Results with intraoperative 3-D angiography

Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie

Universitätsklinik Heidelberg

Ärztlicher Direktor: Prof. Dr. D.Böckler

P. Geisbüsch, C. Schulz, D. Böckler

Disclosure

Research grant by Siemens AG

Speakers fee (Siemens AG)

Contrast enhanced cone beam CT

for EVAR evaluation

=

Completion „Dyna CT“

Dyna CT Aquisition

5s Protocol; 90 LAO - 110 RAO

Dyna CT Aquisition

5s Protocol; 90 LAO - 110 RAO

Dyna CT: Volume of Aquisition

19 cm

24 cm

19 cm

Standard EVAR ✔

FEVAR ✔

Iliac Side branch ✔

Branched Endografts ?

CTA DynaCT

Heidelberg experience

EVAR Patients: n=98, prospective patient cohort

Intraoperative Postoperative

DynaCT DSA CTA

Geisbüsch et al J Vasc Surg Submitted for publication

Study Objective

1. Detection of endograft related complications:

- Endoleaks

- Endograft limb stenoses

- Endograft limb thrombosis

2. Reduction of reinterventions

3. Radiation exposure (Phantom model)

4. Reduction of contrast agent

Detection of endoleaks

Endoleak Type DSA

(n= / %)

DynaCT

(n= / %)

CTA

(n= / %)

I 1

(1.0%)

2

(2.0%)

1

(1.0%)

II 15

(15.3%)

33

(33.7%)

21

(21.4%)

III - - -

total

(n=98)

16

(16.3%)

35

(35.7%)

22

(22.4%)

DSA DynaCT CTA Reintervention

Ia Ballooning Ia -

(Ia)* Ballooning Ia

(dorsal) Ballooning Ia

Endostapler

(neglected by patient)

II II II

Distal Stentgraft-

extension

(Typ Ib in CEUS)

*treated after DSA and not seen on control-DSA

Endoleak Typ I

DSA DynaCT CTA Reintervention

Ia Ballooning Ia -

(Ia)* Ballooning Ia

(dorsal) Ballooning Ia

Endostapler

(neglected by patient)

II II II

Distal Stentgraft-

extension

(Typ Ib in CEUS)

*treated after DSA and not seen on control-DSA

Endoleak Typ I

DSA DynaCT CTA Reintervention

Ia Ballooning Ia -

(Ia)* Ballooning Ia

(dorsal) Ballooning Ia

Endostapler

(neglected by patient)

II II II

Distal Stentgraft-

extension

(Typ Ib in CEUS)

*treated after DSA and not seen on control-DSA

Endoleak Typ I

DSA DynaCT CTA Reintervention

Ia Ballooning Ia -

(Ia)* Ballooning Ia

(dorsal) Ballooning Ia

Endostapler

(neglected by patient)

II II II

Distal Stentgraft-

extension

(Typ Ib in CEUS)

*treated after DSA and not seen on control-DSA

Endoleak Typ I

Endoleak Type DSA

(n= / %)

DynaCT

(n= / %)

CTA

(n= / %)

I 1

(1.0%)

2

(2.0%)

1

(1.0%)

II 15

(15.3%)

33

(33.7%)

21

(21.4%)

III - - -

total

(n=98)

16

(16.3%)

35

(35.7%)

22

(22.4%)

Endoleak Typ II

Endoleak Type DSA

(n= / %)

DynaCT

(n= / %)

CTA

(n= / %)

I 1

(1.0%)

2

(2.0%)

1

(1.0%)

II 15

(15.3%)

33

(33.7%)

21

(21.4%)

III - - -

total

(n=98)

16

(16.3%)

35

(35.7%)

22

(22.4%)

Detection of endoleaks

DSA DynaCT Intraoperative

Intervention CTA Reintervention

- 1 PTA -

- 1 Stentgraft

Implantation -

- 1 PTA 1 Stentgraft

Implantation

Endograft limb stenosis

DSA DynaCT Intraoperative

Intervention CTA Reintervention

- 1 Thrombectomy -

- 1 Thrombectomy -

- 1 Thrombectomy -

Endograft limb thrombosis

Reinterventionen Heidelberg Author (Year) Patients Protocol Radiation Dose

Intra-

operative

cDSA

Intervention

DynaCT

(n= / %)

Postoperative

Control

Method

Reinterven-

tions after

CTA / CEUS

Heidelberg1 n=98 5s, 200°2

248f3 40 x 30 cm4

43.7 ± 10.8

Gycm² X

7/98

(7.1%) CTA

2/98

(2.0%)

1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size

Literatur (Reintervention ceCBCT) Author (Year) Patients Protocol Radiation Dose

Intra-

operative

cDSA

Intervention

DynaCT

(n= / %)

Postoperative

Control

Method

Reinterven-

tions after

CTA / CEUS

Heidelberg1 n=98 5s, 200°2

248f3 40 x 30 cm4

43.7 ± 10.8

Gycm² X

7/98

(7.1%) CTA

2/98

(2.0%)

Hertault et al.

(2015)

Lille

n=54 8s, 200°

150f 30 x 30 cm

7 Gycm²

(5.25 - 8) -

17/54

(31.5%) CEUS

2/54

(3.7%)

Törnqvist et al.

(2015)

Malmö n=51

8s, 200° 397f

40 x 30 cm

70.6 Gycm²

(34.9 –

126.5)

X 4/59

(6.7%) CTA

3/51

(5.9%)

Dijkstra et al.

(2011)

Cleveland

n=19

8s 397f

-

0.55 ± 0.036

Gy -

6/19

(31.5%) CTA n.a.

Biasi et al.

(2009)

St. George’s

London

n=65 8s 200°

248f 40 x 30 cm

- X 5/65 (7.7%) CTA 0/65

1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size

Literatur (Reintervention w/o DSA) Author (Year) Patients Protocol Radiation Dose

Intra-

operative

cDSA

Intervention

DynaCT

(n= / %)

Postoperative

Control

Method

Reinterven-

tions after

CTA / CEUS

Heidelberg1 n=98 5s, 200°2

248f3 40 x 30 cm4

43.7 ± 10.8

Gycm² X

7/98

(7.1%) CTA

2/98

(2.0%)

Hertault et al.

(2015)

Lille

n=54 8s, 200°

150f 30 x 30 cm

7 Gycm²

(5.25 - 8) -

17/54

(31.5%) CEUS

2/54

(3.7%)

Törnqvist et al.

(2015)

Malmö n=51

8s, 200° 397f

40 x 30 cm

70.6 Gycm²

(34.9 –

126.5)

X 4/59

(6.7%) CTA

3/51

(5.9%)

Dijkstra et al.

(2011)

Cleveland

n=19

8s 397f

-

0.55 ± 0.036

Gy -

6/19

(31.5%) CTA n.a.

Biasi et al.

(2009)

St. George’s

London

n=65 8s 200°

248f 40 x 30 cm

- X 5/65 (7.7%) CTA 0/65

1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size

Literatur (Reintervention CTA) Author (Year) Patients Protocol Radiation Dose

Intra-

operative

cDSA

Intervention

DynaCT

(n= / %)

Postoperative

Control

Method

Reinterven-

tions after

CTA / CEUS

Heidelberg1 n=98 5s, 200°2

248f3 40 x 30 cm4

43.7 ± 10.8

Gycm² X

7/98

(7.1%) CTA

2/98

(2.0%)

Hertault et al.

(2015)

Lille

n=54 8s, 200°

150f 30 x 30 cm

7 Gycm²

(5.25 - 8) -

17/54

(31.5%) CEUS

2/54

(3.7%)

Törnqvist et al.

(2015)

Malmö n=51

8s, 200° 397f

40 x 30 cm

70.6 Gycm²

(34.9 –

126.5)

X 4/59

(6.7%) CTA

3/51

(5.9%)

Dijkstra et al.

(2011)

Cleveland

n=19

8s 397f

-

0.55 ± 0.036

Gy -

6/19

(31.5%) CTA n.a.

Biasi et al.

(2009)

St. George’s

London

n=65 8s 200°

248f 40 x 30 cm

- X 5/65 (7.7%) CTA 0/65

1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size

Literatur (Protokoll) Author (Year) Patients Protocol Radiation Dose

Intra-

operative

cDSA

Intervention

DynaCT

(n= / %)

Postoperative

Control

Method

Reinterven-

tions after

CTA / CEUS

Heidelberg1 n=98 5s, 200°2

248f3 40 x 30 cm4

43.7 ± 10.8

Gycm² X

7/98

(7.1%) CTA

2/98

(2.0%)

Hertault et al.

(2015)

Lille

n=54 8s, 200°

150f 30 x 30 cm

7 Gycm²

(5.25 - 8) -

17/54

(31.5%) CEUS

2/54

(3.7%)

Törnqvist et al.

(2015)

Malmö n=51

8s, 200° 397f

40 x 30 cm

70.6 Gycm²

(34.9 –

126.5)

X 4/59

(6.7%) CTA

3/51

(5.9%)

Dijkstra et al.

(2011)

Cleveland

n=19

8s 397f

-

0.55 ± 0.036

Gy -

6/19

(31.5%) CTA n.a.

Biasi et al.

(2009)

St. George’s

London

n=65 8s 200°

248f 40 x 30 cm

- X 5/65 (7.7%) CTA 0/65

1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size

Literatur (Protokoll) Author (Year) Patients Protocol Radiation Dose

Heidelberg1 n=98 5s, 200°2

248f3 40 x 30 cm4

43.7 ± 10.8

Gycm²

Hertault et al.

(2015)

Lille

n=54 8s, 200°

150f 30 x 30 cm

7 Gycm²

(5.25 - 8)

Törnqvist et al.

(2015)

Malmö n=51

8s, 200° 397f

40 x 30 cm

70.6 Gycm²

(34.9 – 126.5)

1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size

Phantom Model: Effective Dose

Dyna CT vs CTA

• RANDO Alderson Phantoms

Thermo-Luminescent Dosimeters

(TLD)

• BMI ≈ 22 kg/m² + BMI ≈ 30 kg/m²

• Same field of view (FOV) for both

modalities

Geisbüsch et al J Endovasc Ther. Submitted for publication

Single Phase

CTA, abdominal

FOV

Three Phase CTA,

Thoracoabdominal

FOV

DynaCT

BMI ≈ 22 kg/m² 2.0 9.6 3.5

BMI ≈ 30 kg/m² 2.1 10.1 5.1

All values are given in mSv according to IRCP 103

- 64 %

Phantom Model: Effective Dose

Dyna CT vs CTA

Geisbüsch et al J Endovasc Ther. Submitted for publication

Reduction of

„in hospital use of contrast“

Conclusion

Reliable detection of endograft related complications

Immediate correction of intraoperative complications in a

relevant proportion of patients (7%)

Potential to further reduce reintervention rates

Reduces in hospital use of contrast and radiation exposure

Optimal protocol needs to be defined

Conclusion

Standard Follow-Up

Completion

DSA

CTA

Secondary Reintervention

Conclusion

Standard Follow-Up Standard Follow-Up

Completion

DSA

Completion Dyna CT

CTA

Secondary Reintervention

Immediate Revision

Duplex / CEUS

+

-

Results with intraoperative 3-D angiography

Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie

Universitätsklinik Heidelberg

Ärztlicher Direktor: Prof. Dr. D.Böckler

P. Geisbüsch, C. Schulz, D. Böckler