The detectors that are used for endovascular image-guided interventions
(EIGI), particularly for neurovascular interventions, do not provide clinicians
with adequate visualization to ensure the best possible treatment outcomes.
Developing an improved x-ray imaging detector requires the determination of
estimated clinical x-ray entrance exposures to the detector. The range of
exposures to the detector in clinical studies was found for the three modes of
operation: fluoroscopic mode, high frame-rate digital angiographic mode (HD
fluoroscopic mode), and DSA mode. Using these estimated detector exposure ranges
and available CMOS detector technical specifications, design requirements were
developed to pursue a quantum limited, high resolution, dynamic x-ray detector
based on a CMOS sensor with 50 μm pixel size. For the proposed MAF-CMOS,
the estimated charge collected within the full exposure range was found to be
within the estimated full well capacity of the pixels. Expected instrumentation
noise for the proposed detector was estimated to be 50–1,300 electrons.
Adding a gain stage such as a light image intensifier would minimize the effect
of the estimated instrumentation noise on total image noise but may not be
necessary to ensure quantum limited detector operation at low exposure levels. A
recursive temporal filter may decrease the effective total noise by 2 to 3
times, allowing for the improved signal to noise ratios at the lowest estimated
exposures despite consequent loss in temporal resolution. This work can serve as
a guide for further development of dynamic x-ray imaging prototypes or
improvements for existing dynamic x-ray imaging systems.
MAF; CMOS; ROI; fluoroscopy; angiography; x-ray imaging; detector design; neurovascular interventions
We demonstrate a novel approach for achieving patient dose savings during image-guided neurovascular interventions, involving a combination of a material x-ray region of interest (ROI) attenuator and a spatially different ROI temporal filtering technique. The part of the image under the attenuator is reduced in dose but noisy and less bright due to fewer x-ray quanta reaching the detector, as compared to the non-attenuating (or less attenuating) region. First the brightness is equalized throughout the image by post processing and then a temporal filter with higher weights is applied to the high attenuating region to reduce the noise, at the cost of increased lag; however, in the regions where less attenuation is present, a lower temporal weight is needed and is applied to preserve temporal resolution.
A simulation of the technique is first presented on an actual image sequence obtained from an endovascular image guided interventional (EIGI) procedure. Then the actual implementation of the technique with a physical ROI attenuator is presented. Quantitative analysis including noise analysis and integral dose calculations are presented to validate the proposed technique.
To assess the feasibility of the use of preprocedural imaging for guide wire, catheter, and needle navigation with electromagnetic tracking in phantom and animal models.
MATERIALS AND METHODS
An image-guided intervention software system was developed based on open-source software components. Catheters, needles, and guide wires were constructed with small position and orientation sensors in the tips. A tetrahedral-shaped weak electromagnetic field generator was placed in proximity to an abdominal vascular phantom or three pigs on the angiography table. Preprocedural computed tomographic (CT) images of the phantom or pig were loaded into custom-developed tracking, registration, navigation, and rendering software. Devices were manipulated within the phantom or pig with guidance from the previously acquired CT scan and simultaneous real-time angiography. Navigation within positron emission tomography (PET) and magnetic resonance (MR) volumetric datasets was also performed. External and endovascular fiducials were used for registration in the phantom, and registration error and tracking error were estimated.
The CT scan position of the devices within phantoms and pigs was accurately determined during angiography and biopsy procedures, with manageable error for some applications. Preprocedural CT depicted the anatomy in the region of the devices with real-time position updating and minimal registration error and tracking error (<5 mm). PET can also be used with this system to guide percutaneous biopsies to the most metabolically active region of a tumor.
Previously acquired CT, MR, or PET data can be accurately codisplayed during procedures with reconstructed imaging based on the position and orientation of catheters, guide wires, or needles. Multimodality interventions are feasible by allowing the real-time updated display of previously acquired functional or morphologic imaging during angiography, biopsy, and ablation.
Image-guided endovascular intervention (EIGI), using new flow modifying endovascular devices for intracranial aneurysm treatment is an active area of stroke research. The new polyurethane-asymmetric vascular stent (P-AVS), a vascular stent partially covered with a polyurethane-based patch, is used to cover the aneurysm neck, thus occluding flow into the aneurysm. This study involves angiographic imaging of partially covered aneurysm orifices. This particular situation could occur when the vascular geometry does not allow full aneurysm coverage. Four standard in-vivo rabbit-model aneurysms were investigated; two had stent patches placed over the distal region of the aneurysm orifice while the other two had stent patches placed over the proximal region of the aneurysm orifice. Angiographic analysis was used to evaluate aneurysm blood flow before and immediately after stenting and at four-week follow-up. The treatment results were also evaluated using histology on the aneurysm dome and electron microscopy on the aneurysm neck. Post-stenting angiographic flow analysis revealed aneurysmal flow reduction in all cases with faster flow in the distally-covered case and very slow flow and prolonged pooling for proximal-coverage. At follow-up, proximally-covered aneurysms showed full dome occlusion. The electron microscopy showed a remnant neck in both distally-placed stent cases but complete coverage in the proximally-placed stent cases. Thus, direct flow (impingement jet) removal from the aneurysm dome, as indicated by angiograms in the proximally-covered case, was sufficient to cause full aneurysm healing in four weeks; however, aneurysm healing was not complete for the distally-covered case. These results support further investigations into the treatment of aneurysms by flow-modification using partial aneurysm-orifice coverage.
Asymmetric Vascular Stent; AVS; Aneurysm treatment; hemodynamics; flow modification; angiography
Multi-detector computed tomography (MDCT) scanners produce high-resolution images of the chest. Given a patient’s MDCT scan, a physician can use an image-guided intervention system to first plan and later perform bronchoscopy to diagnostic sites situated deep in the lung periphery. An accurate definition of complete routes through the airway tree leading to the diagnostic sites, however, is vital for avoiding navigation errors during image-guided bronchoscopy. We present a system for the robust definition of complete airway routes suitable for image-guided bronchoscopy. The system incorporates both automatic and semiautomatic MDCT analysis methods for this purpose. Using an intuitive graphical user interface, the user invokes automatic analysis on a patient’s MDCT scan to produce a series of preliminary routes. Next, the user visually inspects each route and quickly corrects the observed route defects using the built-in semiautomatic methods. Application of the system to a human study for the planning and guidance of peripheral bronchoscopy demonstrates the efficacy of the system.
3D pulmonary imaging; Procedure planning; Image-guided intervention; Bronchoscopy; Lung cancer; MDCT; Virtual bronchoscopic navigation; Route planning
Present day treatment for neurovascular pathological conditions involves the use of devices with very small features such as stents, coils, and balloons; hence, these interventional procedures demand high resolution x-ray imaging under fluoroscopic conditions to provide the capability to guide the deployment of these fine endovascular devices. To address this issue, a high resolution x-ray detector based on EMCCD technology is being developed. The EMCCD field-of-view is enlarged using a fiber-optic taper so that the detector features an effective pixel size of 37 µm giving it a Nyquist frequency of 13.5 lp/mm, which is significantly higher than that of the state of the art Flat Panel Detectors (FPD). Quantitative analysis of the detector, including gain calibration, instrumentation noise equivalent exposure (INEE) and modulation transfer function (MTF) determination, are presented in this work. The gain of the detector is a function of the detector temperature; with the detector cooled to 5° C, the highest relative gain that could be achieved was calculated to be 116 times. At this gain setting, the lowest INEE was measured to be 0.6 µR/frame. The MTF, measured using the edge method, was over 2% up to 7 cycles/ mm. To evaluate the performance of the detector under clinical conditions, an aneurysm model was placed over an anthropomorphic head phantom and a coil was guided into the aneurysm under fluoroscopic guidance using the detector. Image sequences from the procedure are presented demonstrating the high resolution of this SSXII.
Phantom equivalents of different human anatomical parts are routinely used for imaging system evaluation or dose calculations. The various recommendations on the generic phantom structure given by organizations such as the AAPM, are not always accurate when evaluating a very specific task. When we compared the AAPM head phantom containing 3 mm of aluminum to actual neuro-endovascular image guided interventions (neuro-EIGI) occurring in the Circle of Willis, we found that the system automatic exposure rate control (AERC) significantly underestimated the x-ray parameter selection. To build a more accurate phantom for neuro-EIGI, we reevaluated the amount of aluminum which must be included in the phantom. Human skulls were imaged at different angles, using various angiographic exposures, at kV’s relevant to neuro-angiography. An aluminum step wedge was also imaged under identical conditions, and a correlation between the gray values of the imaged skulls and those of the aluminum step thicknesses was established. The average equivalent aluminum thickness for the skull samples for frontal projections in the Circle of Willis region was found to be about 13 mm. The results showed no significant changes in the average equivalent aluminum thickness with kV or mAs variation. When a uniform phantom using 13 mm aluminum and 15 cm acrylic was compared with an anthropomorphic head phantom the x-ray parameters selected by the AERC system were practically identical. These new findings indicate that for this specific task, the amount of aluminum included in the head equivalent must be increased substantially from 3 mm to a value of 13 mm.
Head equivalent phantom; uniform phantom; Circle of Willis; fluoroscopy; digital subtracted angiography
Several new image-guidance tools and devices are being prototyped, investigated, and compared. These tools are introduced and include prototype software for image registration and fusion, thermal modeling, electromagnetic tracking, semiautomated robotic needle guidance, and multimodality imaging. The integration of treatment planning with computed tomography robot systems or electromagnetic needle-tip tracking allows for seamless, iterative, “see-and-treat,” patient-specific tumor ablation. Such automation, navigation, and visualization tools could eventually optimize radiofrequency ablation and other needle-based ablation procedures and decrease variability among operators, thus facilitating the translation of novel image-guided therapies. Much of this new technology is in use or will be available to the interventional radiologist in the near future, and this brief introduction will hopefully encourage research in this emerging area.
Magnetic resonance imaging (MRI), which provides superior soft-tissue imaging and no known harmful effects, has the potential as an alternative modality to guide various medical interventions. This review will focus on MR-guided endovascular interventions and present its current state and future outlook. In the first technical part, enabling technologies such as developments in fast imaging, catheter devices, and visualization techniques are examined. This is followed by a clinical survey that includes proof-of-concept procedures in animals and initial experience in human subjects. In preclinical experiments, MRI has already proven to be valuable. For example, MRI has been used to guide and track targeted cell delivery into or around myocardial infarctions, to guide atrial septal puncture, and to guide the connection of portal and systemic venous circulations. Several investigational MR-guided procedures have already been reported in patients, such as MR-guided cardiac catheterization, invasive imaging of peripheral artery atheromata, selective intraarterial MR angiography, and preliminary angioplasty and stent placement. In addition, MR-assisted transjugular intrahepatic portosystemic shunt procedures in patients have been shown in a novel hybrid double-doughnut x-ray/MRI system. Numerous additional investigational human MR-guided endovascular procedures are now underway in several medical centers around the world. There are also significant hurdles: availability of clinical-grade devices, device-related safety issues, challenges to patient monitoring, and acoustic noise during imaging. The potential of endovascular interventional MRI is great because as a single modality, it combines 3-dimensional anatomic imaging, device localization, hemodynamics, tissue composition, and function.
interventional MRI; endovascular procedures; real-time MRI
Image-guided endovascular interventions have gained increasing popularity in clinical practice, and magnetic resonance imaging (MRI) is emerging as an attractive alternative to X-ray fluoroscopy for guiding such interventions. Steering catheters by remote control under MRI guidance offers unique challenges and opportunities.
In this review, the benefits and limitations of MRI-guided remote control intervention are addressed, and the tools for guiding such interventions in the magnetic environment are summarized. Designs for remote control catheter guidance include a catheter tip electromagnetic microcoil design, a ferromagnetic sphere-tipped catheter design, smart material-actuated catheters, and hydraulically actuated catheters. Remote control catheter guidance systems were compared and contrasted with respect to visualization, safety, and performance. Performance is characterized by bending angles achievable by the catheter, time to achieve bending, degree of rotation achievable, and miniaturization capacity of the design. Necessary improvements for furthering catheter design, especially for use in the MRI environment, are addressed, as are hurdles that must be overcome in order to make MRI guided endovascular procedures more accessible for regular use in clinical practice.
MR-guided endovascular interventions under remote control steering are in their infancy due to issues regarding safety and reliability. Additional experimental studies are needed prior to their use in humans.
Interventional MRI; Remote control catheter guidance
Vascular and cardiac disease remains a leading cause of morbidity and mortality in developed and emerging countries. Vascular and cardiac interventions require extensive fluoroscopic guidance to navigate endovascular catheters. X-ray fluoroscopy is considered the current modality for real time imaging. It provides excellent spatial and temporal resolution, but is limited by exposure of patients and staff to ionizing radiation, poor soft tissue characterization and lack of quantitative physiologic information. MR fluoroscopy has been introduced with substantial progress during the last decade. Clinical and experimental studies performed under MR fluoroscopy have indicated the suitability of this modality for: delivery of ASD closure, aortic valves, and endovascular stents (aortic, carotid, iliac, renal arteries, inferior vena cava). It aids in performing ablation, creation of hepatic shunts and local delivery of therapies. Development of more MR compatible equipment and devices will widen the applications of MR-guided procedures. At post-intervention, MR imaging aids in assessing the efficacy of therapies, success of interventions. It also provides information on vascular flow and cardiac morphology, function, perfusion and viability. MR fluoroscopy has the potential to form the basis for minimally invasive image–guided surgeries that offer improved patient management and cost effectiveness.
Cardiac imaging; Magnetic resonance imaging; Vascular imaging
In modern endoscopy, wide field of view and full color are considered necessary for navigating inside the body, inspecting tissue for disease and guiding interventions such as biopsy or surgery. Current flexible endoscope technologies suffer from reduced resolution when device diameter shrinks. Endoscopic procedures today using coherent fiber bundle technology, on the scale of 1 mm, are performed with such poor image quality that the clinician’s vision meets the criteria for legal blindness. Here, we review a new and versatile scanning fiber imaging technology and describe its implementation for ultrathin and flexible endoscopy. This scanning fiber endoscope (SFE) or catheterscope enables high quality, laser-based, video imaging for ultrathin clinical applications while also providing new options for in vivo biological research of subsurface tissue and high resolution fluorescence imaging.
medical imaging; optical scanning; endoscopy; endomicroscopy; two-photon microscopy
Real-time MR imaging (rtMRI) is now technically capable of guiding catheter-based cardiovascular interventions. Compared with x-ray, rtMRI offers superior tissue imaging in any orientation without ionizing radiation. Translation to clinical trials has awaited the availability of clinical-grade catheter devices that are both MRI visible and safe. We report a preclinical safety and feasibility study of rtMRI-guided stenting in a porcine model of aortic coarctation using only commercially available catheter devices.
Method and Results
Coarctation stenting was performed wholly under rtMRI guidance in 13 swine. rtMRI permitted procedure planning, device tracking, and accurate stent deployment. “Active” guidewires, incorporating MRI antennas, improved device visualization compared with unmodified “passive” nitinol guidewires and shortened procedure time (26±11 versus 106±42 minutes; P = 0.008). Follow-up catheterization and necropsy showed accurate stent deployment, durable gradient reduction, and appropriate neointimal formation. MRI immediately identified aortic rupture when oversized devices were tested.
This experience demonstrates preclinical safety and feasibility of rtMRI-guided aortic coarctation stenting using commercially available catheter devices. Patients may benefit from rtMRI in the future because of combined device and tissue imaging, freedom from ionizing radiation, and the ability to identify serious complications promptly.
angioplasty; catheterization; coarctation; heart defects; congenital; stents
Personalized therapies play an increasingly critical role in cancer care; Image guidance with multimodality image fusion facilitates the targeting of specific tissue for tissue characterization, and plays a role in drug discovery and optimization of tailored therapies. PET, MRI and contrast enhanced CT may offer additional information not otherwise available to the operator during minimally invasive image guided procedures such as biopsy and ablation. With use of multimodality image fusion for image-guided interventions, navigation with advanced modalities does not require the physical presence of the PET, MRI, or CT imaging system. Several commercially available methods of image fusion and device navigation are reviewed along with an explanation of common tracking hardware and software. An overview of current clinical applications for multimodality navigation is provided.
New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.
Medicine; Issue 74; Anatomy; Physiology; Biomedical Engineering; Surgery; Cardiology; catheter ablation; remote navigation; magnetic; robotic; catheter; positioning; electrophysiology; clinical techniques
High resolution imaging capabilities are essential for accurately guiding successful endovascular interventional procedures. Present x-ray imaging detectors are not always adequate due to their inherent limitations. The newly-developed high-resolution micro-angiographic fluoroscope (MAF-CCD) detector has demonstrated excellent clinical image quality; however, further improvement in performance and physical design may be possible using CMOS sensors. We have thus calculated the theoretical performance of two proposed CMOS detectors which may be used as a successor to the MAF.
The proposed detectors have a 300 μm thick HL-type CsI phosphor, a 50 μm-pixel CMOS sensor with and without a variable gain light image intensifier (LII), and are designated MAF-CMOS-LII and MAF-CMOS, respectively. For the performance evaluation, linear cascade modeling was used. The detector imaging chains were divided into individual stages characterized by one of the basic processes (quantum gain, binomial selection, stochastic and deterministic blurring, additive noise). Ranges of readout noise and exposure were used to calculate the detectors’ MTF and DQE.
The MAF-CMOS showed slightly better MTF than the MAF-CMOS-LII, but the MAF-CMOS-LII showed far better DQE, especially for lower exposures.
The proposed detectors can have improved MTF and DQE compared with the present high resolution MAF detector. The performance of the MAF-CMOS is excellent for the angiography exposure range; however it is limited at fluoroscopic levels due to additive instrumentation noise. The MAF-CMOS-LII, having the advantage of the variable LII gain, can overcome the noise limitation and hence may perform exceptionally for the full range of required exposures; however, it is more complex and hence more expensive.
MTF; DQE; CMOS; MAF; Linear Cascade Model; interventional imaging; x-ray image detector
Fluoroscopic systems have excellent temporal resolution, but are relatively noisy. In this paper we present a recursive temporal filter with different weights (lag) for different user selected regions of interest (ROI) to assist the neurointerventionalist during an image guided catheter procedure. The filter has been implemented on a Graphics Processor (GPU), enabling its usage for fast frame rates such as during fluoroscopy.
We first demonstrate the use of this GPU-implemented rapid temporal filtering technique during an endovascular image guided intervention with normal fluoroscopy. Next we demonstrate its use in combination with ROI fluoroscopy where the exposure is substantially reduced in the peripheral region outside the ROI, which is then software-matched in brightness and filtered using the differential temporal filter. This enables patient dose savings along with improved image quality.
Medical imaging data is becoming increasing valuable in interventional medicine, not only for preoperative planning, but also for real-time guidance during clinical procedures. Three key components necessary for image-guided intervention are real-time tracking of the surgical instrument, aligning the real-world patient space with image-space, and creating a meaningful display that integrates the tracked instrument and patient data. Issues to consider when developing image-guided intervention systems include the communication scheme, the ability to distribute CPU intensive tasks, and flexibility to allow for new technologies. In this work, we have designed a communication architecture for use in image-guided catheter ablation therapy. Communication between the system components is through a database which contains an event queue and auxiliary data tables. The communication scheme is unique in that each system component is responsible for querying and responding to relevant events from the centralized database queue. An advantage of the architecture is the flexibility to add new system components without affecting existing software code. In addition, the architecture is intrinsically distributed, in that components can run on different CPU boxes, and even different operating systems. We refer to this Framework for Image-Guided Navigation using a Distributed Event-Driven Database in Real-Time as the FINDER architecture. This architecture has been implemented for the specific application of image-guided cardiac ablation therapy. We describe our prototype image-guidance sytem and demonstrate its functionality by emulating a cardiac ablation procedure with a patient-specific phantom. The proposed architecture, designed to be modular, flexible, and intuitive, is a key step towards our goal of developing a complete system for visualization and targeting in image-guided cardiac ablation procedures.
Endovascular imaging techniques encompass a variety of methods, including angiography, computed tomography, magnetic resonance imaging, angioscopy, and intravascular ultrasound. Each method provides unique information regarding the continuity of vascular structures and the morphology and distribution of lesions. Although arteriography has been the "gold standard" for imaging arterial anatomy, recent data have confirmed that even sophisticated arteriographic imaging substantially underestimates the degree of residual lesions, and that future observations and end-points for treatment will most likely be determined by data accumulated by computed tomography, magnetic resonance imaging, angioscopy, and intravascular ultrasound. Successful therapeutic applications of endovascular devices have developed because of improved patient selection using computed tomography, spiral computed tomography, magnetic resonance imaging, and computerized high-resolution angiography. Procedural success has been enhanced by improved mobile cinefluoroscopy, angioscopy, intraluminal ultrasound monitoring of angioplasty procedures, and the use of intravascular ultrasound for stent and stent-graft sizing and deployment. Newly developed methods and low-profile delivery systems enabling deployment and fixation of vascular prostheses by an endoluminal approach have heightened the interest of many interventionalists, particularly surgeons, in the use of endovascular surgical techniques. The evolution of this method promises to add a new dimension to the treatment of vascular lesions and relies heavily on the incorporation of miniaturized imaging systems, such as intravascular ultrasound, as a means to provide precise placement of devices.
We have designed and developed from the discrete component level a high resolution dynamic detector for neurovascular interventions. The heart of the detector is a 1024 × 1024 pixel electron multiplying charge coupled device (EMCCD) with a pixel size of 13 × 13 μm2, bonded to a fiber optic plate (FOP), and optically coupled to a 350 μm micro-columnar CsI(TI) scintillator via a 3.3:1 fiber optic taper (FOT). The detector provides x-ray images of 9 cycles/mm resolution at 15 frames/sec and real time live video at 30 frames/sec with binning at a lower resolution, both independent of gain applied to EMCCD, as needed for region-of-interest (ROI) image guidance during neurovascular interventions.
Direct visualization of pancreatic ductal tissue is critical for early diagnosis of pancreatic diseases and for guiding therapeutic interventions. A novel, ultrathin (5 Fr) scanning fiber endoscope (SFE) with tip-bending capability has been developed specifically to achieve high resolution imaging as a pancreatoscope during endoscopic retrograde cholangiopancreatography (ERCP). This device has potential to dramatically improve both diagnostic and therapeutic capabilities during ERCP by providing direct video feedback and tool guidance to clinicians.
Invasiveness of the new tip-bending SFE was evaluated by a performance comparison to ERCP guide wires, which are routinely inserted into the pancreatic duct during ERCP. An in vitro test model with four force sensors embedded in a synthetic pancreas was designed to detect and compare the insertion forces for 0.89 mm and 0.53 mm diameter guide wires as well as the 1.7 mm diameter SFE. Insertions were performed through the working channel of a therapeutic duodenoscope for the two types of guide wires and using a statistically similar direct insertion method for comparison to the SFE.
Analysis of the forces detected by the sensors showed the smaller diameter 0.53 mm wire produced significantly less average and maximum forces during insertion than the larger diameter 0.89 mm wire. With the use of tip-bending and optical visualization, the 1.7 mm diameter SFE produced significantly less average force during insertion than the 0.89 mm wire at every sensor, despite its larger size. It was further shown that the use of tip-bending with the SFE significantly reduced the forces at all sensors, compared to insertions when tip-bending was not used.
Combining high quality video imaging with two-axis tip-bending allows a larger diameter guide wire-style device to be inserted into the pancreatic duct during ERCP with improved capacity to perform diagnostics and therapy.
endoscopic retrograde cholangiopancreatography (ERCP); scanning fiber endoscope (SFE); pancreatic cancer; minimally invasive therapy
For treatment of cerebral aneurysms, the low porosity patch-like region of a new asymmetric stent must be accurately aligned both longitudinally and rotationally to cover the aneurysm orifice. Image guided interventions (IGI) for this task using either a high spatial resolution microangiographic detector (MA) or a standard x-ray image intensifier (XII) are compared. MA is a custom built phosphor-fiberoptic-CCD x-ray detector; the MA array is 1024X1024 with 43 microns pixels. We designed an experimental simulation of the IGI which involved localization using a combination of a computer-controlled rotational stage supported on a linear traverse. A catheter containing the asymmetric stent with special gold markers was positioned near the aneurysm of a vessel phantom which is contained in a flow loop to enable contrast injection for creation of roadmap images. We used four different configurations for the markers consisting of dots and lines. The true stent alignment, obtained by direct visual viewing, was determined to better than one degree rotational accuracy. The resultant IGI localization accuracy under radiographic control with the microangiographic detector was 4° compared to 12° for the XII. In general the line markers performed better than the dot markers. Experimental data show that high resolution detectors such as MA can vastly improve the accuracy of localization and tracking of devices such as asymmetric stents. This should enable development of more effective treatment devices and interventions. (Partial support from NIH grants NS38746, NS43294, and EB002873; UB STOR, Toshiba MSC, and Guidant Corp.)
Endovascular surgical techniques have become an accepted standard of care for high-risk patients with abdominal aortic aneurysms and for certain patients with thoracic aortic pathology and peripheral arterial aneurysms. In Canada, endovascular surgery has been concentrated in tertiary-care academic teaching institutions. As the technology evolves and as expertise advances, the applicability of endovascular techniques will expand. With time, and as the demand for endovascular techniques rises, this expertise will increasingly need to be delivered by dedicated vascular surgical services in nonteaching institutions. The dissemination of endovascular surgical capabilities represent a unique challenge. We report the successful implementation of an endovascular surgical program in a tertiary-care nonteaching institution using a carefully planned preceptorship model. We review our initial 49 cases and discuss 6 factors important to the successful establishment of an endovascular surgical service: education, teamwork, strict selection of patients, use of a single stent–graft manufacturer, industry support and endovascular preceptorship. Our experience may be used as a model by other institutions in Canada.
Abdominal aortic aneurysm is a common vascular disease that affects elderly population. Open surgical repair is regarded as the gold standard technique for treatment of abdominal aortic aneurysm, however, endovascular aneurysm repair has rapidly expanded since its first introduction in 1990s. As a less invasive technique, endovascular aneurysm repair has been confirmed to be an effective alternative to open surgical repair, especially in patients with co-morbid conditions. Computed tomography (CT) angiography is currently the preferred imaging modality for both preoperative planning and post-operative follow-up. 2D CT images are complemented by a number of 3D reconstructions which enhance the diagnostic applications of CT angiography in both planning and follow-up of endovascular repair. CT has the disadvantage of high cummulative radiation dose, of particular concern in younger patients, since patients require regular imaging follow-ups after endovascular repair, thus, exposing patients to repeated radiation exposure for life. There is a trend to change from CT to ultrasound surveillance of endovascular aneurysm repair. Medical image visualizations demonstrate excellent morphological assessment of aneurysm and stent-grafts, but fail to provide hemodynamic changes caused by the complex stent-graft device that is implanted into the aorta. This article reviews the treatment options of abdominal aortic aneurysm, various image visualization tools, and follow-up procedures with use of different modalities including both imaging and computational fluid dynamics methods. Future directions to improve treatment outcomes in the follow-up of endovascular aneurysm repair are outlined.
Abdominal aortic aneurysm; Computed tomography; Follow-up; Stent graft; Treatment; Visualization.
Currently, a large number of endovascular interventions are performed for treatment of intracranial aneurysms. For these treatments, correct positioning of microcatheter tips, microguide wire tips, or coils is essential. Techniques to detect such devices may facilitate endovascular interventions. In this paper, we describe an algorithm for tracking of microcatheter tips during fluoroscopically guided neuroendovascular interventions. A sequence of fluoroscopic images (1,024 × 1,024 × 12 bits) was acquired using a C-arm angiography system as a microcatheter was passed through a carotid phantom which was on top of a head phantom. The carotid phantom was a silicone cylinder containing a simulated vessel with the shape and curvatures of the internal carotid artery. The head phantom consisted of a human skull and tissue-equivalent material. To detect the microcatheter in a given fluoroscopic frame, a background image consisting of an average of the four previous frames is subtracted from the current frame, the resulting image is filtered using a matched filter, and the position of maximum intensity in the filtered image is taken as the catheter tip position in the current frame. The distance between the tracked position and the correct position (error distance) was measured in each of the fluoroscopic images. The mean and standard deviation of the error distance values were 0.277 mm (1.59 pixels) and 0.26 mm (1.5 pixels), respectively. The error distance was less than 3 pixels in the 93.0% frames. Although the algorithm intermittently failed to correctly detect the catheter, the algorithm recovered the catheter in subsequent frames.
Catheter motion tracking; vascular intervention; fluorography; cerebral artery; image subtraction; microcatheter; navigation system