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AXIOM Innovations      The Magazine for Interventional Radiology, Cardiology and Surgery      Issue Number 14 | November 2...
Editorial               “Keeping image quality                high and radiation                dose low is one of the    ...
EditorialDear Reader,                                                                                                     ...
Content                                                                                                 26                ...
Content                 32                                           42                 syngo Neuro PBV IR Helps During   ...
NewsLess Radiation DuringCatheter InterventionsSiemens’ Artis zee® angiography system hasrecently integrated the MediGuide...
NewsIntegrated FFR Calculation SavesSpace and TimeThe measurement of fractionalflow reserve (FFR) helps to deter-mine the ...
NewsA New Era: Hybrid Operating Roomsin the American Hospital                                                As one of the...
NewsSiemens IntegratesMaquet’s Magnus OR Tablefor Hybrid ORs1                                                             ...
Cover Story CARELow Dose,High Principles:Cardiac CARE for All10 AXIOM Innovations · November 2011 · www.siemens.com/health...
CARE Cover Story                     At Fundación Cardioinfantil in                     Bogotá, Colombia, no one is       ...
Cover Story CARE                                             Any day now, Nelsy, a five-year-old          because her moth...
CARE Cover StoryA Vision of Improved Healthcare AccessFundación Cardioinfantil’s history began in        brigades – teams ...
Cover Story CARE  Combined Applications to Reduce Exposure:  An Integrated Answer to Dose Reduction                       ...
CARE Cover StoryFewer procedures also mean a patient         says Echeverri, because he, Ronderosreceives fewer injections...
Cover Story CAREA Pediatric Radiologist’sApproach to RadiationReductionSiemens has long been a leader in addressing the ne...
CARE Cover StoryAXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine   17
Cover Story CAREdoses are constantly measured and             has experienced three major benefits of      only are fewer ...
CARE Cover Story                                                                                                 “Store Fl...
Cover Story CARETreatment of Complex Head and NeckLymphatic Malformation in an InfantSupported by syngo DynaCTCourtesy of ...
CARE Cover Story1                            1 Axial T2 weighted MR image demonstrating                           the macr...
Cover Story CAREEvaluation of CAREposition:Radiation-Free Positioning withCAREposition Results in a Decreasein Screening T...
CARE Cover Story                            Table 1: Screening Times Pre & Post CAREposition                            30...
Cover Story CARETable 2: Screening time measurements during diagnostic and interventional procedures  Procedure           ...
CARE Cover Story1a                                                      1b                                          1c 1 U...
Angiography syngo iGuideEndoleak Treatment:Enhanced VisualizationMeets Enhanced NavigationDiagnostic CT scan showes an End...
syngo iGuide Angiographysyngo iGuideprovides abulls eyeview and pro-gressionviews foroptimal nee-                         ...
Angiography syngo iGuide                                             Interventional radiologists such as         much shor...
Ax kundenmagazin 14
Ax kundenmagazin 14
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Ax kundenmagazin 14
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  1. 1. AXIOM Innovations The Magazine for Interventional Radiology, Cardiology and Surgery Issue Number 14 | November 2011Treatment ofEndoleaksUsing syngo iGuidePage 26New Hopefor StenoticPatientsAortic ValveImplantationPage 38EndovascularSurgery with3D ImagingNew ImagingPossibilitiesPage 42 Low Dose - High Principles Saving Dose with CARE and syngo DynaCT
  2. 2. Editorial “Keeping image quality high and radiation dose low is one of the key drivers in the development of our imaging portfolio.” Dr. Heinrich Kolem, CEO of the Angiography & Interventional X-Ray Business Unit (AX) at Siemens Healthcare2 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  3. 3. EditorialDear Reader, Dr. Heinrich Kolem CEO AX DivisionEarlier this year, I had the opportunity to patients. They are also key drivers for possibility especially for high-riskattend the Cardiovascular and Interven- our development. We know that our patients who cannot undergo open sur-tional Radiological Society of Europe’s customers carry a lot of responsibility gery. New innovative applications such(CIRSE) annual conference in Munich. for each individual patient they treat. as syngo Aortic ValveGuide* help sur-The CIRSE is one of the most renowned In return, it is our responsibility to offer geons and cardiologists replace calcifiedconferences for interventional imag- reliable systems to support our cus- aortic heart valves with more guidanceing. There were approximately 6,000 tomers worldwide. We are constantly and a new automated workflow.attendees eager to learn about the lat- exploring new possibilities to reduceest technologies and advances in their dose without compromising image qual- Looking back on a very exciting yearclinical field. I was very pleased to see ity. The title of this issue reflects that for Siemens Healthcare, I am proudhow many visitors were interested in line of thought, “Low Dose - High Prin- to present to you this issue of AXIOMour products and solutions. For the first ciples.” Our dose saving initiative with Innovations. You can read more abouttime, we showcased how “The Future is CARE (Combined Applications to Reduce CARE technology, new functionalities inFlexible” with the Artis zeego, our multi- Exposure) and CLEAR (an imaging tech- endovascular and thoracic surgery, andaxis C-arm system based on robotic nology to enhance visualization with many other innovative topics. Enjoy!technology. We introduced the Hybrid IR X-ray) not only reduces radiation doseconcept which offers new opportunities for patients and staff, but also boostsfor interventional radiologists looking image quality to an outstanding level.to expand to more complex cases. Inorder to meet current and future imag- A growing trend in the market for inter-ing needs, Artis zeego allows a variety ventional cardiology and hybrid surgery Dr. Heinrich Kolemof working heights and delivers large is the minimally invasive replacementvolume image results. of valves. With demographic changes in our society and a growing percentage ofImproving clinical workflow and elderly patients, new treatment meth-radiation dose reduction are of great ods will evolve. Minimally invasive pro-importance to our customers and their cedures are an exciting new treatment* The syngo Aortic ValveGuide is pending 510(k) clearance, and is not yet commercially available in the United States. AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 3
  4. 4. Content 26 16 Enhanced Endoleak Content Radiation Reduction is Key in Pediatrics Treatment Through Improved Navigation 10 A long-term commitment 3 Editorial to reduce radiation dose Siemens has long been a leader in addressing the need to provide opti- mal images at the lowest possible 6 News radiation dose following the ALARA principle. Many institutions world- wide working with Siemens angio- graphy systems use the CARE 10 Cover Story applications in their daily routine when imaging patients of all ages. Low Dose, High Principles: It is most importatnt to them to Cardiac CARE for All keep radiation dose low, especially A Report from Fundación for children and also their own staff. Cardioinfantil in Colombia A Pediatric Radiologists Approach to Radiation Reduction Interview with Dr. Anne Marie Cahill, Childrens Hospital of Philadelphia Treatment of Complex Head and Cover Neck Malformation in an Infant Clinical Case Imaging of temporal mandibular joint with reduced radiation dose. CAREposition Courtesy of Anne An Evaluation of Radiation-Free Marie Cahill, M.D., Department of Positioning Interventional Radiology, Children´s Hospital of Philadelphia, 61 Imprint Pennsylvania, USA4 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  5. 5. Content 32 42 syngo Neuro PBV IR Helps During Advanced Technology Revolutionizes Revascularization Treatment Endovascular Surgery Angiography 38 Minimally Invasive Aortic Valve 54 An Innovative Setting – Implantation Offers New Hope to Hybrid Room 3D Imaging Delivers26 Endoleak Treatment: Stenotic Patients Groundbreaking Care Enhanced Visualization Meets Interview with Dr. Antonio Dager St. Joseph Hospital in California Enhanced Navigation at Angiographia de Occidente in chooses an interdisciplinary syngo iGuide facilitates better Colombia approach to maximize patient care Workflow30 Quantitative Evidences of Surgery Customer Care Hemodynamic Improvement of Brain Arteriovenous Malformation 42 3D Imaging Brings a New Vision 58 Upcoming Congresses & after Surgical Intervention to Endovascular Surgery Workshops Clinical case Interview with Dr. Alan Lumsden, Director of the Methodist Hospital 60 Subscription & Information32 Revascularization Treatment DeBakey Heart and Vascular Center of Acute Cerebral Stenosis in Houston Clinical case 48 Accuracy Far Beyond Conventional Pneumological Practice Cardiology Dr. Hohenforst-Schmidt pioneers new navigation techniques in34 Overlay of MRI Images pneumology in Pulmonary Vein Isolation A clinical evaluation 48 Navigation in the Lung by Prof. Rukshen Weerasooriya Clinical Case36 Accurate Placement 50 Heart Valve Replacement – of Aortic Valves Significant Changes Thanks to Clinical case Hybrid Surgery Dr. Tatsuhiro Komiya talks about new surgical procedures AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 5
  6. 6. NewsLess Radiation DuringCatheter InterventionsSiemens’ Artis zee® angiography system hasrecently integrated the MediGuide Technologyfrom St. Jude Medical, a medical positioningsystem that visualizes the position of a catheterwithout radiation.Like a GPS system, the MediGuide Technologylocates the catheter during cardiac interventionsand projects its precise position in real time ona previously acquired fluoroscopy image of thepatient. During electrophysiological interventions,a miniaturized sensor integrated into the cathetercan be located by receiving electromagnetic posi-tioning signals from the MediGuide transmitters,which are incorporated into the detector housingof the Artis zee system. The MediGuide Technologythen calculates the respective position and orien-tation of the catheter and displays it in real timeon fluoroscopic images of the patient that wererecorded earlier. The technology also compensatesfor patient movement caused by respiration andheart motion.The MediGuide Technology provides significantbenefits especially during complex electrophysi-ological procedures. The electrophysiologist nolonger has to take fluoroscopic images of thepatient each time the catheter is re-positioned.As a result, less radiation and less contrast agentuse is expected.The Heart Center Leipzig, Germany, has alreadyperformed the first interventions with Artiszee and the MediGuide Technology. “The low-radiation, precise localization of the catheter tiponto the pre-recorded fluoroscopy image is a mostimpressive function, because the system is able tocompensate the motion from the heart beat andbreathing,” said Professor Dr. Gerhard Hindricks,Director of the Rhythmology Department. “For myteam and me, this is clearly the future in electro-physiology.” Localization of the catheter supported by MediGuide Technology and EnSite Velocity Mapping System.6 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  7. 7. NewsIntegrated FFR Calculation SavesSpace and TimeThe measurement of fractionalflow reserve (FFR) helps to deter-mine the hemodynamic signifi-cance of a coronary stenosis andto guide balloon and stent place-ment. FFR is being measured bycomparing the blood pressuresdistal (behind) and proximal (infront) to a lesion. Once this ratioreaches 0.75 or below, a stenosisis considered hemodynamicallysignificant and a stent placementis recommended.The FAME study publishedin 2009 (N Engl J Med 2009;360:213-224) evaluated FFR-guided CAD treatment andclearly found an increase inpatient survival of 30 % while atthe same time treatment costsdecreased by 30 %.St Jude Medical and Volcanooffer FFR measurement solu-tions in the cath lab that nowhave been fully integrated withthe Siemens AXIOM Sensis XPrecording system, which offerssimple plug&play connectivityand makes using an externalworkstation obsolete.For getting the new FFR mea-surement capabilities, AXIOMSensis XP software must beupgraded to the latest softwareversion due for release at theend of 2011. The FFR option canalready be ordered today and willbecome available with the newsoftware version.All systems in the field currentlyrunning software version VC10will be upgraded free of charge toVC11 starting in spring 2012. AXIOM Sensis XP running VC11 software and FFR option. AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 7
  8. 8. NewsA New Era: Hybrid Operating Roomsin the American Hospital As one of the most modern hospitals where TAVI (Transcatheter Aortic Valve not only in Turkey but the entire region, Implantation) procedures have recently the American Hospital in Istanbul begun to be performed with the use continues its leading role in hybrid of the Artis zeego system and Siemens operating room practices with the syngo DynaCT Cardiac software, recently installed Siemens Artis zeego procedures can be completed more multi-axis robotic angiography system. rapidly and reliably with the comfort Thanks to the Artis zeego system, introduced by Artis zeego and the wide both advanced hybrid practices and movement capability of the C-arm. standardized cardiologic procedures can The American Hospital is currently able be performed. In the new procedure to perform interventional procedures, room that has an angiography thanks to the hybrid system it has operating table that tilts in four recently acquired, as well as ongoing different directions, a laminar flow medical, technical and technological unit and anesthesia device pendants, developments. Operating in Istanbul, the latest technological innovations, Turkey since 1920, the American such as a 56" Artis zee Large Display, Hospital offers the latest technologies an integrated Intravascular Ultrasound to aid the hundreds of millions of (IVUS), an integrated hemodynamic people in the region as a hospital heldDr. Genco Yücel, Department of Cardiology, recording system (Siemens AXIOM in high regard not only in Turkey but inin front of the department’s new Artis zeego. Sensis XP), etc., are used. At the center neighboring countries as well.Hybrid OR With Trumpf Table Openedat Clinical Center LudwigsburgSince 2010, Siemens optionally delivers Artis zeego or Artiszee ceiling with the TruSystem 7500 OR table by Trumpf.In May 2011 another hybrid operating room with Trumpf´sOR table and Siemens Artis zeego went live at the clinicalcenter Ludwigsburg, Germany – meanwhile this is the sixthinstallation worldwide that combines an Artis system with aTrumpf OR table. The room at the clinical center Ludwigsburgis located in a brand new building as part of a 35 million europroject to build one of the most modern surgical centers inGermany with altogether 9 fully digital connected operatingrooms. With this new hybrid OR, patients will benefit fromfewer shifts during the procedures, less radiation because offaster and fewer acquisitions, and fewer complications sincethe success of the intervention can be verified right in the ORat the end of the procedure.Siemens is also going to offer a similar integration of theArtis zeego and Artis zee ceiling with Maquet OR tables in View of the new hybrid operating room in Ludwigsburg with the Trumpfearly 2013. TruSystem 7500 OR table and Siemens Artis zeego.8 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  9. 9. NewsSiemens IntegratesMaquet’s Magnus OR Tablefor Hybrid ORs1 2Fig. 1: Siemens Artis zeego with Maquet’s Magnus table with breakable Fig. 2: Maquet also offers a radiolucent table top for artifact-free imagingtop supports complex procedures in advanced positions. in endovascular procedures.The versatile Magnus OR table* from and neurosurgery. The Artis zeego is First clinical user tests of the integratedMaquet will be available together with the only robotic C-arm-system on the solution with Artis zeego are anticipatedArtis zeego and Artis zee ceiling. With the market that can adapt to the complete to start in May 2012; general availabilityexisting family of Artis tables, Trumpf’s height adjustment of the table. The is planned for December 2012. The inte-TruSystem 7500 tables and the Magnus multi-axis robotic system also follows gration with Artis zee ceiling is sched-table to follow, Siemens can provide the movements of the operating table. uled to be available in spring 2013.three fully integrated table systems. This It flexibly adjusts to even complicated Of course Siemens will continue tomeans synchronized C-arm and OR table positions of the segmented table top. offer the tried-and-true family of fullymovements, 2D and 3D imaging, all with This flexibility also allows free access integrated Artis zee tables. They area single integrated operation module. from any side, with a comfortable space available in three different versions: theAnd the right table for surgical require- for the anesthetist and his equipment. standard table, table with tilt, and thements in the hybrid OR. If open procedures without imaging OR table with tilt and cradle. The carbonThe key benefit of the new solution is equipment are performed, Artis zeego’s table tops allow for high-end imaging,the multidisciplinary use of the hybrid multiple park positions allow for maxi- including 3D. The Artis table family isOR – which means it will allow for both mum space in the OR field. the solution of choice for cardiac andinterventional imaging and for open Equipped with an additional floating vascular procedures providing an exten-procedures where extremely flexible carbon table top, the integrated solu- sive longitudinal travel range, full bodypatient positioning may be required. tion enables full cath lab functionality. coverage and a free floating radiolucentThe Magnus OR table is fitted with The table top provides 360° radio- table top.exchangeable table tops – a fully radio- translucency for superb X-ray images,lucent carbon top (Fig. 2) as well as a including 3D. A transport systemhighly flexible, segmented table top ensures the easy exchange of the table(Fig. 1). The latter allows surgeons the tops. The patient can be prepared andmost appropriate patient positioning, positioned on the table top in the * WIP. The information about this product is preliminary. The product is under development and not commerciallyincluding complicated positions, induction area ensuring ahead of time available in the U.S., and its future availability cannotoccurring especially in orthopedics maximum efficiency for the OR. be ensured. AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 9
  10. 10. Cover Story CARELow Dose,High Principles:Cardiac CARE for All10 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  11. 11. CARE Cover Story At Fundación Cardioinfantil in Bogotá, Colombia, no one is turned away for lack of ability to pay. Using the most advanced equipment from Siemens, the hospital’s dedicated staff is making interventional imaging safer for everyone, especially those who need it most: their youngest, weakest patients. By Chris KraulAXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 11
  12. 12. Cover Story CARE Any day now, Nelsy, a five-year-old because her mother and brother have Colombian girl, will undergo an angio- died and her father is worried that he plasty at Bogotá’s Fundación Cardio- will lose her as well,” says Ronderos. infantil hospital that will save her life. By coming to Fundación Cardioinfantil Pale, underweight and short of breath, in Bogotá for treatment, Nelsy will Nelsy was screened in late May by the receive another benefit that could be clinic’s outreach team in the southwest- just as consequential to her long-term ern city of Pasto and found to have per- health. Her procedure will be performed sistent ductus arteriosis, a congenital using Siemens’ state-of-the-art “low condition that, without a procedure to dose” interventional imaging technol- close the ductus, would have proved ogy. The hospital has four Siemens Artis fatal by her mid-teens. systems that – with their advanced Nelsy, whose mother and ten-year old software and imaging innovations – can brother both died of heart disease, will dramatically cut the radiation exposure be brought to Bogotá free of charge of patients like Nelsy, compared with from her home 300 miles away, a poor what they would have received a few fishing village on Colombia’s southwest- years ago. ern Pacific coast. She and her father will Each system is bundled with Siemens’ be put up in the clinic’s housing and, proprietary CARE (Combined Applica- despite the fact that they have no way tions to Reduce Exposure) applica- to pay the hospital bills, Nelsy will be tions that can help to decrease typical“The Siemens given the kind of care that has made exposure in catheterization labs. It does engineers have Fundación Cardioinfantil a private, nonprofit institution, a beacon of car- that by providing a broad range of dose saving applications, enhanced monitor- helped a lot in diovascular treatment in Latin America. The hospital draws paying patients from ing and reporting of the radiation being generated and a flexibility of use that giving individual throughout the Caribbean and Cen- allows doctors at Fundacion Cardioin- tral America, and from as far away as fantil to tailor treatment to a patient’s training to our Florida and Peru. It also takes on scores specific age, weight and diagnosis. personnel with of pro bono “social” cases per year, like Nelsy’s, mainly from Colombia but it “The advances that we are seeing in Siemens’ imaging are allowing us to be the goal of accepts desperately poor patients from Ecuador and Venezuela as well. more precise with our procedures with less risk of complications and failures,” minimizing the Making the Safety Factor a said Dr. Ronderos. Additionally he states the better the imaging, the less time he radiation used in High Priority spends diagnosing the condition and The procedure in the hospital’s heart placing coils, stents and heart valves. a given exam catheterization lab to close the ductus That reduces the patient’s and the medi- and to devise will only take 45 minutes. But it will save Nelsy from probable death by cal staff’s exposure to radiation, he said. That lessened exposure is important additional pneumonia in the coming years and for the operator as well as the patient. give her a good chance of leading a Medical staff who administer the pro- measures of long, healthy life, says Miguel Ronde- cedures are concerned about their own ros, MD, a cardiologist who trained at risk as well. radiological University of Alabama-Birmingham and Making angiography safer has been a protection.” who was part of the outreach team that diagnosed Nelsy. He will also perform Siemens objective since the company entered the medical equipment field the angioplasty. in the early 1960s, and especiallyMiguel Ronderos, M.D., “We immediately classified Nelsy as since a low dose application initiativeDepartment of Cardiology, Fundación a medical emergency, because she is was launched in 1994. Since then,Cardioinfantil, Bogotá, Colombia in heart failure right now. But she is the company has achieved a series of also what we call a social emergency, breakthroughs, all with the goal of 12 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  13. 13. CARE Cover StoryA Vision of Improved Healthcare AccessFundación Cardioinfantil’s history began in brigades – teams of a half-dozen doctors and1971 when two Colombian doctors, brothers nurses – to seek out sick children in remote,Reinaldo and Camilo Cabrera, returned home poverty-stricken areas of the country. Now,from completing their medical training at the about eight times a year, the brigades holdTexas Heart Institute in Houston determined two-day cardiovascular clinics at partnerto address the inequalities of their country’s hospitals from one end of the country to thehealthcare. High on their list of concerns was other where young patients in need gather.the incidence of congenital heart defects, Two months prior to each visit, the founda-affecting one in every 100 babies. In devel- tion’s community relations department startsoped countries, such defects are easily getting the word out via radio announce-diagnosed and treated, but they too often ments and posters that any family who hasproved to be death sentences in Colombia. a child with possible heart problems will bePoverty and difficult geography make access examined for free. It was in one such brigadeto quality medical care an impossible dream visit held at Pasto’s Hospital Los Angeles infor much of the population. May that Ronderos diagnosed Nelsy, oneWith the help of ex-president Carlos Lleras of 400 young people who lined up for anRestrepo, the new physicians opened the pre- examination, and put her on the list of kidsdecessor of today’s foundation in a corner of to be brought to Bogotá. She and her fatherBogotá’s Misericordia Hospital, a charity clinic traveled eight hours by boat and four hoursfor children, specifically to offer cardiovascu- by bus to get to the examination site.lar care to poor youth in the urban area. They Fundación Cardioinfantil’s staff examinerelied on donations of services, equipment, about 4,000 poor young people per yearcash and eventually land from the city of during these outreach clinics. Of those,Bogotá, where the current 300-bed hospital 250 children and adolescents, or aboutis situated. 20 percent of all the children examined,As it grew, the clinic broadened its mission to are subsequently brought to the hospitalinclude children who could pay for treatment for heart surgery or angiography at theas part of a scheme by which paying patients bustling Bogotá hospital, free of charge.helped subsidize care for the poor. Later, as For their service to Colombia, the Cabrerathe clinic’s reputation for quality care spread, brothers were decorated in July 2010 byadult heart patients were admitted, also to then-president Alvaro Uribe with the Orderhelp subsidize treatment for poor children. of Boyaca, the highest national honorAdults now comprise about 70 percent of the attainable by a Colombian civilian. One of thecaseload. doctors, Reinaldo Cabrera, died in NovemberIn 1986, the Cabrera brothers decided to pro- 2010, but his brother Camilo continues tovide care to young patients for whom a trip to be active and currently is the director of theBogotá for life-saving treatment was impos- foundation.sible. The hospital began organizing outreach AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 13
  14. 14. Cover Story CARE Combined Applications to Reduce Exposure: An Integrated Answer to Dose Reduction the imaging and visibility of devices. CAREvision: pulsed fluoroscopy application that provides extremely Over the last five years, Siemens syngo low frequencies to meet individual dose-saving targets. Pulses can DynaCT has made soft tissue imaging drop from a range of 30 p/s to only 0.5 p/s. At 7.5 p/s, a 75 % dose possible, enabling physicians to get reduction is achieved. additional soft tissue information in the interventional suite and thus get a CAREfilter: a variable CU-filter (0.1 mm – 0.9 mm) is automatically set better understanding of the structure of according to the current transparency of the object/C-arm angulation, the vessels and organs they are dealing without any necessary interaction from the user. Dose reduction: up with. to 50 %. Dr. Dario Echeverri, who heads Funda- CAREposition: positioning without repeated fluoroscopy. The feature cion Cardioinfantil’s catheterization lab is especially needed during long-lasting neurointerventions that can and who is also the current president take several hours as the provider can control patient positioning of the Latin American Society of Inter- without the need for additional fluoroscopy. ventionist Cardiology, said the CARE application “CAREguard” is especially CAREprofile: radiation-free adjustment of collimators as well valuable because it tracks radiation skin as radiation-free semitransparent filter parameter setting. Dose dose thresholds of patients and medical reduction: Up to 9 %. staff and sounds a warning if they are CAREguard: a new real-time application that monitors skin dose exceeded. exposure and allows for effective skin dose control. Three separate “It allows us to do a continuous follow- thresholds can be defined with warning indicators that alert up of the radiation dispersed by the for length of exposure time. The feature reduces exposure for machines and helps us reduce exposure radiologists, technicians, and patients. to patients and MDs, nurses and techni- cians working in the lab,” Echeverri said. Low Dose Acquisition: additional low dose protocols that can be Cognizant of the importance of low accessed hands free, directly from a footswitch. These tools can dose imaging, Siemens sends a free reduce radiation dose by 67 %. update of the latest software VC14 Low Dose syngo DynaCT: an optional feature, offers CT-like 3D including all CARE (Combined Applica- imaging for radiosensitive patients and others. As an example, 5 sec tions to Reduce Exposure) and CLEAR protocol can be done at 0.1 µGy/frame instead of 0.36 µGy/frame, (image quality) features to all customers which results in a 72 % reduction. of its Artis zee angiography systems around the world. CAREreport: a structured dose report that contains all patient Siemens’ advances now enable doctors demographics, procedure, and dose information. Using commercially to reduce the number of times a typical available programs or in-house software, this information can be heart patient has to undergo imaging filtered for further processing, such as dose analysis. exams. A decade ago, Nelsy might have had to undergo three different proce- dures during her stay at Cardioinfantil: one to diagnose, a second to treat herlimiting dosage while enhancing image quality images are now captured at disease, and a third to confirm success.quality. Improved safety is doubly criti- 7.5 frames per second, down from 30 But the likelihood now is that a singlecal because of the expanding range of frames previously, making possible a procedure will suffice.diagnoses and treatments for which 75 percent reduction in radiation dur- “Nowadays, we must be much moreangiography is now used, going far ing the procedure. CAREreport offers a careful with our exams in arriving at abeyond its original cardiovascular appli- running account of radiation dispersed diagnosis,” Dr. Ronderos said. “Each daycation to include neuro and abdominal along with the patient’s demographics, we are more aware of the importance tointerventions and surgeries. procedure and dose information. health of the cumulative dose of radia-The low dose equipment is achieving tion over the course of a lifetime and,that goal with a variety of innovations. A Two-Way Flow of Information with the Siemens technology we have,Proprietary technology pulses radia- But there is more than that to low combined with our understanding andtion instead of emitting continuous dose. Efficiency gains from powerful quality of the imaging, we can minimizefluoroscopy. With CAREvision, high new Siemens software have improved exposure in a given exam.”14 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  15. 15. CARE Cover StoryFewer procedures also mean a patient says Echeverri, because he, Ronderosreceives fewer injections of contrast and other medical staff operate theagent, which if overused can damage machines themselves without speciallykidneys. trained technicians.As one of a dozen Siemens “reference “We want the relationship with Siemenssites” at leading hospitals in Latin to go far beyond buying and sellingAmerica and the Caribbean, Fundación equipment. We want Siemens to help usCardioinfantil has become a key prov- in an integral way with training, market-ing ground for Siemens’ low dose ing and advice, a friend who will helpimaging initiative in the region. The distinguish the foundation. The Lowclinic also has become an incubator for Dose Workshop with Siemens was verymore intensive relationships between encouraging, and it produced concreteSiemens product managers and the results,” says Echeverri.medical professionals who use the In exchange for going the extra mile,company’s equipment. The company Siemens is allowed to bring prospec-and its clinical customers see such close tive clients to Cardioinfantil to seerelationships as a necessity, given the the systems in action, and even bringhigh stakes in cardiovascular care: the in doctors and nurses from foreignlife-saving benefits of cutting-edge ther- countries to receive training on theapies as well as the potential hazards of machines. Siemens also gets importantthe imaging devices. feedback that is incorporated into the“Over the last year, a real two-way flow systems’ software and design. A bonusof information with Siemens has begun, for Siemens is its association with one “CAREguardso that we can receive not just thelow dose technology but training and of Colombia’s most admired institutions for its mission of delivering lifesaving allows us to doadvice, and we want that to continue,”says cardiologist Echeverri. “By the same cardiovascular care to poor children and young people who otherwise might die continuoustoken, we offer suggestions on design prematurely. follow-up of theimprovements to better protect the Attesting to Fundación Cardioinfan-patients and people who work in the til’s high standards is its cooperation radiationroom.” Those suggestions have includedsmaller tables to accommodate child arrangement with the Cleveland Clinic, which sends medical staff to Bogotá dispersed by thepatients and design changes for protec-tive clothing. once a year to conduct professional seminars. machines andThe advances of the Artis zee system “Most companies just want to sell helps us reducegive Dr. Echeverri added flexibility in machines and there is usually a discon-devising different protocols “according nect between the sales and technical exposure toto the patient and his or her condition, staff of these companies. Siemens isinstead of using the same program for changing that trend. Together we are patients andall patients. This is new with the latestsoftware of our Artis zee.” Adds Dr. constantly refining the proper use of the machines,” Dr. Ronderos concluded. MDs, nurses andRonderos: “The Siemens engineers have “We have come to a nice arrangement.” technicianshelped a lot in giving individual train-ing to our personnel with the goal of Chris Kraul is a freelance writer based in Bogotá, working in theminimizing the radiation used in a given Colombia, covering stories a wide range of top-exam and to devise additional measures ics. A reporter for the Los Angeles Times for 22 lab.” years, he was most recently the Latin Americanof radiological protection.” Bureau Chief at the newspaper’s Bogotá office.In February, Siemens brought in experts Dario Echeverri, M.D.,to the clinic from Germany to lead a Department of Cardiology, Fundacióndose and radiation workshop on safe Cardioinfantil, Bogotá, Colombia Contactoperation of the angiography sys- vera.juennemann@siemens.comtems. That was an important gesture, AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 15
  16. 16. Cover Story CAREA Pediatric Radiologist’sApproach to RadiationReductionSiemens has long been a leader in addressing the needto provide optimal images at the lowest possible radiationdose. AXIOM Innovations’ Robert L. Bard discussedradiation dose savings and their clinical application inpediatric patients with Anne Marie Cahill, MD, of theChildren’s Hospital of Philadelphia.By Robert L. BardThere is considerable concern among are paramount for Cahill because she grams automatically using the lowestboth medical professionals and the pub- frequently deals with complex cases. possible radiation dose while providinglic these days about radiation exposure, Furthermore, radiation exposure is the best possible images, but cliniciansin part due to the growing use of imag- especially important for her because she still have the ability to increase theing equipment in both diagnostic and is treating children. dose if there is an area of interest thatinterventional medicine. Anne Marie Siemens products have long been requires further investigation. For exam-Cahill, MD, Director of Interventional designed to help clinicians obtain qual- ple, Cahill commonly evaluates patientsRadiology at the Children’s Hospital ity images while following the ALARA with vascular anomalies where she firstof Philadelphia, has worked with the principle. Siemens addresses the ALARA selects a low dose 3D program, syngoSiemens’ product development group principle with its Combined Applica- DynaCT, to deliver the lowest necessaryto find new ways of imaging with lower tions to Reduce Exposure, or “CARE” dose of radiation to image the vascula-radiation doses and at the same time package. CARE is available throughout ture. However, if she notices a sectionachieving the best possible images. This the Siemens line of imaging products of blood vessel that is not imaged wellprinciple is commonly referred to as the and addresses several aspects of the or appears to be abnormal during the“ALARA” principle: as low as reasonably imaging process, including the docu- initial scan, she has the freedom andachievable. mentation and monitoring of radiation ability to interrupt the standardizedWhile clinicians must be aware of acute exposure of both patients and clinicians. program and she can concentrate theradiation exposure from any individual A primary feature of CARE is the ability imaging on that particular area andprocedure, they must be even more to standardize radiation doses at the investigate any potential abnormalities.diligent in managing chronic radiation lowest possible level for each and every Siemens CAREguard is available withdoses for their patients who receive procedure or image. CARE permits the all Artis zee angiography systems,either multiple procedures acutely or interventional radiologist to choose providing skin dose control softwarechronic procedures in a long-term evalu- programs in advance so that ALARA can that helps limit and document radia-ation of their condition. These concerns be achieved. Study-specific imaging pro- tion levels. With CAREguard, radiation16 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  17. 17. CARE Cover StoryAXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 17
  18. 18. Cover Story CAREdoses are constantly measured and has experienced three major benefits of only are fewer images necessary usingthe user can set the parameters to site- the Siemens products in their ability to Overlay Reference, but the images arespecific values. If pre-defined skin dose image at the lowest possible radiation obtained at a lower radiation level.levels are exceeded, an audible warn- doses: Store Fluoro, Overlay Reference, Therefore, radiation is decreased asing sounds, and a skin dose indicator and Low Dose syngo DynaCT. compared to traditional applications thatflashes on the live display. A warning Store Fluoro enables the user to store a relied upon traditional fluoroscopy.pop-up is also prominently displayed on regular fluoro scene during a procedure During common vascular imaging, radia-the touchscreen of the system’s table- for documentation instead of doing a tion dose is decreased because, as Cahillside control, which is located within the new acquisition. Cahill explains that this states, “We can do an angiogram andinterventional radiologist’s view during functionality allows her to decrease the save a specific image and then overlaythe procedure. Radiation exposure lev- number of acquisitions she requires as that image onto the live fluoro. Laterels can be generated with CAREreport, compared to previous clinical methods. that image can be used to track smallerand they can also be archived in the She can save images on the display arteries. This process saves radiationPACS system along with the procedural monitor instead of obtaining further because we do not perform roadmapsimages. Cahill and her colleagues regu- images and exposing the patient – and (comprehensive tracking of blood flowlarly take advantage of this feature by staff – to additional levels of radiation. through the vasculature) as much as weproviding patients with radiation infor- Prior to having this capability, it would used to.”mation when reviewing clinical results. have been necessary for her to acquire additional images to assure she had all C-arm CT and Joint InjectionsClinical Applications of the information she needed before The Children’s Hospital of Philadelphiafor Low-Dose Imaging the patient left the interventional also uses syngo DynaCT to reduce radia-Cahill has worked closely with Siemens radiology suite. tion exposure in patients who requirein developing C-arm CT protocols that Similar to Store Fluoro, Overlay Refer- imaging where the radiation dose is aprovide 3D information in the inter- ence can decrease the number of particular concern. C-arm computedventional radiation suite at very low images acquired as compared to previ- tomography permits joint injectionsradiation doses. She reports that she ous clinical imaging methods. Not with the use of CT and fluoroscopy andAVM nidus extending from T6 to L1 supplied by a left intercostal artery1 2 31 Conventional intercostal artery angiogram 2 VRT (Volume Rendering Technique) 3 Embedded MPR Image of AVM nidus18 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  19. 19. CARE Cover Story “Store Fluoro allows us to decrease theomits an additional dose of radiation latter is used to determine the relation- number of acquiredfrom traditional CT. Cahill references her ship of the airway to the treated lesion images. With theresearch using C-arm CT, which shows to help decide if the patients breathingthat radiation doses can be significantly tube can be safely removed post proce- Store Fluorodecreased when treating and evaluat- dure. In vascular malformation therapy functionality we caning patients with temporal mandibular this helps clinicians determine whetherjoint (TMJ) disorder. She explains that the breathing tube can be safely save images on theradiation savings are largely obtained by removed from patients who are asleep display monitorreducing the need to acquire traditional under general anesthesia.computed tomography examinations In addition, vascular anomalies are instead of obtainingfollowing interventional treatments. treated using Low Dose syngo DynaCT further images andTMJ disorder commonly requires as well, and the radiation savings – alsopatients to receive repeated injections about 50 percent of conventional CT – is exposing the patient,once or twice a year, and the radiation largely obtained once again by omitting and staff, todose savings adds up during the course a post-procedural traditional CT. One ofof treatment. Pediatric TMJ patients are the major advantages of treating vascu- additional levels ofone specific group where imaging with lar anomalies in this fashion is that the radiation.”the ALARA principle is crucial because success of the sclerotherapy procedureof the repeated radiation exposure of a can be evaluated immediately after thevulnerable area, the jaw, because of its procedure by the same interventional Anne Marie Cahill, M.D., Department of Interventional Radiology, Children’sproximity to the eyes and thyroid. radiologist at the same location, which Hospital of Philadelphia, PA, USAJoint injections are a common applica- is an efficient use of hospital resourcestion of C-arm CT because of the ability and an excellent means to improveto image at very low dose. Dr. Cahill patient satisfaction to their clinical care.estimates based on phantom studies The importance of dose savings –about a 50 percent reduction when especially in young patients – willcompared to conventional CT and a only increase with the growth offurther radiation dose reduction of 6% non-invasive imaging and radiologicfrom a manufacturer setting. This dose interventions. Siemens has addressedreduction is possible due to the inher- the need to provide high-quality imagesent high contrast of bone and needle at the lowest possible radiation dosein CT imaging. The benefit of such a with its CARE package, which providessignificant dose savings also applies to a clear indication of the radiation levelsthe treatment of children with juvenile used for every image or procedure. Thisarthritis, who are sometimes as young ALARA approach improves the account-as two or three years old and, as in TMJ ability of the interventional radiologist,cases, require multiple injections dur- interventional cardiologist, and admin-ing the course of their treatment. The istrators while promoting a healthyimportance of reducing the amount of environment for patients and staff.acute and chronic radiation is quite evi-dent in these delicate patients. Robert L. Bard is a freelance medical writer cer-Other areas where significant radiation tified by the American Medical Writer’s Associa- tion who also conducts clinical research at thesavings are achieved include procedures University of Michigan’s Division of Cardiovas-where syngo DynaCT is used to guide cular Medicine.the needle during bone biopsies andto assess the airway and lesion during Contactvascular malformation therapy, whereby heike.theessen@siemens.comthe intermittent imaging used in the AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 19
  20. 20. Cover Story CARETreatment of Complex Head and NeckLymphatic Malformation in an InfantSupported by syngo DynaCTCourtesy of Anne Marie Cahill, M.D., Deddeh Ballah, B.A.Department of Interventional Radiology, Children’s Hospital of Philadelphia, PA, USA Childrens Hospital of Philadelphia – Founded in 1855 as the nations first hospital devoted exclusively to caring for children, it has been the birthplace of many firsts in pe- diatric medicine. In interventional radiology employees are working hand in hand to provide best possible care for their patients.Patient history course of 24 months. Doxycycline is an sible dose while preserving diagnosticAt 40 weeks in utero the male fetus antibiotic that causes inflammation of information. With the inherent contrastwas diagnosed with a large neck mass the lymphatic malformation epithelium provided by the sclerotherapy agent weon prenatal ultrasound. Prenatal MR that eventually leads to scarring and are able to reduce the dose providedimaging was performed demonstrat- regression of the lesion. The second by our typical syngo DynaCT to 6 % ofing a 5.7 cm by 2.7 cm left neck mass. and third sclerotherapy procedures used the manufacturer setting and 50 % ofThe patient was delivered at CHOP Low Dose syngo DynaCT imaging to conventional CT.via Caesarean section for concern of confirm sclerotherapy distribution in the In the future, syngo DynaCT can beairway compromise. The baby boy lesion. The syngo DynaCT was acquired used to direct procedures. By identifyingrequired routine resuscitation and was with a dose value of 0.7 mGy. areas of the lesions that lack sclero-transferred uneventfully to the neonatal therapy agent after injection, additionalintensive care unit. Comments injections may be performed during syngo DynaCT is used to confirm sclero- treatment potentially reducing the num-Diagnosis therapy agent distribution and deter- ber of future sessions.On the third day of life, a neck MRI with mine proximity to the airway in patientsand without gadolinium contrast was with complex head and neck lymphaticperformed on the neonate, showing a malformations. Intraprocedural syngo Pediatr Radiol. 2011 Apr;41(4):T2 hyperintense, multicystic lesion with DynaCT images can provide information 476-82. Epub 2010 Nov 16.evidence of hemorrhage that extended regarding the volume of lesion treatedto the posterior neck and deeper and the necessity for further treatment Results: The manufacturers default setting gave an equivalentstructures of the neck, including the sessions. It enables us to create image CTDI of 4.8 mGy. Optimizing the dose settings andprevertebral and retropharyngeal space, reconstructions in three planes on a adding copper filtration reduced the radiation dose byconfirming a macrocystic lymphatic separate workstation allowing us to 94 %. This represents a 50 % reduction from conven- tional CT.malformation. compare the extent of the lesion treated to the pre-treatment lesion in thoseTreatment three planes on MRI. ContactThis patient underwent three doxycy- Since this is essentially a CT scan it is heike.theessen@siemens.comcline sclerotherapy procedures over the imperative to achieve the lowest pos-20 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  21. 21. CARE Cover Story1 1 Axial T2 weighted MR image demonstrating the macrocystic lymphatic malformation left neck.2 2 Correlating axial syngo DynaCT image demonstrating the distribution of the sclerotherapy agent throughout the lesion when compared to the MRI. Note the close proximity of the sclerotherapy agent and lesion to the airway guiding post-procedure therapy, resulting in the patient remaining intubated post-procedure. AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 21
  22. 22. Cover Story CAREEvaluation of CAREposition:Radiation-Free Positioning withCAREposition Results in a Decreasein Screening TimesBrendan Erskine, and Elissa Marshall from the Department ofRadiology, The Alfred, Melbourne, Australia have conducted astudy on the potential of CAREposition to reduce the fluoroscopicscreening time during various diagnostic procedures. The studywas presented as a paper: “Evaluation of Siemens CAREposition,Radiation-Free Positioning For Angiography and Fluoroscopy” atthe ASMIRRT 2011 conference.by Brendan Erskine and Elissa MarshallIntroduction savings, not to investigate dose minimi- Other techniques for reducing screeningCAREposition is a Siemens functionality zation. While a reduction in screening time,that enables accurate repositioning of time will result in lower patient dose,the patient under visual control without ultimately dose is a product of many • Last Image Hold (LIH) holds the lastradiation exposure. Guidance is pro- factors, beyond the scope of this study, fluoroscopic image on the viewingvided by a centrally positioned crosshair such as: monitor and incorporates radiation-marking the central beam while the free collimation and wedge filtercollimated field of view (FOV) is visually • Patient habitus placementdisplayed as a white outlined rectan- • Object-to-image distancegular box. This is displayed on the last • Source-to-object distance • ‘Fluoro Store’ or ‘Fluoro Loop’ per-image hold and adjusts automatically • Field of view mit the operator to review andto changes in position of the table and • Exposure factors (kV, mA) save the last fluoroscopic imagingC-arm as well as changes in FOV. • Exposure time sequence. While not directly reduc- • Detector quantum efficiency (DQE) ing the screening time, this softwareBackground • Pulsed fluoroscopy functionality may indirectly reduceCAREposition functionality is aimed • Adaptive dose filtration by the screening time and patient dose bypurely at reducing fluoroscopic screen- application of copper/aluminum allowing the storage of fluoroscopicing time and therefore the primary prefiltration sequences instead of formal (higherfocus of this study was to quantify these dose) angiographic sequences22 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  23. 23. CARE Cover Story Table 1: Screening Times Pre & Post CAREposition 30:00Mean Screening Time (min) 25:00 20:00 15:00 pre CAREposition post CAREposition 10:00 05:00 00:00 Aorto-femoral Angiography ERCP Femoral Angiography PICC Line Insertion AV Fistulography Gastrografin Swallow AV Fistula – Interventional Defecating Proctography Tunneled Line Insertion Pain Management Jugular Vonoplasty Video Swallow Erskine Brendan and Marshall Elissa, Dept. of Radiology, The Alfred, Melbourne, Australia• Some fluoroscopic systems especially as the difficulty of laser visualization Methods mobile image intensifiers (I.I.) incor- in brightly lit rooms and refraction Screening times from procedures per- porate the use of I.I. mounted laser of the laser through plastic I.I. cov- formed on all angiographic and fluoro- guidance to assist positioning without ers. Also, accurate positioning of the scopic machines were obtained over a the need for radiation. This relatively laser is made more difficult on heavily six month period. At the trial midpoint, cheap method of image guidance draped patients. three multipurpose fluoroscopic/angio- suffers from many drawbacks such graphic machines were enabled with AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 23
  24. 24. Cover Story CARETable 2: Screening time measurements during diagnostic and interventional procedures Procedure Case Numbers PRE CAREposition POST CAREposition Endoscopic retrograde 94 04:52 03:42 pancreato-cholangiography (ERCP) Gastrografin Swallow 65 01:18 01:24 Video Swallow 50 03:24 03:20 Defecating proctography 39 01:46 01:27 Peripherally Inserted Central Catheter (PICC) 656 00:45 00:45 Tunnelled catheter insertion 103 01:28 01:00 (Hickmans, Permcath, Portocath) Pain management injections 126 00:47 00:47 (Epidural, Facet joint, Medial branch block) Aorto-femoral angiography – Diagnostic 27 03:26 03:11 Femoral angiography – Diagnostic 25 01:30 01:11 Arterio-venous (AV) fistulography – 19 01:06 00:49 Diagnostic Arterio-venous (AV) fistulography – 22 14:50 14:02 Interventional Jugular venoplasty – Interventional 47 27:09 20:11 Erskine Brendan and Marshall Elissa, Dept. of Radiology, The Alfred, Melbourne, AustraliaCAREposition software licensing: interventional) will always lead to a certainly provided more accurate wide spread of results. To obtain the results.• Siemens AXIOM Artis MP most accurate data, only procedures (fluoroscopy) (diagnostic or interventional) with Discussion• Siemens AXIOM Artis MP standardized imaging and relatively […] CAREposition appeared most (angiography) high case numbers were chosen. These beneficial in the scenario of sequen-• Siemens AXIOM Artis dMP procedures along with results are dem- tial diagnostic imaging of peripheral (fluoroscopy/angiography) onstrated in Table 1. vasculature, whereby accurate overlap between acquisitions could be achievedAll machines employed remote (pedes- Study limitations with minimal fluoroscopy. Aorto-femoraltal) C-arm/table controls ran exclusively Since we are primarily a teaching insti- diagnostic angiographic studies saw aby the radiographer. Our main angio- tution, it is likely that even without the 7 % reduction in screening time (3:26graphic machine, a Siemens Artis zee use of CAREposition we might have to 3:11 min), with single leg diagnosticbiplane, had CAREposition licensing observed a small reduction in screen- studies demonstrating a 21 % reductionfrom installation and was therefore ing times given increasing experience (1:30 to 1:11 min). A similar result wasexcluded from the trial. of both medical and allied staff. Also, demonstrated for diagnostic AV fistulog-Although data from approximately despite the six month trial encompass- raphy, where a 26 % reduction (1:06 to2,200 procedures were obtained, ing approximately 2,200 fluoroscopic/ 0:49 min) was observed. Several exam-the variability of fluoroscopic and angiographic procedures, a greater ples for procedures are listed in Table 2.angiographic procedures (particularly period of data collection would have When operators gain confidence in the24 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  25. 25. CARE Cover Story1a 1b 1c 1 Utilization of CAREposition during three angiographic procedures:a Trans-jugular liver biopsyb Cerebral angiographyc Femoral angiographyaccuracy of CAREposition functionality, ing time was demonstrated, however, lization of CAREposition has resulted in ahuge reductions in screening time could noting our case numbers were small. modest decrease in screening times forbe achieved. Such was highlighted when A much larger result was demonstrated a range of diagnostic procedures withreliance exclusively on CAREposition for in jugular venoplasty procedures. This greatest benefit being demonstratedguidance of angiographic positioning in interventional procedure was chosen when used in sequential diagnosticthree peripheral diagnostic studies com- because it provided the largest subject imaging of peripheral vasculature.prising 19 separate acquisitions, were group of all the interventional proce-achieved with totals of only 4, 6 and 8 dures and involved standardized imag- Thanks to the following angiographers for theirseconds fluoroscopy time […] ing of both internal jugular veins and assistance in compiling procedural data: Jane Chow, Karen Patel, Alix Fell, Wayne Chan, Neal[…] screening times in interventional azygos system with subsequent angio- Russell, Lisa Broadley.procedures are heavily dependent on plasty of stenosed vessels, providing usboth the patient pathology and the with a more accurate reflection of theskill of the clinician. Although difficult benefits of CAREposition.to quantify, CAREposition appearedextremely useful in complex and chal- Conclusionlenging interventional procedures CAREposition provides radiation-free flu-especially when multiple working oroscopic and angiographic positioningprojections were employed. In the with the use of graphic markers overlaid Contactangiographic intervention of AV fistulas on the fluoroscopic last image hold. vera.juennemann@siemens.comonly a small reduction (5 %) in screen- Our study has demonstrated that the uti- AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 25
  26. 26. Angiography syngo iGuideEndoleak Treatment:Enhanced VisualizationMeets Enhanced NavigationDiagnostic CT scan showes an Endoleak Type II. The CT images are fused with the syngo iGuide allows you to place target and syngo DynaCT dataset. skin entry point on the CT image, which is overlaid onto the syngo DynaCT. 1 2 3syngo iGuide integrated needle guidance The endovascular repair of abdominal aortic aneurysms (EVAR) with stentenables vascular surgeons and grafts has surged in popularity overinterventional radiologists to efficiently, the past decade, dramatically reduc- ing the amount of recovery time forprecisely, and effectively treat type II patients in comparison with open repair.endoleaks, one of the most vexing However, approximately one-third1 of patients who undergo EVAR will havecomplications following endovascular an endoleak, a condition in whichabdominal aortic aneurysm repair. blood flows outside the lumen of the endograft but within the aneurysm sac,By Sameh Fahmy, MS potentially increasing the risk of rupture. In type II endoleaks, aortic branches that26 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine
  27. 27. syngo iGuide Angiographysyngo iGuideprovides abulls eyeview and pro-gressionviews foroptimal nee- After reaching the target a catheter will be A DSA scene shows clearly all endoleak relateddle tracking. placed in the endoleak. vessels. The feeding vessels will be embolized with various coils and Cordis Trufill n-Butyl Cyanoacrylate glue. 4 5 6have been excluded by the endograft, pital DeBakey Heart and Vascular Center syngo DynaCT, the solution frees upsuch as the lumbar arteries and the in Houston, Texas, USA, and Professor of the hospital’s computed tomographyinferior mesenteric artery, perfuse the Cardiovascular Surgery at Weill Cornell (CT) scanners for routine diagnosticaneurysm sac via retrograde blood flow. Medical College of Cornell University. imaging and enhances workflow byType II endoleaks are the most common In July 2010, Lumsden and his collea- eliminating the need to transfer theendoleak and can have multiple feeding gues began using syngo iGuide inte- patient during the procedure. “The mostand draining vessels that make their grated needle guidance, a software important thing for us is that the aneu-treatment challenging. “Sometimes solution that enables physicians to per- rysm stops growing,” says Lumsden,when we get referred to these patients, form needle procedures more precisely who uses the multi-axis Artis zeego.they may have had three or four trans- and efficiently using the Artis zee family “And in the majority of patients thatfemoral attempts at blocking the en- of C-arm systems. Because the planning we have treated with syngo iGuide, thedoleak off,” says Alan Lumsden, MD, of the procedure is accomplished using aneurysm has stopped growing and theMedical Director of the Methodist Hos- cross-sectional images acquired with endoleak has gone away.” AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 27
  28. 28. Angiography syngo iGuide Interventional radiologists such as much shorter amount of time. Detailed David Lacey, MD, at Iowa Methodist anatomical information is obtained with Medical Center in Des Moines, Iowa syngo DynaCT, and the images are fused report similar promising results. “I’m with a diagnostic CT that was obtained more apt to be able to select small ves- earlier. To define the needle path, physi- sels and embolize them, and our results cians mark the needle target point in have been very good,” says Lacey, who the CT dataset and then mark the loca- in 2008 became one of the first users of tion of the skin entry point. By scrolling syngo iGuide in the USA. through the multiplanar reformations, physicians can follow the needle path Saving Time easily and verify that there are no vital and Streamlining Workflow structures, such as the inferior vena The two most common approaches cava, in the way of the planned path. for treating type II endoleaks are the syngo iGuide automatically proposes transarterial approach, often via trans- two needle progression views, in which femoral access, and direct translumbar the planned path is graphically overlaid puncture. The success rate of the tran- onto the fluoroscopic image. The needle sarterial approach is low, with up to 80 is advanced under fluoro guidance, and percent recurrence rate due to the com- an additional syngo DynaCT run is per- plexity of endoleaks and the potentially formed in slab mode to check the final circuitous route.2 position of the needle. Once the needle “The transfemoral approach has been position is verified, the physicians per- tried and largely has failed,” Lumsden form the embolization. says. “The idea behind the translum- Lacey estimates that the use of syngo bar procedure is that instead of going iGuide reduces the time it takes to per- through multiple feeding branches, you form the procedure by an hour, while go right where they all come together Lumsden notes that it may save even and work into those feeding branches more time in particularly complicated from inside that. The access in trying to cases. “The last one we did probably “In the majority of go transfemoral or transmesenteric is took an hour,” Lumsden says. “Before, it patients that we very long and torturous; some catheters probably took two to three hours.” can’t even get to them.” In addition to the measurable reduc- have treated with Lacey explains that before Iowa Meth- tion in time associated with the use of syngo iGuide, the odist Medical Center began using syngo syngo iGuide, the elimination of patient iGuide with its ceiling-mounted Artis transfer from the CT has the theoretical aneurysm has zee, he and his colleagues would use a advantage of maintaining sterility, since stopped growing translumbar approach and advance the physicians no longer have to transfer a needle into the endoleak cavity using CT patient with a wire extending from the and the endoleak fluoroscopy. After confirming that the aneurysm sac, out the patient’s back, has gone away.” needle was in position by the pulsatile and to the outside world. return of blood, the physicians would A CT scanner can be used for many exchange the needle over a guidewire, diagnostic scans in the time it takes to Alan B. Lumsden, M.D., Medical Director secure the wire with tape, and then complete a single needle procedure, so Methodist DeBakey Heart and Vascular transfer the patient to the interven- the elimination of the CT scanner for Center, The Methodist Hospital, Houston, TX, USA tional radiology angio suite. The patient needle guidance also has clear finan- would then be re-prepped before physi- cial benefits. Lacey points out that the cians used the guidewire to advance a increasing use of interventions such as catheter under fluoroscopic guidance CT biopsies and CT ablations has put into the endoleak cavity, where coils additional scheduling demands on the and glue are used for the embolization. scanners at Iowa Methodist Medical With the installation of syngo iGuide, Center, making any technology that however, the entire procedure is per- reduces demand for the CT scanners formed in the angio suite – and in a especially welcome.28 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

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