Intraoperative Imaging for EVAR What's New, What's Coming? None - PowerPoint PPT Presentation

4/6/2017 Disclosures Intraoperative Imaging for EVAR— What's New, What's Coming? None Acknowledgements � Matt Eagleton � Stephon Haulon � Gustavo Oderich Darren B. Schneider, MD Associate Professor of Surgery Chief, Vascular and Endovascular Surgery Intraoperative Imaging for EVAR Intraoperative Imaging for EVAR Traditionally EVAR Traditionally EVAR performed using 2-D performed using 2-D fluoro and DSA fluoro and DSA What if we could … See anatomy in 3-D � Eliminate need for DSA � Assess repair � intraoperatively Eliminate the need for � fluoro altogether 1

4/6/2017 Improving Imaging for EVAR Cone Beam CT (CBCT) � Cone Beam CT (CBCT) � Image fusion � Digital zoom (radiation reduction) � Non radiation-based imaging guidance (GPS navigation) GE Discovery CBCT Courtesy of G. Oderich Fusion Imaging Fusion Imaging � Pre-operative CTA � Pre-operative CTA � Create anatomic markers � Create anatomic landmarks � Intra-op CBCT � Image registration Pre-op CTA + CBCT Markers Image Registration 2

4/6/2017 Fusion Imaging Fusion Imaging � Pre-operative CTA Benefits: � Create anatomic landmarks � Reduce need for DSA runs � Intra-op CBCT � Identify optimal c- � Image registration arm angles Pre-op CTA + CBCT � Fuse to form 3-D model � Reduce radiation dose � Overlay 3-D model on 2-D fluoro � Streamline case 3-D on 2-D Overlay Verifying Fusion Registration 3

4/6/2017 Fusion Imaging Accuracy Affected by: � CTA slice thickness � Patient movement � Respiratory motion � Vessel distortion from stiff guidewires and devices Image Fusion Image Fusion : reposition anatomy without fluoro Title or Job Number | XX Month 201X 16 Courtesy of S. Haulon Courtesy of S. Haulon 4

4/6/2017 Completion CBCT assessment Courtesy of S. Haulon Courtesy of S. Haulon Intra-op CBCT assessment Intra-op CBCT assessment Courtesy of S. Haulon Courtesy of G. Oderich 5

4/6/2017 Advanced Imaging Applications Endo TAAA Trends and Learning Curve HOME Procedure Trends 1200 1000 800 600 1200 1040 400 755 525 475.1 423 200 366.9 340 0 New generation of clinical apps with seamless integration 1-10 11-20 21-30 31-40 to PLAN, GUIDE & ASSESS complex procedures PATIENTS EBL (cc) Procedure Time (min) Benefits of digital treatment of images Digital zoom and Collimation IOPS • I ntra o perative P ositioning S ystem • What does it provide? – Interactive 3D Vascular Imaging – EM tracking of endovascular “tools” within the vascular tree Courtesy of S. Haulon Courtesy of M. Eagleton 6

4/6/2017 Developed a Mathematical Model for Vascular 3-Dimensional Wireframe Model Image Construction • Based on DICOM CT data • The model was tested by assessing the relative geometry of the aortic branches Goel VR, et al. IEEE Computer Graphics and Applications, May/June 2008 Overlay Fusion of Mathematical Model Model Over Angio � Bare Angio � Model � Aorta � Branch vessels � Celiac � SMA � LRA � RRA 7

4/6/2017 Navigation System Development Sensors on Sheaths, Wires, Patient sensors – overcome Catheters patient/table movement DEVICE LOCALIZATION WITHIN THE MODEL Display System Development Proof of Concept Testing 8

4/6/2017 Merging of Imaging and Guidance in Preclinical Study – porcine model Model April 6, 2017 34 Able to re-orient 3-D image to And magnify image provide the optimal view April 6, 2017 36 9

4/6/2017 Transition to Clinical Application IOPS Guided Cannulation: Left Renal Artery IOPS-Fluoro Correlation April 6, 2017 37 April 6, 2017 38 Cannulation of Left Renal Artery with Computer “Anticipated” Deformations Catheter • Can affect alterations at discrete sections of the vessel 10

4/6/2017 Can be applied to overlay imaging Incremental Deformation . � Low stiffness � Moderate stiffness � High stiffness Low Stiffness Medium Stiffness April 6, 2017 43 11

4/6/2017 High Stiffness What does IOPS provide • Enhanced three dimensional imaging • Ability to manipulate the imaging to provide multiple, ideal views • Ability to track the endovascular tools within the vascular image – correlating directly with in vivo localization • Provide superior imaging and navigation to standard 3-D fluoroscopy DIVISION OF VASCULAR AND ENDOVASCULAR SURGERY Conclusions • Fusion imaging provides continuous 3-D image visualization to facilitate EVAR, especially complex cases: • Learning curve, but can easily be integrated into workflow • Facilitates device positioning, deployment, and target vessel cannulation • Can reduce radiation dose • Completion CBCT can detect technical problems to allow intraoperative correction • Future technology • Automated corrections for vessel deformation and movement • Non-radiation-based image guidance 12