R obertY.R hee,M DR obertY.R hee,M DChief,VascularandEndovascularS urgery
Director,AorticCenter
M aim onidesM edicalCenter
BrooklynBrooklyn
Houston Aortic Sy m p osium 2017
• W L Gore:consultant,researchsupport,principalinvestigatorinvestigator
• Cook:researchsupport
M edtronic:researchsupport• M edtronic:researchsupport
• BostonS cientific:researchsupport,M AB• BostonS cientific:researchsupport,M AB
• GEHealthcare:consultant,researchsupport
Decem ber1948
Dr.R udolphN issen,chairm anofsurgery atM M C (1945-52),laterfam edforfundoplicationsurgery… .operatedonAlbertDr.R udolphN issen,chairm anofsurgery atM M C (1945-52),laterfam edforfundoplicationsurgery… .operatedonAlbertEinsteinforaAAA (w rappedtheaneurysm w ithcellophane)… … survived5yearspostopcellophane)… … survived5yearspostop
“ Dow hatyou can,w ithw hatyou have,w hereyou are”
~T heodoreR oosevelt~T heodoreR oosevelt
How tom akeendovascularproceduresm oresaferandeffectivem oresaferandeffective
T heFuture… 3D im agingforinterventions
W illbethestandardofcarew ithin5 years
HighDefinitionversusS tandardDefinitionHighDefinitionversusS tandardDefinition
9
FusionofpatientCTFusionofpatientCTintosim ulationunitintosim ulationunit
S im ulatedS im ulatedEVAR
T roubleshootbeforetheT roubleshootbeforetheoperation/procedure
2002 Ph illip sHOR ce iling m ount2002 Ph illip sHOR ce iling m ountUPMC, Pittsb urgh
2006 GE Innova HOR floorm ountUPMC, Pittsb urgh
Se im e nsArtisZ e e goSe im e nsArtisZ e e go
GE Discove ry 740
FusionGuidedEVAR /T EVAR
3D P recisionininterventions3D P recisionininterventions
R adiationDoseR eductionw ithCT A fusionR adiationDoseR eductionw ithCT A fusiontechniquestechniques
3D overlayCT Angio fuse d into p roce dure
P lannedL andingzones
O stium outline
O ptim izedC-armangulations
T ranslum barT ype2 endoleaktreatm ent
•70% ofallvascularproceduresperform edw ith70% ofallvascularproceduresperform edw ithendovascularapproach
•15% ofallO P EN vascularproceduresrequire•15% ofallO P EN vascularproceduresrequireim aginginconjunction
•FU T U R E...U pto90% ofallvascular•FU T U R E...U pto90% ofallvascularinterventioncouldbeendovascularinterventioncouldbeendovascular
•Hybrid O R is“ requiredequipm ent”
Geoffrey W hite R oy Greenberg
R educedDoseandContrastw ithIm ageFusion… .655
112.5
177.5 189159
312L illestudy
T acherV.etal.
S ailerAM etal.
44-47
105-120
150-205
45.5
112.5
65
Dose(DA P Gy.cm 2) Contrast(m l) P roceduretim e(m in)
44-47
Dose(DA P Gy.cm 2) Contrast(m l) P roceduretim e(m in)
L AO 13°-CAU 27°L AO 5°-CR A 25°
HaqqaniJVascS urg 2012
W henL AO /R AO angleare>30°,doserateincreasesexponentially.increasesexponentially.S am ew ithCR A/CAU >15°
A B C
Doserate
B
C
L AO /R AO
A
U selow estacceptableprotocol& fram erate
100%
50%50%
24%
9%5% 2%2%
IQ +N orm al…
IQ +N orm al…
R DL +N orm al…
R DL +L ow …
R DL +L ow …
R DLL ow …
Interm ofdose,1 DS A im age ~ 100 fluoroim ages1 DS A im age ~ 100 fluoroim ages
45
• Standard EVAR (85 p atie nts)
• 6 ce nte rsworldwide
• Brooklyn• Brooklyn
• Lille, Toulouse
• Be lgium , Jap an, UK
• GE Discove ry IGS
• Each ce nte rh asre ce ive d a dose and
fusion im aging training b e fore e nrolling
p atie nts
• Monitoring dose and p ractice via• Monitoring dose and p ractice via
Dose watch , cloud-b ase d tracking
sy ste m
46GE Title orjob num b e r
2/25/2017
P restudy R esult:T heIm portanceofpracticefeedbacks
AfterP racticeanalysisand dedicated training…Number OfCases 8
30 Irradiated
Collimation(% of estimated collimated area per FOV)
Cases 8
Me an DAP 16.5Gy.cm ²
Me an AK 0.105Gy 30
0% 20% 40% 60% 80% 100%
Irradiated
Collim ated
Me an AK 0.105Gy
Me an Fluoro Tim e 14.05m in
Me an SID 1.15m
100%8%
18%
Acquisition Type(% of Total DAP)
Frame Rate(% of Total DAP)
Angulation(% of Fluoro Time & DAP)
FOV
(% of Total DAP)
32%
68%
100%19%
81%
68%
Fluoro DS A7.5
100%
30
74%
M edianA irKerm a M edianDA P M edianFluorotim e
S ite3
S ite4
M edianA irKerm a(m Gy)
S ite3
S ite4
M edianDA P(cGy.cm 2)
S ite3
S ite4
M edianFluorotim e(sec)
0 50 100 150 200
S ite1
S ite2
S ite3
0 1000 2000 3000
S ite1
S ite2
S ite3
0 500 1000 1500
S ite1
S ite2
S ite3
Achieving consistentlow doseresultsacrosssitesM edianAK< 110 m Gy,DAP < 15 Gycm 2M edianAK< 110 m Gy,DAP < 15 Gycm 2
• M ultim odality advancedim agingprovidestheinterventionalist a3Droadmap forinterventionroadmap forintervention
• S uccessofendovascularinterventions:P L AN N IN G andS IM U L AT IO N
• Integratedw orkflow ofplanningandintra-operative3D guidance• Integratedw orkflow ofplanningandintra-operative3D guidance
– DecreasesR adiation(topatientandoperater)
– DecreasesContrastU se
– DecreasesO R tim e(increasesO R efficiency)
– Decreasestim erequired forvascularinterventions
– S AFER forpatientsandstaff– S AFER forpatientsandstaff
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