Do More with Less Dose Optimised Imaging Protocols for Endovascular Procedures

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1 Do More with Less Dose Optimised Imaging Protocols for Endovascular Procedures T.G. Giannakopoulos, A. Katsargyris, K. Oikonomou, W. Ritter, and E.L. Verhoeven Paracelsus Medical University Nuremberg Germany

2 Disclosures William Cook Europe/Cook Inc. Consultant & Research grants W.L. Gore & Associates Consultant & Research grants Atrium Consultant Siemens Consultant Medtronic Consultant

3 Topics Have we underestimated radiation exposure? New powerfull fixed imaging systems More complex procedures Physician strategy during the intervention Doing more with less: Real life practice

4 Advantages of Hybrid OR Sterile environment Open access Hybrid Procedures Conversion Safer environment team Logistics OR-lights

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6 Advantages of Hybrid OR Sterile environment Open access Hybrid Procedures Conversion Safer environment team Logistics OR-lights

7 Conclusions (of past presentations) Hybrid room is the standard of care Certainly for advanced endovascular procedures For all endovascular in the near future.

8 Risk of fixed Systems Potentially much higher Radiation!!!!

9 Fixed System Build-in options to reduce risk Low Dose Programs Automap Fluorostore 3D imaging

10 Fixed System Do not forget basic rules. ALARA Collimation DSA angulation Protection shields

11 SIEMENS CARE Applications

12 Radiation free positioning of detector The next field of view of the next detector position is indicated by the graphic on the screen. No radiation is required.

13 2D Automap Live Image Reference Image The c-arm can be moved to exactly the angulation of a reference Image. This workflow is faster and reduces the need for additional radiation and contrast use.

14 2D Automap Reference Image C_arm moves automatically to the angulation of the reference image

15 Reduced pulse rate during Fluoroscopy 65 % less dose when reducing from 10 to 4 pulses per second fluoro.

16 Low dose Fluoro 3 mgy/min ** ** 16 ngy/pulse, 4 Pulse /sec

17 High quality Fluoro only when really needed High contrast Fluoro 32 mgy/min* Low dose fluoro 2 mgy/min ** 55 ngy/pulse, 10 Pulse / sec ** 23 ngy/pulse, 4 Pulse /sec

18 Collimation 100 % 75 % 53 % 43 % Dose saving of 57% just by using collimation to the area of interest!

19 Low Dose DSA Normal DSA 3000 ngy/frame* Low dose DSA 360 ngy/frame ** AXIOM Artis 2004 ** Artis zee 2013

20 DSA only when really needed Low dose DSA 321 mgy/min* Stored Fuoro 12 mgy/min*

21 2D Guidance with Fluorostore Fluoroscopy + contrast instead of DSA Use as Overlay

22 2D 3D registration of MSCT to Angio System Two fluoro projections are needed to fuse pre operative MSCT to the angio system for EVAR guidance

23 3D Guidance with fusion imaging Pre operational MSCT Preparation of CT dataset Overlay to fluoro Landingzone

24 3D Guidance with fusion imaging The 3D overlay of pre operative MSCT is synchronized with C- Arm angulation and table movement.

25 Automated segmentation Automatic centerline and surface extraction of - Aorta - Iliac arteries - Renal arteries Clinical prototype Siemens Healthcare

26 Automated detection of Landmarks Help to mark the relevant anatomical landmarks - Landing zone for stent / Renal arteries / SMA - Clinical prototype Siemens Healthcare

27 Automated Overlay The 3D guidance automatically compensates C-arm angulation, zoom, detector distance, table position. Clinical prototype Siemens Healthcare

28 Real Life Practice: 3x FEVAR case DAP 27.7 Gy.cm 2 (-25%) Fluoro time 29.9 min Contrast use 120ml

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30 Our Patient data: DAP 27,7 Gy.cm 2 Contrast use 120mL Fluoro time 29.9 min Potential improvements: no completion DSA for each target vessel (DSA completion for SMA costs 18% of DAP!!!!!)

31 What do we do? EVAR, IBD, TEVAR, FEVAR No fusion 2D Automap Fluorostore ALARA Branched EVAR (TAAA, post-dissections) Fusion: 2D-3D fusion Fluoro with contrast for target vessel control No completion CBCT (yet.?)

32 Conclusions 3D imaging Development Already beneficial in selected procedures Do not forget Use of SIEMENS CARE/CLEAR programs General ALARA principles 2D Automap Fluoro w. contrast instead of DSA