Related Articles

New advances in catheter technology and remote actuation for minimally invasive procedures are continuously increasing the demand for better x-ray imaging technology. The new x-ray high-sensitivity Micro-Angiographic Fluoroscope (HS-MAF) detector offers high resolution and real-time image-guided capabilities which are unique when compared with commercially available detectors. This detector consists of a 300 μm CsI input phosphor coupled to a dual stage GEN2 micro-channel plate light image intensifier (LII), followed by minifying fiber-optic taper coupled to a CCD chip. The HS-MAF detector image array is 1024×1024 pixels, with a 12 bit depth capable of imaging at 30 frames per second. The detector has a round field of view with 4 cm diameter and 35 microns pixels. The LII has a large variable gain which allows usage of the detector at very low exposures characteristic of fluoroscopic ranges while maintaining very good image quality. The custom acquisition program allows real-time image display and data storage. We designed a set of in-vivo experimental interventions in which placement of specially designed endovascular stents were evaluated with the new detector and with a standard x-ray image intensifier (XII). Capabilities such fluoroscopy, angiography and ROI-CT reconstruction using rotational angiography data were implemented and verified. The images obtained during interventions under radiographic control with the HS-MAF detector were superior to those with the XII. In general, the device feature markers, the device structures, and the vessel geometry were better identified with the new detector. High-resolution detectors such as HS-MAF can vastly improve the accuracy of localization and tracking of devices such stents or catheters.

Effective minimally invasive treatment of cerebral bifurcation aneurysms is challenging due to the complex and remote vessel morphology. An evaluation of endovascular treatment in a phantom involving image-guided deployment of new asymmetric stents consisting of polyurethane patches placed to modify blood flow into the aneurysm is reported. The 3D lumen-geometry of a patient-specific basilar-artery bifurcation aneurysm was derived from a segmented computed-tomography dataset. This was used in a stereolithographic rapid-prototyping process to generate a mold which was then used to create any number of exact wax models. These models in turn were used in a lost-wax technique to create transparent elastomer patient-specific aneurysm phantoms (PSAP) for evaluating the effectiveness of asymmetric-stent deployment for flow modification. Flow was studied by recording real-time digitized video images of optical dye in the PSAP and its feeding vessel. For two asymmetric stent placements: through the basilar into the right-posterior communicating artery (RPCA) and through the basilar into the left-posterior communicating artery (LPCA), the greatest deviation of flow streamlines away from the aneurysm occurred for the RPCA stent deployment. Flow was also substantially affected by variations of inflow angle into the basilar artery, resulting in alternations in washout times as derived from time-density curves. Evaluation of flow in the PSAPs with real-time optical imaging can be used to determine new EIGI effectiveness and to validate computational-fluid-dynamic calculations for EIGI-treatment planning.

PURPOSE

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.

RESULTS

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.

CONCLUSIONS

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.

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.

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.

Background

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.

Methods

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.

Conclusions

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.

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.

Background

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.

Conclusions

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.

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.

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.

Images

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.

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.

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.

Purpose

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.

Methods

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.

Results

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.

Conclusion

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.

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.

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.)

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.

Purpose

To enhance real-time magnetic resonance guided catheter navigation by overlaying colorized multiphase MR angiography (MRA) and cholangiopancreatography (MRCP) roadmaps for anatomic context.

Materials and Methods

Time-resolved MRA and respiratory-gated MRCP were acquired prior to real-time imaging in a pig model. MRA and MRCP data were loaded into a custom real-time MRI reconstruction and visualization workstation where they were displayed as Maximum Intensity Projections (MIPs) in distinct colors. The MIPs were rendered in three dimensions (3D) together with real-time multi-slice imaging data using alpha blending. Interactive rotation allowed different views of the combined data.

Results

Fused display of the previously acquired MIP angiography data with real-time imaging added anatomical context during endovascular interventions in swine. The use of multiple MIPs rendered in different colors facilitated differentiation of vascular structures, improving visual feedback during device navigation.

Conclusion

Interventional real-time MR imaging may be enhanced by combining with previously acquired multiphase angiograms. Rendered as 3D MIPs together with 2D slice data, this technique provided useful anatomical context that enhanced MRI guided interventional applications.

Purpose

The purpose of the study was to develop an image guidance system that incorporates volumetric planning of spherical ablations and electromagnetic tracking of radiofrequency electrodes during insertion.

Methods

Simulated tumors were created in 3 live swine by percutaneously injecting agar nodules into the lung. A treatment plan was devised for each tumor using our optimization software to solve the planning problem. The desired output was the minimum number of overlapping ablation spheres necessary to ablate each tumor and the margin. The insertion plan was executed using the electromagnetic tracking system that guided the insertion of the probe into pre-computed locations. After a 72 hour survival, histopathologic sections of the tissue were examined for cell viability and burn pattern analysis.

Results

A planning algorithm to spherically cover the tumors and the margin was computed. Electromagnetic tracking allowed successful insertion of the instrument and impedance roll-off was reached in all ablations. Depending on their size, the tumors and the tumor margins were successfully covered with 2 to 4 ablation spheres. The image registration error was 1.0 ± 0.64mm. The overall error of probe insertion was 9.4 ± 3.0mm (n=8). Histopathologic sections confirmed successful ablations of the tissue.

Conclusions

Computer assisted RF ablation planning and electromagnetically tracked probe insertion were successful in 3 swine, thus validating the feasibility of electromagnetic tracking assisted tumor targeting. Image mis-registration due to respiratory motion and tissue deformation contributed to the overall error of probe insertion.

Purpose

To develop and test a novel interactive real-time MRI environment that facilitates image-guided cardiovascular interventions.

Materials and Methods

Color highlighting of device-mounted receiver coils, accelerated imaging of multiple slices, adaptive projection modes, live 3D renderings and other interactive features are utilized to enhance navigation of devices and targeting of tissue.

Results

Images are shown from several catheter-based interventional procedures performed in swine that benefit from this custom interventional MRI interface. These include endograft repair of aortic aneurysm, balloon septostomy of the cardiac interatrial septum, angioplasty and stenting, and endomyocardial cell injection, all using active catheters containing MRI receiver coils.

Conclusion

Interactive features not available on standard clinical scanners enhance real-time MRI for guiding cardiovascular interventional procedures.

During the last decade, the convergence of medical imaging and computational modeling technologies has enabled tremendous progress in the development and application of image-based computational fluid dynamics modeling of patient-specific blood flows. These techniques have been used for studying the basic mechanisms involved in the initiation and progression of vascular diseases, for studying possible ways to improve the diagnosis and evaluation of patients by incorporating hemodynamics information to the anatomical data typically available, and for the development of computational tools that can be used to improve surgical and endovascular treatment planning. However, before these technologies can have a significant impact on the routine clinical practice, it is still necessary to demonstrate the connection between the extra information provided by the models and the natural progression of vascular diseases and the outcome of interventions. This paper summarizes some of our contributions in this direction, focusing in particular on cerebral aneurysms.

Dr. Takao Hiraki is a scientist carrying out interventional radiology research in the Department of Radiology at Okayama University Medical School, Japan. He has conducted animal and human clinical studies on interventional radiology for various conditions. For example, he clarified the hepatic hemodynamic changes caused by hepatic venous occlusion. He also developed new devices, such as hydrogel coils for the occlusion of the aneurismal sac after an endovascular stent-graft of an aortic aneurysm to prevent endoleakage and small intestinal submucosa-covered stents for transjugular intrahepatic portosystemic shunts. Further, he performed a number of studies on the radiofrequency ablation of lung cancer, mediastinal lymph node metastasis, and computed tomography-fluoroscopy-guided lung biopsies. He intends to continue to dedicate his academic career to expand the role of interventional radiology in clinical medicine.

This paper focuses on the design of an integrated navigation and guidance system for unmanned helicopters. The integrated navigation system comprises two systems: the Flight Path Planning System (FPPS) and the Flight Control System (FCS). The FPPS finds the shortest flight path by the A-Star (A*) algorithm in an adaptive manner for different flight conditions, and the FPPS can add a forbidden zone to stop the unmanned helicopter from crossing over into dangerous areas. In this paper, the FPPS computation time is reduced by the multi-resolution scheme, and the flight path quality is improved by the path smoothing methods. Meanwhile, the FCS includes the fuzzy inference systems (FISs) based on the fuzzy logic. By using expert knowledge and experience to train the FIS, the controller can operate the unmanned helicopter without dynamic models. The integrated system of the FPPS and the FCS is aimed at providing navigation and guidance to the mission destination and it is implemented by coupling the flight simulation software, X-Plane, and the computing software, MATLAB. Simulations are performed and shown in real time three-dimensional animations. Finally, the integrated system is demonstrated to work successfully in controlling the unmanned helicopter to operate in various terrains of a digital elevation model (DEM).

Background

Current cancer management faces several challenges, including the occurrence of residual tumor after resection, the use of radioactive materials or high concentrations of blue dyes for sentinel lymph node (SLN) biopsy, and use of bulky systems in surgical suites for image guidance. To overcome these limitations, we developed a real-time intraoperative imaging device that, when combined with near infrared (NIR) fluorescent molecular probes, can aid identification of tumor margins, guide surgical resections, map SLNs, and transfer acquired data wirelessly for remote analysis.

Methods

We developed a new compact, wireless, wearable, and battery-operated device that allows hands-free operation by surgeons. A CCD-based consumer-grade night vision viewer was used to develop the detector portion of the device and the light source portion was developed from a compact headlamp. This piece was retrofitted to provide both NIR excitation and white light illumination simultaneously. Wireless communication was enabled by integrating a battery-operated miniature radio-frequency video transmitter into the system. We applied the device in several types of oncologic surgical procedures in murine models, including SLN mapping, fluorescence-guided tumor resection, and surgery under remote expert guidance.

Results

Unlike conventional imaging instruments, the device directly displays fluorescence information on its eyepiece. When employed in SLN mapping, the locations of SLNs were clearly visualized, even with tracer level dosing of a NIR fluorescent dye, indocyanine green. When utilized in tumor resection, tumor margins and small nodules not visible to the naked eye were readily visualized. In a simulated point-of-care setting, tumors were successfully located and removed under remote guidance using the wireless feature of the device. Importantly, the total cost of this prototype system ($1200) is significantly lower than existing imaging instruments.

Conclusion

Our results demonstrate the feasibility of using the new device to aid surgical resection of tumors, map SLNs, and facilitate telemedicine.