publication All values are given in msv according to IRCP 103

28 Reduction of in hospital use of contrast

29 Conclusion Reliable detection of endograft related complications Immediate correction of intraoperative complications in a relevant proportion of patients (7%) Potential to further reduce reintervention rates Reduces in hospital use of contrast and radiation exposure Optimal protocol needs to be defined

30 Conclusion Completion DSA Secondary Reintervention Standard Follow-Up

31 Conclusion Completion DSA Secondary Reintervention Completion Dyna CT + - Immediate Revision Duplex / CEUS Standard Follow-Up Standard Follow-Up

32 Results with intraoperative 3-D angiography P. Geisbüsch, C. Schulz, D. Böckler Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie Universitätsklinik Heidelberg Ärztlicher Direktor: Prof. Dr. D.Böckler