Stéphan Haulon, Richard McWilliams and Alan Lumsden, Faculty members of the CX Imaging Day, new style Parallel Session of the Charing Cross Symposium 2015), outline the relevance of therapeutic imaging for vascular and endovascular procedures, the use of robotics and radiation exposure concerns. These topics will be discussed at the CX Imaging Day on Thursday 30 April.

This year, the CX Imaging Day will provide a comprehensive programme on state-of-the-art imaging applied for the intervention of the aorta, carotid arteries, peripheral arteries and veins, involving planning and using hybrid theatres, robotics, 3D fusion and guidance, intravascular ultrasound (IVUS), perfusion angiography, cone beam computed tomography (CT) and carbon dioxide angiography. In the morning, attendees will hear the latest data on high-quality imaging and be able to discuss the different applications. During the afternoon, the “Ask the expert” workshop is organised in the Exhibition Hall with visits to the industry stands, focusing on sizing, 2D/3D fusion imaging and how to achieve optimal dose levels.

Stéphan Haulon (Aortic Centre, Hôpital Cardiologique, CHRU Lille, France), says delegates will get insights from large cohort published studies to identify the various strengths and limitations of high-end imaging. He adds: “We will report the latest progress, provide an update on radiation baseline for various procedures, and see how these new imaging techniques can be extended to peripheral limbs.”

Richard McWilliams (Radiology Department, Royal Liverpool University Hospital, Liverpool, UK) notes that the immediate and continuing success of endovascular interventions relies heavily on medical imaging. He comments: “The processing power of modern imaging workstations allows the physician to rapidly assimilate the relevant anatomy before intervention. Procedural success is facilitated by the quality of modern hybrid suites and the associated software that accompanies these allowing 3D imaging, 3D fusion and 3D guidance. Surveillance after endovascular treatment is now of higher quality because of improvements in CT scanners and ultrasound techniques including contrast-enhanced ultrasound. Direct comparison of one CT after aneurysm repair with a prior CT is now a joy when these are registered and locked together on dual monitors and reviewed in cine mode.”

Haulon states that the rise of catheter-based procedures and minimally invasive surgery has required concomitant advances in intraoperative imaging applications, and that hybrid rooms have made this possible by combining the mobility and sterility of an optimal open surgical environment with the latest advanced imaging capabilities of a fixed system such as image fusion or cone beam CT. “Experience has shown that the routine use of advanced imaging techniques, such as fusion, during endovascular aneurysm repair has significantly reduced the radiation exposure to patients and operators, as well as the contrast volume load, without jeopardising the overall procedure workflow,” he says.

The role of intraoperative imaging will be also highlighted in the Main Programme – Abdominal Aortic Controversies session (Wednesday 29 April) with a presentation by Dittmar Boeckler on intraoperative CT in ruptured abdominal aortic aneurysm treatment with EVAR. 

The portability of imaging (eg. ultrasound) and the more widespread availability of CT and MRI scans have transformed diagnosis and now the treatment of vascular disease, according to Alan Lumsden (Houston Methodist Hospital, Houston, USA). “We are in an era where portability makes imaging technology available in the operating room—image-guided surgery and endovascular surgery. This can be either by direct imaging or increasingly the use of image fusion methodologies.

At the CX Imaging Day, Lumsden will show how the use of robotics can be beneficial for different procedures—carotid, complex cases and even retrieval of inferior vena cava filters. “Navigation through the vascular system depends on the use of wires, catheters and a series of wall interactions with these devices. Such techniques have not fundamentally changed in decades. Catheter robotics promises a level of catheter and wire control that simply cannot be achieved using traditional techniques,” he says. Lumsden explains that his group’s interest in robotics was generated by watching an electrophysiologist take the robotic catheter through the inter-atrial septum, in a beating heart, while applying measured pressure and radiofrequency energy at multiple points, under precise control to the wall of the left atrium. He adds, “It was hard not to be impressed with these capabilities, hence our interest in the peripheral application of robotics. We believe that controlled navigation, stability and pushability of the Magellan catheter (Hansen Medical) will permit us to perform procedures which cannot be completed using manual techniques. Further it will allow us to steer devices which lack sterility (snares, thrombectomy devices, atherectomy catheters), thereby improving their capabilities.”

Haulon will present a new integrated workflow for sizing, 2D/3D fusion and assessment of endovascular aneurysm repair (EVAR). He explains: “Time is crucial, improving vascular surgeon sizing and fusion workflow is key, so why not preparing both steps at the same time? Completion contrast-enhanced cone beam CT has also demonstrated its capacity to assess technical success, reducing the requirement for a postoperative CT angiography and allowing accurate detection of complications requiring additional treatment right on the spot. Also, there is a need to consider radiation dose at a higher level than that of the procedure itself… we need to take into consideration the patient’s dose throughout the entire treatment process, from diagnosis, to treatment and including follow-up. Having the right dose management tools in place allows me to achieve this.” Giuseppe Pannuccio (Muenster, Germany) will be also presenting on the role of 2D/3D fusion imaging in complex aortic procedures.

3D imaging will be further explored by Tara Mastracci (London,UK) who will discuss the role of 3D guidance in fenestrated endovascular aneurysm repair (FEVAR) and by Frank Vermassen (Ghent, Belgium) who will show how 3D imaging can be used in carotid procedures. Jan Brunkwall (Cologne, Germany) will focus on 3D imaging in complex aortic procedures. 


Radiation exposure concerns

Radiation protection remains a major concern and will be one the topics discussed at the CX Imaging Day, and new technology is helping to change behaviour and lower doses, says McWilliams, and adds: “Live dose monitoring provides instant feedback to operators and assistants so that they are aware how their actions increase or decrease dose. Newer equipment is increasingly being designed with dose-saving in mind. Intravascular ultrasound during venous procedures is an important part of this.”

He maintains that “we must also remember the simple things that reduce dose which I see forgotten very commonly. These include increasing the distance from the X-ray source, using face screens, using pump injections rather than hand-injections to allow the operator to increase his/her distance, reducing the pulse rate and frame rate and knowing the relevant projections from the preoperative dataset rather than by trial and error during the procedure. An unfortunate reality is that although modern equipment is capable of exquisite fluoroscopic images, the operator needs to ensure that the images are good enough but not needlessly better than this, to avoid excessive dose to the patient and staff. If the image quality is too good then this is bad”.

Radiation exposure will be also highlighted in the Main Programme – Abdominal Aortic Controversies session with a mini-symposium dedicated to explore radiation reduction strategies for the operator and the patient, including a presentation on dose optimised imaging protocols for complex endovascular procedures by Eric Verhoeven (Nurnberg, Germany). In the Peripheral Arterial Controversies session (Tuesday 28 April) of the Main Programme, Martin Malina (Malmo, Sweden) will be speaking about contrast reduction angiography for peripheral arterial disease.    

In the afternoon, delegates will visit the Exhibition Hall (GE Healthcare, Hansen Medical, Philips and Siemens booths) for technology demonstrations.

The New CX Imaging Day will take place at the Charing Cross Symposium on Thursday 30 April – Olympia Room Learning Centre in the morning and Exhibition Hall in the afternoon, Olympia Grand, London, UK. 

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