AXIOM Innovations

The Magazine for Interventional Radiology, Cardiology and Surgery

Issue Number 14 | November 2011

Treatment of
Endoleaks
Using syngo iGuide
Page 26

New Hope
for Stenotic
Patients
Aortic Valve
Implantation
Page 38

Endovascular
Surgery with
3D Imaging
New Imaging
Possibilities
Page 42

Low Dose - High Principles

Saving Dose with CARE and syngo DynaCT
Editorial Editorial

Dear Reader,

“Keeping image quality

high and radiation Dr. Heinrich Kolem
CEO AX Division

dose low is one of the Earlier this year, I had the opportunity to
attend the Cardiovascular and Interven-
patients. They are also key drivers for
our development. We know that our
possibility especially for high-risk
patients who cannot undergo open sur-
tional Radiological Society of Europe’s customers carry a lot of responsibility gery. New innovative applications such

key drivers in the (CIRSE) annual conference in Munich.

The CIRSE is one of the most renowned
conferences for interventional imag-
for each individual patient they treat.
In return, it is our responsibility to offer
reliable systems to support our cus-
as syngo Aortic ValveGuide* help sur-
geons and cardiologists replace calcified
aortic heart valves with more guidance

development of our ing. There were approximately 6,000

attendees eager to learn about the lat-
est technologies and advances in their
tomers worldwide. We are constantly
exploring new possibilities to reduce
dose without compromising image qual-
and a new automated workflow.

Looking back on a very exciting year

clinical field. I was very pleased to see ity. The title of this issue reflects that for Siemens Healthcare, I am proud

imaging portfolio.” how many visitors were interested in

our products and solutions. For the first
time, we showcased how “The Future is
line of thought, “Low Dose - High Prin-
ciples.” Our dose saving initiative with
CARE (Combined Applications to Reduce
to present to you this issue of AXIOM
Innovations. You can read more about
CARE technology, new functionalities in
Flexible” with the Artis zeego, our multi- Exposure) and CLEAR (an imaging tech- endovascular and thoracic surgery, and
Dr. Heinrich Kolem, axis C-arm system based on robotic nology to enhance visualization with many other innovative topics. Enjoy!
CEO of the Angiography & Interventional X-Ray Business Unit (AX) technology. We introduced the Hybrid IR X-ray) not only reduces radiation dose
at Siemens Healthcare concept which offers new opportunities for patients and staff, but also boosts
for interventional radiologists looking image quality to an outstanding level.
to expand to more complex cases. In
order to meet current and future imag- A growing trend in the market for inter-
ing needs, Artis zeego allows a variety ventional cardiology and hybrid surgery Dr. Heinrich Kolem
of working heights and delivers large is the minimally invasive replacement
volume image results. of valves. With demographic changes in
our society and a growing percentage of
Improving clinical workflow and elderly patients, new treatment meth-
radiation dose reduction are of great ods will evolve. Minimally invasive pro-
importance to our customers and their cedures are an exciting new treatment

* The syngo Aortic ValveGuide is pending 510(k) clearance, and is not yet commercially available in the United States.

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Content Content

26
16 Enhanced Endoleak 32 42
Content Radiation Reduction
is Key in Pediatrics
Treatment Through
Improved Navigation
syngo Neuro PBV IR Helps During
Revascularization Treatment
Advanced Technology Revolutionizes
Endovascular Surgery

10 A long-term commitment 3 Editorial Angiography 38 Minimally Invasive Aortic Valve 54 An Innovative Setting –
to reduce radiation dose Implantation Offers New Hope to Hybrid Room 3D Imaging Delivers
Siemens has long been a leader in 26 Endoleak Treatment: Stenotic Patients Groundbreaking Care
addressing the need to provide opti- Enhanced Visualization Meets Interview with Dr. Antonio Dager St. Joseph Hospital in California
mal images at the lowest possible 6 News Enhanced Navigation at Angiographia de Occidente in chooses an interdisciplinary
radiation dose following the ALARA syngo iGuide facilitates better Colombia approach to maximize patient care
principle. Many institutions world- Workflow
wide working with Siemens angio-
graphy systems use the CARE 10 Cover Story 30 Quantitative Evidences of Surgery Customer Care
applications in their daily routine Hemodynamic Improvement of
when imaging patients of all ages. Low Dose, High Principles: Brain Arteriovenous Malformation 42 3D Imaging Brings a New Vision 58 Upcoming Congresses &
It is most importatnt to them to Cardiac CARE for All after Surgical Intervention to Endovascular Surgery Workshops
keep radiation dose low, especially A Report from Fundación Clinical case Interview with Dr. Alan Lumsden,
for children and also their own staff. Cardioinfantil in Colombia Director of the Methodist Hospital 60 Subscription & Information
32 Revascularization Treatment DeBakey Heart and Vascular Center
A Pediatric Radiologist's Approach of Acute Cerebral Stenosis in Houston
to Radiation Reduction Clinical case
Interview with Dr. Anne Marie 48 Accuracy Far Beyond Conventional
Cahill, Children's Hospital of Pneumological Practice
Philadelphia Cardiology Dr. Hohenforst-Schmidt pioneers
new navigation techniques in
Treatment of Complex Head and 34 Overlay of MRI Images pneumology
Cover Neck Malformation in an Infant in Pulmonary Vein Isolation
Clinical Case A clinical evaluation 48 Navigation in the Lung
Imaging of temporal
mandibular joint with
by Prof. Rukshen Weerasooriya Clinical Case
reduced radiation dose. CAREposition
Courtesy of Anne An Evaluation of Radiation-Free 36 Accurate Placement 50 Heart Valve Replacement –
Marie Cahill, M.D.,
Department of
Positioning of Aortic Valves Significant Changes Thanks to
Interventional Clinical case Hybrid Surgery
Radiology, Dr. Tatsuhiro Komiya talks about
Children´s Hospital
of Philadelphia, 61 Imprint new surgical procedures
Pennsylvania, USA

4 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 5
News News

Less Radiation During Integrated FFR Calculation Saves

Catheter Interventions Space and Time
Siemens’ Artis zee® angiography system has The measurement of fractional
recently integrated the MediGuide Technology flow reserve (FFR) helps to deter-
from St. Jude Medical, a medical positioning mine the hemodynamic signifi-
system that visualizes the position of a catheter cance of a coronary stenosis and
without radiation. to guide balloon and stent place-
Like a GPS system, the MediGuide Technology ment. FFR is being measured by
locates the catheter during cardiac interventions comparing the blood pressures
and projects its precise position in real time on distal (behind) and proximal (in
a previously acquired fluoroscopy image of the front) to a lesion. Once this ratio
patient. During electrophysiological interventions, reaches 0.75 or below, a stenosis
a miniaturized sensor integrated into the catheter is considered hemodynamically
can be located by receiving electromagnetic posi- significant and a stent placement
tioning signals from the MediGuide transmitters, is recommended.
which are incorporated into the detector housing The FAME study published
of the Artis zee system. The MediGuide Technology in 2009 (N Engl J Med 2009;
then calculates the respective position and orien- 360:213-224) evaluated FFR-
tation of the catheter and displays it in real time guided CAD treatment and
on fluoroscopic images of the patient that were clearly found an increase in
recorded earlier. The technology also compensates patient survival of 30 % while at
for patient movement caused by respiration and the same time treatment costs
heart motion. decreased by 30 %.
The MediGuide Technology provides significant St Jude Medical and Volcano
benefits especially during complex electrophysi- offer FFR measurement solu-
ological procedures. The electrophysiologist no tions in the cath lab that now
longer has to take fluoroscopic images of the have been fully integrated with
patient each time the catheter is re-positioned. the Siemens AXIOM Sensis XP
As a result, less radiation and less contrast agent recording system, which offers
use is expected. simple plug&play connectivity
The Heart Center Leipzig, Germany, has already and makes using an external
performed the first interventions with Artis workstation obsolete.
zee and the MediGuide Technology. “The low- For getting the new FFR mea-
radiation, precise localization of the catheter tip surement capabilities, AXIOM
onto the pre-recorded fluoroscopy image is a most Sensis XP software must be
impressive function, because the system is able to upgraded to the latest software
compensate the motion from the heart beat and version due for release at the
breathing,” said Professor Dr. Gerhard Hindricks, end of 2011. The FFR option can
Director of the Rhythmology Department. “For my already be ordered today and will
team and me, this is clearly the future in electro- become available with the new
physiology.” software version.
All systems in the field currently
running software version VC10
Localization of the catheter supported by MediGuide Technology will be upgraded free of charge to
and EnSite Velocity Mapping System. VC11 starting in spring 2012. AXIOM Sensis XP running VC11 software and FFR option.

6 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 7
News News

A New Era: Hybrid Operating Rooms

in the American Hospital Siemens Integrates
As one of the most modern hospitals
not only in Turkey but the entire region,
where TAVI (Transcatheter Aortic Valve
Implantation) procedures have recently
Maquet’s Magnus OR Table
the American Hospital in Istanbul
continues its leading role in hybrid
operating room practices with the
begun to be performed with the use
of the Artis zeego system and Siemens
syngo DynaCT Cardiac software,
for Hybrid ORs
recently installed Siemens Artis zeego procedures can be completed more
1 2
multi-axis robotic angiography system. rapidly and reliably with the comfort
Thanks to the Artis zeego system, introduced by Artis zeego and the wide
both advanced hybrid practices and movement capability of the C-arm.
standardized cardiologic procedures can The American Hospital is currently able
be performed. In the new procedure to perform interventional procedures,
room that has an angiography thanks to the hybrid system it has
operating table that tilts in four recently acquired, as well as ongoing
different directions, a laminar flow medical, technical and technological
unit and anesthesia device pendants, developments. Operating in Istanbul,
the latest technological innovations, Turkey since 1920, the American
such as a 56" Artis zee Large Display, Hospital offers the latest technologies
an integrated Intravascular Ultrasound to aid the hundreds of millions of
(IVUS), an integrated hemodynamic people in the region as a hospital held Fig. 1: Siemens Artis zeego with Maquet’s Magnus table with breakable Fig. 2: Maquet also offers a radiolucent table top for artifact-free imaging
Dr. Genco Yücel, Department of Cardiology, recording system (Siemens AXIOM in high regard not only in Turkey but in top supports complex procedures in advanced positions. in endovascular procedures.
in front of the department’s new Artis zeego. Sensis XP), etc., are used. At the center neighboring countries as well.
The versatile Magnus OR table* from and neurosurgery. The Artis zeego is First clinical user tests of the integrated
Maquet will be available together with the only robotic C-arm-system on the solution with Artis zeego are anticipated
Artis zeego and Artis zee ceiling. With the market that can adapt to the complete to start in May 2012; general availability
existing family of Artis tables, Trumpf’s height adjustment of the table. The is planned for December 2012. The inte-
Hybrid OR With Trumpf Table Opened TruSystem 7500 tables and the Magnus multi-axis robotic system also follows gration with Artis zee ceiling is sched-
table to follow, Siemens can provide the movements of the operating table. uled to be available in spring 2013.
at Clinical Center Ludwigsburg three fully integrated table systems. This
means synchronized C-arm and OR table
It flexibly adjusts to even complicated
positions of the segmented table top.
Of course Siemens will continue to
offer the tried-and-true family of fully
Since 2010, Siemens optionally delivers Artis zeego or Artis movements, 2D and 3D imaging, all with This flexibility also allows free access integrated Artis zee tables. They are
zee ceiling with the TruSystem 7500 OR table by Trumpf. a single integrated operation module. from any side, with a comfortable space available in three different versions: the
In May 2011 another hybrid operating room with Trumpf´s And the right table for surgical require- for the anesthetist and his equipment. standard table, table with tilt, and the
OR table and Siemens Artis zeego went live at the clinical ments in the hybrid OR. If open procedures without imaging OR table with tilt and cradle. The carbon
center Ludwigsburg, Germany – meanwhile this is the sixth The key benefit of the new solution is equipment are performed, Artis zeego’s table tops allow for high-end imaging,
installation worldwide that combines an Artis system with a the multidisciplinary use of the hybrid multiple park positions allow for maxi- including 3D. The Artis table family is
Trumpf OR table. The room at the clinical center Ludwigsburg OR – which means it will allow for both mum space in the OR field. the solution of choice for cardiac and
is located in a brand new building as part of a 35 million euro interventional imaging and for open Equipped with an additional floating vascular procedures providing an exten-
project to build one of the most modern surgical centers in procedures where extremely flexible carbon table top, the integrated solu- sive longitudinal travel range, full body
Germany with altogether 9 fully digital connected operating patient positioning may be required. tion enables full cath lab functionality. coverage and a free floating radiolucent
rooms. With this new hybrid OR, patients will benefit from The Magnus OR table is fitted with The table top provides 360° radio- table top.
fewer shifts during the procedures, less radiation because of exchangeable table tops – a fully radio- translucency for superb X-ray images,
faster and fewer acquisitions, and fewer complications since lucent carbon top (Fig. 2) as well as a including 3D. A transport system
the success of the intervention can be verified right in the OR highly flexible, segmented table top ensures the easy exchange of the table
at the end of the procedure. (Fig. 1). The latter allows surgeons the tops. The patient can be prepared and
Siemens is also going to offer a similar integration of the most appropriate patient positioning, positioned on the table top in the * WIP. The information about this product is preliminary.
The product is under development and not commercially
Artis zeego and Artis zee ceiling with Maquet OR tables in View of the new hybrid operating room in Ludwigsburg with the Trumpf including complicated positions, induction area ensuring ahead of time available in the U.S., and its future availability cannot
early 2013. TruSystem 7500 OR table and Siemens Artis zeego. occurring especially in orthopedics maximum efficiency for the OR. be ensured.

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Cover Story CARE CARE Cover Story

Low Dose,
High Principles:
Cardiac CARE for All

At Fundación Cardioinfantil in
Bogotá, Colombia, no one is
turned away for lack of ability
to pay. Using the most
advanced equipment from
Siemens, the hospital’s
dedicated staff is making
interventional imaging safer
for everyone, especially those
who need it most: their
youngest, weakest patients.
By Chris Kraul

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 Cover Story CARE CARE Cover Story

Any day now, Nelsy, a five-year-old because her mother and brother have
Colombian girl, will undergo an angio- died and her father is worried that he
plasty at Bogotá’s Fundación Cardio- will lose her as well,” says Ronderos.
infantil hospital that will save her life. By coming to Fundación Cardioinfantil
Pale, underweight and short of breath, in Bogotá for treatment, Nelsy will
Nelsy was screened in late May by the receive another benefit that could be A Vision of Improved Healthcare Access
clinic’s outreach team in the southwest- just as consequential to her long-term
ern city of Pasto and found to have per- health. Her procedure will be performed Fundación Cardioinfantil’s history began in brigades – teams of a half-dozen doctors and
sistent ductus arteriosis, a congenital using Siemens’ state-of-the-art “low 1971 when two Colombian doctors, brothers nurses – to seek out sick children in remote,
condition that, without a procedure to dose” interventional imaging technol- Reinaldo and Camilo Cabrera, returned home poverty-stricken areas of the country. Now,
close the ductus, would have proved ogy. The hospital has four Siemens Artis from completing their medical training at the about eight times a year, the brigades hold
fatal by her mid-teens. systems that – with their advanced Texas Heart Institute in Houston determined two-day cardiovascular clinics at partner
Nelsy, whose mother and ten-year old software and imaging innovations – can to address the inequalities of their country’s hospitals from one end of the country to the
brother both died of heart disease, will dramatically cut the radiation exposure healthcare. High on their list of concerns was other where young patients in need gather.
be brought to Bogotá free of charge of patients like Nelsy, compared with the incidence of congenital heart defects, Two months prior to each visit, the founda-
from her home 300 miles away, a poor what they would have received a few affecting one in every 100 babies. In devel- tion’s community relations department starts
fishing village on Colombia’s southwest- years ago. oped countries, such defects are easily getting the word out via radio announce-
ern Pacific coast. She and her father will Each system is bundled with Siemens’ diagnosed and treated, but they too often ments and posters that any family who has
be put up in the clinic’s housing and, proprietary CARE (Combined Applica- proved to be death sentences in Colombia. a child with possible heart problems will be
despite the fact that they have no way tions to Reduce Exposure) applica- Poverty and difficult geography make access examined for free. It was in one such brigade
to pay the hospital bills, Nelsy will be tions that can help to decrease typical to quality medical care an impossible dream visit held at Pasto’s Hospital Los Angeles in
“The Siemens given the kind of care that has made exposure in catheterization labs. It does for much of the population. May that Ronderos diagnosed Nelsy, one

engineers have Fundación Cardioinfantil a private,

nonprofit institution, a beacon of car-
that by providing a broad range of dose
saving applications, enhanced monitor-
With the help of ex-president Carlos Lleras
Restrepo, the new physicians opened the pre-
of 400 young people who lined up for an
examination, and put her on the list of kids
helped a lot in diovascular treatment in Latin America.
The hospital draws paying patients from
ing and reporting of the radiation being
generated and a flexibility of use that
decessor of today’s foundation in a corner of
Bogotá’s Misericordia Hospital, a charity clinic
to be brought to Bogotá. She and her father
traveled eight hours by boat and four hours
giving individual throughout the Caribbean and Cen- allows doctors at Fundacion Cardioin- for children, specifically to offer cardiovascu- by bus to get to the examination site.
tral America, and from as far away as fantil to tailor treatment to a patient’s lar care to poor youth in the urban area. They Fundación Cardioinfantil’s staff examine
training to our Florida and Peru. It also takes on scores specific age, weight and diagnosis. relied on donations of services, equipment, about 4,000 poor young people per year

personnel with of pro bono “social” cases per year, like

Nelsy’s, mainly from Colombia but it
“The advances that we are seeing in
Siemens’ imaging are allowing us to be
cash and eventually land from the city of
Bogotá, where the current 300-bed hospital
during these outreach clinics. Of those,
250 children and adolescents, or about
the goal of accepts desperately poor patients from
Ecuador and Venezuela as well.
more precise with our procedures with
less risk of complications and failures,”
is situated.
As it grew, the clinic broadened its mission to
20 percent of all the children examined,
are subsequently brought to the hospital
minimizing the Making the Safety Factor a
said Dr. Ronderos. Additionally he states include children who could pay for treatment for heart surgery or angiography at the
the better the imaging, the less time he as part of a scheme by which paying patients bustling Bogotá hospital, free of charge.
radiation used in High Priority spends diagnosing the condition and helped subsidize care for the poor. Later, as For their service to Colombia, the Cabrera
The procedure in the hospital’s heart placing coils, stents and heart valves. the clinic’s reputation for quality care spread, brothers were decorated in July 2010 by
a given exam catheterization lab to close the ductus That reduces the patient’s and the medi- adult heart patients were admitted, also to then-president Alvaro Uribe with the Order
and to devise will only take 45 minutes. But it will
save Nelsy from probable death by
cal staff’s exposure to radiation, he said.
That lessened exposure is important
help subsidize treatment for poor children.
Adults now comprise about 70 percent of the
of Boyaca, the highest national honor
attainable by a Colombian civilian. One of the
additional pneumonia in the coming years and for the operator as well as the patient. caseload. doctors, Reinaldo Cabrera, died in November
give her a good chance of leading a Medical staff who administer the pro- In 1986, the Cabrera brothers decided to pro- 2010, but his brother Camilo continues to
measures of long, healthy life, says Miguel Ronde- cedures are concerned about their own vide care to young patients for whom a trip to be active and currently is the director of the
ros, MD, a cardiologist who trained at risk as well. Bogotá for life-saving treatment was impos- foundation.
radiological University of Alabama-Birmingham and Making angiography safer has been a sible. The hospital began organizing outreach
protection.” who was part of the outreach team that
diagnosed Nelsy. He will also perform
Siemens objective since the company
entered the medical equipment field
the angioplasty. in the early 1960s, and especially
Miguel Ronderos, M.D., “We immediately classified Nelsy as since a low dose application initiative
Department of Cardiology, Fundación a medical emergency, because she is was launched in 1994. Since then,
Cardioinfantil, Bogotá, Colombia
in heart failure right now. But she is the company has achieved a series of
also what we call a social emergency, breakthroughs, all with the goal of

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Cover Story CARE CARE Cover Story

Combined Applications to Reduce Exposure:

An Integrated Answer to Dose Reduction the imaging and visibility of devices. Fewer procedures also mean a patient says Echeverri, because he, Ronderos
CAREvision: pulsed fluoroscopy application that provides extremely Over the last five years, Siemens syngo receives fewer injections of contrast and other medical staff operate the
low frequencies to meet individual dose-saving targets. Pulses can DynaCT has made soft tissue imaging agent, which if overused can damage machines themselves without specially
drop from a range of 30 p/s to only 0.5 p/s. At 7.5 p/s, a 75 % dose possible, enabling physicians to get kidneys. trained technicians.
reduction is achieved. additional soft tissue information in As one of a dozen Siemens “reference “We want the relationship with Siemens
the interventional suite and thus get a sites” at leading hospitals in Latin to go far beyond buying and selling
CAREfilter: a variable CU-filter (0.1 mm – 0.9 mm) is automatically set better understanding of the structure of America and the Caribbean, Fundación equipment. We want Siemens to help us
according to the current transparency of the object/C-arm angulation, the vessels and organs they are dealing Cardioinfantil has become a key prov- in an integral way with training, market-
without any necessary interaction from the user. Dose reduction: up with. ing ground for Siemens’ low dose ing and advice, a friend who will help
to 50 %. Dr. Dario Echeverri, who heads Funda- imaging initiative in the region. The distinguish the foundation. The Low
CAREposition: positioning without repeated fluoroscopy. The feature cion Cardioinfantil’s catheterization lab clinic also has become an incubator for Dose Workshop with Siemens was very
is especially needed during long-lasting neurointerventions that can and who is also the current president more intensive relationships between encouraging, and it produced concrete
take several hours as the provider can control patient positioning of the Latin American Society of Inter- Siemens product managers and the results,” says Echeverri.
without the need for additional fluoroscopy. ventionist Cardiology, said the CARE medical professionals who use the In exchange for going the extra mile,
application “CAREguard” is especially company’s equipment. The company Siemens is allowed to bring prospec-
CAREprofile: radiation-free adjustment of collimators as well valuable because it tracks radiation skin and its clinical customers see such close tive clients to Cardioinfantil to see
as radiation-free semitransparent filter parameter setting. Dose dose thresholds of patients and medical relationships as a necessity, given the the systems in action, and even bring
reduction: Up to 9 %. staff and sounds a warning if they are high stakes in cardiovascular care: the in doctors and nurses from foreign
CAREguard: a new real-time application that monitors skin dose exceeded. life-saving benefits of cutting-edge ther- countries to receive training on the
exposure and allows for effective skin dose control. Three separate “It allows us to do a continuous follow- apies as well as the potential hazards of machines. Siemens also gets important
thresholds can be defined with warning indicators that alert up of the radiation dispersed by the the imaging devices. feedback that is incorporated into the
for length of exposure time. The feature reduces exposure for machines and helps us reduce exposure “Over the last year, a real two-way flow systems’ software and design. A bonus
radiologists, technicians, and patients. to patients and MDs, nurses and techni- of information with Siemens has begun, for Siemens is its association with one “CAREguard
Low Dose Acquisition: additional low dose protocols that can be
cians working in the lab,” Echeverri said.
Cognizant of the importance of low
so that we can receive not just the
low dose technology but training and
of Colombia’s most admired institutions
for its mission of delivering lifesaving
allows us to do
accessed hands free, directly from a footswitch. These tools can
reduce radiation dose by 67 %.
dose imaging, Siemens sends a free
update of the latest software VC14
advice, and we want that to continue,”
says cardiologist Echeverri. “By the same
cardiovascular care to poor children and
young people who otherwise might die
continuous
Low Dose syngo DynaCT: an optional feature, offers CT-like 3D including all CARE (Combined Applica- token, we offer suggestions on design prematurely. follow-up of the
imaging for radiosensitive patients and others. As an example, 5 sec tions to Reduce Exposure) and CLEAR improvements to better protect the Attesting to Fundación Cardioinfan-
protocol can be done at 0.1 µGy/frame instead of 0.36 µGy/frame, (image quality) features to all customers patients and people who work in the til’s high standards is its cooperation radiation
which results in a 72 % reduction. of its Artis zee angiography systems
around the world.
room.” Those suggestions have included
smaller tables to accommodate child
arrangement with the Cleveland Clinic,
which sends medical staff to Bogotá
dispersed by the
CAREreport: a structured dose report that contains all patient
demographics, procedure, and dose information. Using commercially
Siemens’ advances now enable doctors
to reduce the number of times a typical
patients and design changes for protec-
tive clothing.
once a year to conduct professional
seminars.
machines and
available programs or in-house software, this information can be
filtered for further processing, such as dose analysis.
heart patient has to undergo imaging The advances of the Artis zee system “Most companies just want to sell helps us reduce
exams. A decade ago, Nelsy might have give Dr. Echeverri added flexibility in machines and there is usually a discon-
had to undergo three different proce- devising different protocols “according nect between the sales and technical exposure to
dures during her stay at Cardioinfantil: to the patient and his or her condition, staff of these companies. Siemens is
one to diagnose, a second to treat her instead of using the same program for changing that trend. Together we are patients and
limiting dosage while enhancing image
quality. Improved safety is doubly criti-
quality images are now captured at
7.5 frames per second, down from 30
disease, and a third to confirm success.
But the likelihood now is that a single
all patients. This is new with the latest
software of our Artis zee.” Adds Dr.
constantly refining the proper use of
the machines,” Dr. Ronderos concluded.
MDs, nurses and
cal because of the expanding range of frames previously, making possible a procedure will suffice. Ronderos: “The Siemens engineers have “We have come to a nice arrangement.” technicians
diagnoses and treatments for which 75 percent reduction in radiation dur- “Nowadays, we must be much more helped a lot in giving individual train-
angiography is now used, going far ing the procedure. CAREreport offers a careful with our exams in arriving at a ing to our personnel with the goal of Chris Kraul is a freelance writer based in Bogotá, working in the
beyond its original cardiovascular appli- running account of radiation dispersed diagnosis,” Dr. Ronderos said. “Each day minimizing the radiation used in a given Colombia, covering stories a wide range of top-
cation to include neuro and abdominal along with the patient’s demographics, we are more aware of the importance to exam and to devise additional measures ics. A reporter for the Los Angeles Times for 22 lab.”
years, he was most recently the Latin American
interventions and surgeries. procedure and dose information. health of the cumulative dose of radia- of radiological protection.” Bureau Chief at the newspaper’s Bogotá office.
The low dose equipment is achieving tion over the course of a lifetime and, In February, Siemens brought in experts Dario Echeverri, M.D.,
that goal with a variety of innovations. A Two-Way Flow of Information with the Siemens technology we have, to the clinic from Germany to lead a Department of Cardiology, Fundación
Proprietary technology pulses radia- But there is more than that to low combined with our understanding and dose and radiation workshop on safe Cardioinfantil, Bogotá, Colombia
Contact
tion instead of emitting continuous dose. Efficiency gains from powerful quality of the imaging, we can minimize operation of the angiography sys-
vera.juennemann@siemens.com
fluoroscopy. With CAREvision, high new Siemens software have improved exposure in a given exam.” tems. That was an important gesture,

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Cover Story CARE CARE Cover Story

A Pediatric Radiologist’s
Approach to Radiation
Reduction

Siemens has long been a leader in addressing the need

to provide optimal images at the lowest possible radiation
dose. AXIOM Innovations’ Robert L. Bard discussed
radiation dose savings and their clinical application in
pediatric patients with Anne Marie Cahill, MD, of the
Children’s Hospital of Philadelphia.
By Robert L. Bard

There is considerable concern among are paramount for Cahill because she grams automatically using the lowest
both medical professionals and the pub- frequently deals with complex cases. possible radiation dose while providing
lic these days about radiation exposure, Furthermore, radiation exposure is the best possible images, but clinicians
in part due to the growing use of imag- especially important for her because she still have the ability to increase the
ing equipment in both diagnostic and is treating children. dose if there is an area of interest that
interventional medicine. Anne Marie Siemens products have long been requires further investigation. For exam-
Cahill, MD, Director of Interventional designed to help clinicians obtain qual- ple, Cahill commonly evaluates patients
Radiology at the Children’s Hospital ity images while following the ALARA with vascular anomalies where she first
of Philadelphia, has worked with the principle. Siemens addresses the ALARA selects a low dose 3D program, syngo
Siemens’ product development group principle with its Combined Applica- DynaCT, to deliver the lowest necessary
to find new ways of imaging with lower tions to Reduce Exposure, or “CARE” dose of radiation to image the vascula-
radiation doses and at the same time package. CARE is available throughout ture. However, if she notices a section
achieving the best possible images. This the Siemens line of imaging products of blood vessel that is not imaged well
principle is commonly referred to as the and addresses several aspects of the or appears to be abnormal during the
“ALARA” principle: as low as reasonably imaging process, including the docu- initial scan, she has the freedom and
achievable. mentation and monitoring of radiation ability to interrupt the standardized
While clinicians must be aware of acute exposure of both patients and clinicians. program and she can concentrate the
radiation exposure from any individual A primary feature of CARE is the ability imaging on that particular area and
procedure, they must be even more to standardize radiation doses at the investigate any potential abnormalities.
diligent in managing chronic radiation lowest possible level for each and every Siemens CAREguard is available with
doses for their patients who receive procedure or image. CARE permits the all Artis zee angiography systems,
either multiple procedures acutely or interventional radiologist to choose providing skin dose control software
chronic procedures in a long-term evalu- programs in advance so that ALARA can that helps limit and document radia-
ation of their condition. These concerns be achieved. Study-specific imaging pro- tion levels. With CAREguard, radiation

16 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 17
Cover Story CARE CARE Cover Story

“Store Fluoro allows

us to decrease the
doses are constantly measured and has experienced three major benefits of only are fewer images necessary using omits an additional dose of radiation latter is used to determine the relation-
number of acquired
the user can set the parameters to site- the Siemens products in their ability to Overlay Reference, but the images are from traditional CT. Cahill references her ship of the airway to the treated lesion images. With the
specific values. If pre-defined skin dose image at the lowest possible radiation obtained at a lower radiation level. research using C-arm CT, which shows to help decide if the patient's breathing
levels are exceeded, an audible warn- doses: Store Fluoro, Overlay Reference, Therefore, radiation is decreased as that radiation doses can be significantly tube can be safely removed post proce-
Store Fluoro
ing sounds, and a skin dose indicator and Low Dose syngo DynaCT. compared to traditional applications that decreased when treating and evaluat- dure. In vascular malformation therapy functionality we can
flashes on the live display. A warning Store Fluoro enables the user to store a relied upon traditional fluoroscopy. ing patients with temporal mandibular this helps clinicians determine whether
pop-up is also prominently displayed on regular fluoro scene during a procedure During common vascular imaging, radia- joint (TMJ) disorder. She explains that the breathing tube can be safely
save images on the
the touchscreen of the system’s table- for documentation instead of doing a tion dose is decreased because, as Cahill radiation savings are largely obtained by removed from patients who are asleep display monitor
side control, which is located within the new acquisition. Cahill explains that this states, “We can do an angiogram and reducing the need to acquire traditional under general anesthesia.
interventional radiologist’s view during functionality allows her to decrease the save a specific image and then overlay computed tomography examinations In addition, vascular anomalies are instead of obtaining
the procedure. Radiation exposure lev- number of acquisitions she requires as that image onto the live fluoro. Later following interventional treatments. treated using Low Dose syngo DynaCT further images and
els can be generated with CAREreport, compared to previous clinical methods. that image can be used to track smaller TMJ disorder commonly requires as well, and the radiation savings – also
and they can also be archived in the She can save images on the display arteries. This process saves radiation patients to receive repeated injections about 50 percent of conventional CT – is exposing the patient,
PACS system along with the procedural monitor instead of obtaining further because we do not perform roadmaps once or twice a year, and the radiation largely obtained once again by omitting and staff, to
images. Cahill and her colleagues regu- images and exposing the patient – and (comprehensive tracking of blood flow dose savings adds up during the course a post-procedural traditional CT. One of
larly take advantage of this feature by staff – to additional levels of radiation. through the vasculature) as much as we of treatment. Pediatric TMJ patients are the major advantages of treating vascu- additional levels of
providing patients with radiation infor- Prior to having this capability, it would used to.” one specific group where imaging with lar anomalies in this fashion is that the radiation.”
mation when reviewing clinical results. have been necessary for her to acquire the ALARA principle is crucial because success of the sclerotherapy procedure
additional images to assure she had all C-arm CT and Joint Injections of the repeated radiation exposure of a can be evaluated immediately after the
Clinical Applications of the information she needed before The Children’s Hospital of Philadelphia vulnerable area, the jaw, because of its procedure by the same interventional Anne Marie Cahill, M.D., Department
for Low-Dose Imaging the patient left the interventional also uses syngo DynaCT to reduce radia- proximity to the eyes and thyroid. radiologist at the same location, which of Interventional Radiology, Children’s
Hospital of Philadelphia, PA, USA
Cahill has worked closely with Siemens radiology suite. tion exposure in patients who require Joint injections are a common applica- is an efficient use of hospital resources
in developing C-arm CT protocols that Similar to Store Fluoro, Overlay Refer- imaging where the radiation dose is a tion of C-arm CT because of the ability and an excellent means to improve
provide 3D information in the inter- ence can decrease the number of particular concern. C-arm computed to image at very low dose. Dr. Cahill patient satisfaction to their clinical care.
ventional radiation suite at very low images acquired as compared to previ- tomography permits joint injections estimates based on phantom studies The importance of dose savings –
radiation doses. She reports that she ous clinical imaging methods. Not with the use of CT and fluoroscopy and about a 50 percent reduction when especially in young patients – will
compared to conventional CT and a only increase with the growth of
further radiation dose reduction of 6% non-invasive imaging and radiologic
from a manufacturer setting. This dose interventions. Siemens has addressed
AVM nidus extending from T6 to L1 supplied by a left intercostal artery reduction is possible due to the inher- the need to provide high-quality images
ent high contrast of bone and needle at the lowest possible radiation dose
1 2 3
in CT imaging. The benefit of such a with its CARE package, which provides
significant dose savings also applies to a clear indication of the radiation levels
the treatment of children with juvenile used for every image or procedure. This
arthritis, who are sometimes as young ALARA approach improves the account-
as two or three years old and, as in TMJ ability of the interventional radiologist,
cases, require multiple injections dur- interventional cardiologist, and admin-
ing the course of their treatment. The istrators while promoting a healthy
importance of reducing the amount of environment for patients and staff.
acute and chronic radiation is quite evi-
dent in these delicate patients. Robert L. Bard is a freelance medical writer cer-
Other areas where significant radiation tified by the American Medical Writer’s Associa-
tion who also conducts clinical research at the
savings are achieved include procedures University of Michigan’s Division of Cardiovas-
where syngo DynaCT is used to guide cular Medicine.
the needle during bone biopsies and
to assess the airway and lesion during
1 Conventional intercostal artery angiogram 2 VRT (Volume Rendering Technique) 3 Embedded MPR Image of AVM nidus Contact
vascular malformation therapy, whereby
heike.theessen@siemens.com
the intermittent imaging used in the

18 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 19
Cover Story CARE CARE Cover Story

Treatment of Complex Head and Neck 1

1 Axial T2 weighted MR image demonstrating

Lymphatic Malformation in an Infant the macrocystic lymphatic malformation left neck.

Supported by syngo DynaCT

Courtesy of Anne Marie Cahill, M.D., Deddeh Ballah, B.A.
Department of Interventional Radiology, Children’s Hospital of Philadelphia, PA, USA

Children's Hospital of Philadelphia

– Founded in 1855 as the nation's
first hospital devoted exclusively
to caring for children, it has been
the birthplace of many firsts in pe-
diatric medicine. In interventional
radiology employees are working
hand in hand to provide best
possible care for their patients.

Patient history course of 24 months. Doxycycline is an sible dose while preserving diagnostic
At 40 weeks in utero the male fetus antibiotic that causes inflammation of information. With the inherent contrast
2
was diagnosed with a large neck mass the lymphatic malformation epithelium provided by the sclerotherapy agent we 2 Correlating axial syngo DynaCT image
on prenatal ultrasound. Prenatal MR that eventually leads to scarring and are able to reduce the dose provided demonstrating the distribution of the
imaging was performed demonstrat- regression of the lesion. The second by our typical syngo DynaCT to 6 % of sclerotherapy agent throughout the lesion
when compared to the MRI. Note the close
ing a 5.7 cm by 2.7 cm left neck mass. and third sclerotherapy procedures used the manufacturer setting and 50 % of
proximity of the sclerotherapy agent and
The patient was delivered at CHOP Low Dose syngo DynaCT imaging to conventional CT. lesion to the airway guiding post-procedure
via Caesarean section for concern of confirm sclerotherapy distribution in the In the future, syngo DynaCT can be therapy, resulting in the patient remaining
airway compromise. The baby boy lesion. The syngo DynaCT was acquired used to direct procedures. By identifying intubated post-procedure.
required routine resuscitation and was with a dose value of 0.7 mGy. areas of the lesions that lack sclero-
transferred uneventfully to the neonatal therapy agent after injection, additional
intensive care unit. Comments injections may be performed during
syngo DynaCT is used to confirm sclero- treatment potentially reducing the num-
Diagnosis therapy agent distribution and deter- ber of future sessions.
On the third day of life, a neck MRI with mine proximity to the airway in patients
and without gadolinium contrast was with complex head and neck lymphatic
performed on the neonate, showing a malformations. Intraprocedural syngo
Pediatr Radiol. 2011 Apr;41(4):
T2 hyperintense, multicystic lesion with DynaCT images can provide information
476-82. Epub 2010 Nov 16.
evidence of hemorrhage that extended regarding the volume of lesion treated
to the posterior neck and deeper and the necessity for further treatment Results:
The manufacturer's default setting gave an equivalent
structures of the neck, including the sessions. It enables us to create image
CTDI of 4.8 mGy. Optimizing the dose settings and
prevertebral and retropharyngeal space, reconstructions in three planes on a adding copper filtration reduced the radiation dose by
confirming a macrocystic lymphatic separate workstation allowing us to 94 %. This represents a 50 % reduction from conven-
tional CT.
malformation. compare the extent of the lesion treated
to the pre-treatment lesion in those
Treatment three planes on MRI.
Contact
This patient underwent three doxycy- Since this is essentially a CT scan it is
heike.theessen@siemens.com
cline sclerotherapy procedures over the imperative to achieve the lowest pos-

20 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 21
Cover Story CARE CARE Cover Story

Evaluation of CAREposition:
Radiation-Free Positioning with
CAREposition Results in a Decrease
in Screening Times

Table 1: Screening Times Pre & Post CAREposition

Brendan Erskine, and Elissa Marshall from the Department of
Radiology, The Alfred, Melbourne, Australia have conducted a 30:00

study on the potential of CAREposition to reduce the fluoroscopic

Mean Screening Time (min)

screening time during various diagnostic procedures. The study 25:00

was presented as a paper: “Evaluation of Siemens CAREposition,

Radiation-Free Positioning For Angiography and Fluoroscopy” at 20:00

the ASMIRRT 2011 conference.

15:00
by Brendan Erskine and Elissa Marshall pre CAREposition
post CAREposition
10:00

05:00

Introduction 00:00
savings, not to investigate dose minimi- Other techniques for reducing screening
CAREposition is a Siemens functionality zation. While a reduction in screening time, Aorto-femoral Angiography ERCP
that enables accurate repositioning of time will result in lower patient dose, Femoral Angiography PICC Line Insertion
the patient under visual control without ultimately dose is a product of many • Last Image Hold (LIH) holds the last AV Fistulography Gastrografin Swallow
radiation exposure. Guidance is pro- factors, beyond the scope of this study, fluoroscopic image on the viewing AV Fistula – Interventional Defecating Proctography
vided by a centrally positioned crosshair such as: monitor and incorporates radiation- Tunneled Line Insertion Pain Management
marking the central beam while the free collimation and wedge filter Jugular Vonoplasty Video Swallow
collimated field of view (FOV) is visually • Patient habitus placement
Erskine Brendan and Marshall Elissa, Dept. of Radiology, The Alfred, Melbourne, Australia
displayed as a white outlined rectan- • Object-to-image distance
gular box. This is displayed on the last • Source-to-object distance • ‘Fluoro Store’ or ‘Fluoro Loop’ per-
image hold and adjusts automatically • Field of view mit the operator to review and
to changes in position of the table and • Exposure factors (kV, mA) save the last fluoroscopic imaging
C-arm as well as changes in FOV. • Exposure time sequence. While not directly reduc- • Some fluoroscopic systems especially as the difficulty of laser visualization Methods
• Detector quantum efficiency (DQE) ing the screening time, this software mobile image intensifiers (I.I.) incor- in brightly lit rooms and refraction Screening times from procedures per-
Background • Pulsed fluoroscopy functionality may indirectly reduce porate the use of I.I. mounted laser of the laser through plastic I.I. cov- formed on all angiographic and fluoro-
CAREposition functionality is aimed • Adaptive dose filtration by the screening time and patient dose by guidance to assist positioning without ers. Also, accurate positioning of the scopic machines were obtained over a
purely at reducing fluoroscopic screen- application of copper/aluminum allowing the storage of fluoroscopic the need for radiation. This relatively laser is made more difficult on heavily six month period. At the trial midpoint,
ing time and therefore the primary prefiltration sequences instead of formal (higher cheap method of image guidance draped patients. three multipurpose fluoroscopic/angio-
focus of this study was to quantify these dose) angiographic sequences suffers from many drawbacks such graphic machines were enabled with

22 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 23
Cover Story CARE CARE Cover Story

Table 2: Screening time measurements during diagnostic and interventional procedures

Procedure Case Numbers PRE CAREposition POST CAREposition

Endoscopic retrograde
94 04:52 03:42 1a 1b 1c
pancreato-cholangiography (ERCP)
Gastrografin Swallow 65 01:18 01:24
Video Swallow 50 03:24 03:20
Defecating proctography 39 01:46 01:27
Peripherally Inserted Central Catheter (PICC) 656 00:45 00:45
Tunnelled catheter insertion
103 01:28 01:00
(Hickmans, Permcath, Portocath)
Pain management injections
126 00:47 00:47
(Epidural, Facet joint, Medial branch block)
Aorto-femoral angiography – Diagnostic 27 03:26 03:11
Femoral angiography – Diagnostic 25 01:30 01:11
1 Utilization of CAREposition during three angiographic procedures:
Arterio-venous (AV) fistulography – a Trans-jugular liver biopsy
19 01:06 00:49
Diagnostic b Cerebral angiography
c Femoral angiography
Arterio-venous (AV) fistulography –
22 14:50 14:02
Interventional
Jugular venoplasty – Interventional 47 27:09 20:11

Erskine Brendan and Marshall Elissa, Dept. of Radiology, The Alfred, Melbourne, Australia

CAREposition software licensing: interventional) will always lead to a certainly provided more accurate accuracy of CAREposition functionality, ing time was demonstrated, however, lization of CAREposition has resulted in a
wide spread of results. To obtain the results. huge reductions in screening time could noting our case numbers were small. modest decrease in screening times for
• Siemens AXIOM Artis MP most accurate data, only procedures be achieved. Such was highlighted when A much larger result was demonstrated a range of diagnostic procedures with
(fluoroscopy) (diagnostic or interventional) with Discussion reliance exclusively on CAREposition for in jugular venoplasty procedures. This greatest benefit being demonstrated
• Siemens AXIOM Artis MP standardized imaging and relatively […] CAREposition appeared most guidance of angiographic positioning in interventional procedure was chosen when used in sequential diagnostic
(angiography) high case numbers were chosen. These beneficial in the scenario of sequen- three peripheral diagnostic studies com- because it provided the largest subject imaging of peripheral vasculature.
• Siemens AXIOM Artis dMP procedures along with results are dem- tial diagnostic imaging of peripheral prising 19 separate acquisitions, were group of all the interventional proce-
(fluoroscopy/angiography) onstrated in Table 1. vasculature, whereby accurate overlap achieved with totals of only 4, 6 and 8 dures and involved standardized imag- Thanks to the following angiographers for their
between acquisitions could be achieved seconds fluoroscopy time […] ing of both internal jugular veins and assistance in compiling procedural data: Jane
Study limitations Chow, Karen Patel, Alix Fell, Wayne Chan, Neal
All machines employed remote (pedes- with minimal fluoroscopy. Aorto-femoral […] screening times in interventional azygos system with subsequent angio- Russell, Lisa Broadley.
tal) C-arm/table controls ran exclusively Since we are primarily a teaching insti- diagnostic angiographic studies saw a procedures are heavily dependent on plasty of stenosed vessels, providing us
by the radiographer. Our main angio- tution, it is likely that even without the 7 % reduction in screening time (3:26 both the patient pathology and the with a more accurate reflection of the
graphic machine, a Siemens Artis zee use of CAREposition we might have to 3:11 min), with single leg diagnostic skill of the clinician. Although difficult benefits of CAREposition.
biplane, had CAREposition licensing observed a small reduction in screen- studies demonstrating a 21 % reduction to quantify, CAREposition appeared
from installation and was therefore ing times given increasing experience (1:30 to 1:11 min). A similar result was extremely useful in complex and chal- Conclusion
excluded from the trial. of both medical and allied staff. Also, demonstrated for diagnostic AV fistulog- lenging interventional procedures CAREposition provides radiation-free flu-
Although data from approximately despite the six month trial encompass- raphy, where a 26 % reduction (1:06 to especially when multiple working oroscopic and angiographic positioning
2,200 procedures were obtained, ing approximately 2,200 fluoroscopic/ 0:49 min) was observed. Several exam- projections were employed. In the with the use of graphic markers overlaid
Contact
the variability of fluoroscopic and angiographic procedures, a greater ples for procedures are listed in Table 2. angiographic intervention of AV fistulas on the fluoroscopic last image hold.
vera.juennemann@siemens.com
angiographic procedures (particularly period of data collection would have When operators gain confidence in the only a small reduction (5 %) in screen- Our study has demonstrated that the uti-

24 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 25
Angiography syngo iGuide syngo iGuide Angiography

Endoleak Treatment:
Enhanced Visualization
Meets Enhanced Navigation

syngo iGuide
provides a
bull's eye
view and pro-
gression
views for
Diagnostic CT scan showes an Endoleak Type II. The CT images are fused with the syngo iGuide allows you to place target and optimal nee- After reaching the target a catheter will be A DSA scene shows clearly all endoleak related
syngo DynaCT dataset. skin entry point on the CT image, which is dle tracking. placed in the endoleak. vessels. The feeding vessels will be embolized
overlaid onto the syngo DynaCT. with various coils and Cordis Trufill n-Butyl
Cyanoacrylate glue.

1 2 3 4 5 6
syngo iGuide integrated needle guidance The endovascular repair of abdominal have been excluded by the endograft, pital DeBakey Heart and Vascular Center syngo DynaCT, the solution frees up
aortic aneurysms (EVAR) with stent such as the lumbar arteries and the in Houston, Texas, USA, and Professor of the hospital’s computed tomography
enables vascular surgeons and grafts has surged in popularity over inferior mesenteric artery, perfuse the Cardiovascular Surgery at Weill Cornell (CT) scanners for routine diagnostic
interventional radiologists to efficiently, the past decade, dramatically reduc- aneurysm sac via retrograde blood flow. Medical College of Cornell University. imaging and enhances workflow by
ing the amount of recovery time for Type II endoleaks are the most common In July 2010, Lumsden and his collea- eliminating the need to transfer the
precisely, and effectively treat type II patients in comparison with open repair. endoleak and can have multiple feeding gues began using syngo iGuide inte- patient during the procedure. “The most
endoleaks, one of the most vexing However, approximately one-third1 of and draining vessels that make their grated needle guidance, a software important thing for us is that the aneu-
patients who undergo EVAR will have treatment challenging. “Sometimes solution that enables physicians to per- rysm stops growing,” says Lumsden,
complications following endovascular an endoleak, a condition in which when we get referred to these patients, form needle procedures more precisely who uses the multi-axis Artis zeego.
abdominal aortic aneurysm repair. blood flows outside the lumen of the they may have had three or four trans- and efficiently using the Artis zee family “And in the majority of patients that
endograft but within the aneurysm sac, femoral attempts at blocking the en- of C-arm systems. Because the planning we have treated with syngo iGuide, the
By Sameh Fahmy, MS potentially increasing the risk of rupture. doleak off,” says Alan Lumsden, MD, of the procedure is accomplished using aneurysm has stopped growing and the
In type II endoleaks, aortic branches that Medical Director of the Methodist Hos- cross-sectional images acquired with endoleak has gone away.”

26 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 27
Angiography syngo iGuide syngo iGuide Angiography

Interventional radiologists such as much shorter amount of time. Detailed Lacey points out several components of these feeding vessels.”
David Lacey, MD, at Iowa Methodist anatomical information is obtained with syngo iGuide that he says reflect a level The physicians say the power of the
Medical Center in Des Moines, Iowa syngo DynaCT, and the images are fused of refinement not seen in similar needle technology is evident by the ease with
report similar promising results. “I’m with a diagnostic CT that was obtained guidance systems. The ability to obtain which it handles challenging cases.
more apt to be able to select small ves- earlier. To define the needle path, physi- a control scan after the needle has been Lacey points out that he often encoun-
sels and embolize them, and our results cians mark the needle target point in placed helps ensure accuracy by auto- ters aneurysm sacs that measure less
have been very good,” says Lacey, who the CT dataset and then mark the loca- matically correcting for patient motion than a centimeter. The difficulty of
in 2008 became one of the first users of tion of the skin entry point. By scrolling or even the deformation of tissues accessing them is compounded in larger
syngo iGuide in the USA. through the multiplanar reformations, “The 3D overlay lets caused by the pressure of the needle on patients, who in many cases require a
physicians can follow the needle path the skin. The Artis zee ceiling-mounted 20-centimeter needle. “That’s a long
Saving Time easily and verify that there are no vital
you look at any an- system he uses is equipped with an way to go to get an accurate placement
and Streamlining Workflow structures, such as the inferior vena gle to figure out integrated laser crosshair that precisely with a needle, but it turns out to be
The two most common approaches cava, in the way of the planned path. marks the skin entry point. This reduces pretty easy to do with this system,” he
for treating type II endoleaks are the syngo iGuide automatically proposes how to best navigate radiation dose by eliminating the need says. “I’m always impressed that I can hit
transarterial approach, often via trans- two needle progression views, in which the otherwise un- for fluoroscopy to match the needle tip that target, often in just one pass, using
femoral access, and direct translumbar the planned path is graphically overlaid with the path in the bulls-eye view and this system.”
puncture. The success rate of the tran- onto the fluoroscopic image. The needle predictable pathway improves ease of use. After acquiring The physicians say that long-term
sarterial approach is low, with up to 80 is advanced under fluoro guidance, and into this lesion.” the initial syngo DynaCT scan to define follow-up and several additional cases
percent recurrence rate due to the com- an additional syngo DynaCT run is per- small structures, Lacey uses syngo will be required to quantify improved
plexity of endoleaks and the potentially formed in slab mode to check the final DynaCT in low-dose mode to further patient outcomes using syngo iGuide,
circuitous route.2 position of the needle. Once the needle David L. Lacey, M.D., Department of Ra- minimize radiation to the patient. but the early results are certainly prom-
diology, Iowa Methodist Medical Center,
“The transfemoral approach has been position is verified, the physicians per- Once the endoleak site has been ising. Lacey says the success in treating
Des Moines, Iowa, USA
tried and largely has failed,” Lumsden form the embolization. accessed, Lacey uses an additional tool type II endoleaks at Iowa Methodist
says. “The idea behind the translum- Lacey estimates that the use of syngo known as syngo iPilot to overlay a 3D Medical Center has already led to refer-
bar procedure is that instead of going iGuide reduces the time it takes to per- syngo DynaCT angiography image on rals. In one recent case, the referring
through multiple feeding branches, you form the procedure by an hour, while the live fluoro as he navigates the cath- physician tried and failed to treat the
go right where they all come together Lumsden notes that it may save even eter. “The 3D overlay lets you look at any patient using conventional tools and
and work into those feeding branches more time in particularly complicated angle to figure out how to best navigate sent the patient to Iowa Methodist,
from inside that. The access in trying to cases. “The last one we did probably the otherwise unpredictable pathway nearly four hours away.
“In the majority of go transfemoral or transmesenteric is took an hour,” Lumsden says. “Before, it into this lesion,” Lacey says. “It allows Lacey adds that syngo iGuide is so easy
patients that we very long and torturous; some catheters probably took two to three hours.” you to very quickly and easily pick off to use that it can give physicians who
can’t even get to them.” In addition to the measurable reduc- the supplying vessels and really helps lack significant experience or confi-
have treated with Lacey explains that before Iowa Meth- tion in time associated with the use of you address the full extent of the leak.” dence with needle procedures the abil-
syngo iGuide, the odist Medical Center began using syngo syngo iGuide, the elimination of patient
Handling Challenging Cases
ity to successfully perform procedures,
iGuide with its ceiling-mounted Artis transfer from the CT has the theoretical including type II endoleak repairs, that
aneurysm has zee, he and his colleagues would use a advantage of maintaining sterility, since with Ease they might otherwise find challenging.
stopped growing translumbar approach and advance the physicians no longer have to transfer a Lumsden says that using conventional Using syngo iGuide is so simple, he
needle into the endoleak cavity using CT patient with a wire extending from the techniques, most physicians are quite says, “It’s kind of like cheating.”
and the endoleak fluoroscopy. After confirming that the aneurysm sac, out the patient’s back, happy just to get the needle into the
has gone away.” needle was in position by the pulsatile and to the outside world. aneurysm sac. The precision that syngo Sameh Fahmy, MS, is an award-winning free-
lance medical and technology journalist based
return of blood, the physicians would A CT scanner can be used for many iGuide enables, however, allows physi-
in Athens, Georgia, U.S.
exchange the needle over a guidewire, diagnostic scans in the time it takes to cians to enter the aneurysm sac at a
Alan B. Lumsden, M.D., Medical Director secure the wire with tape, and then complete a single needle procedure, so location that maximizes their likelihood 1 Baum RA, et. al. Endoleaks after Endovascular
Methodist DeBakey Heart and Vascular Repair of Abdominal Aortic Aneurysms J Vasc Inerv
transfer the patient to the interven- the elimination of the CT scanner for of embolizing the vessels that are feed-
Center, The Methodist Hospital, Radiol 2003; 14:1111-1117
Houston, TX, USA tional radiology angio suite. The patient needle guidance also has clear finan- ing the endoleak. 2 Baum et al. Treatment of type 2 endoleaks after
would then be re-prepped before physi- cial benefits. Lacey points out that the “If you have two lumbar arteries that are endovascular repair of abdominal aortic aneu-
rysms: comparison of transarterial and translumbar
cians used the guidewire to advance a increasing use of interventions such as feeding into the aneurysm and we enter techniques. J VascSurg 2002; 35:23–29.
catheter under fluoroscopic guidance CT biopsies and CT ablations has put right alongside one of them, we can’t
into the endoleak cavity, where coils additional scheduling demands on the bend the catheters around to get to it,”
and glue are used for the embolization. scanners at Iowa Methodist Medical Lumsden explains. “So one of the things
With the installation of syngo iGuide, Center, making any technology that we’re looking at is trying to choose
Contact
however, the entire procedure is per- reduces demand for the CT scanners the trajectory that will give us the best
heike.theessen@siemens.com
formed in the angio suite – and in a especially welcome. opportunity to catheterize and block off

28 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 29
Angiography syngo iFlow syngo iFlow Angiography

Quantitative Evidences of Hemodynamic 1

Improvement of Brain Arteriovenous

Malformation after Surgical Intervention
Supported by Artis zee and syngo iFlow
Courtesy of Wan-Yuo Guo, M.D., Ph.D.
Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan

1 Before surgery, the TTP of the left PCA (the main feeding artery of AVM) is 2.83 seconds, which
LPCA
RPCA is shorter than the right PCA (3.83 seconds).

Wan-Yuo Guo, M.D., practices

in the Department of Radiology 2
in the Taipei Veterans General
Hospital.

Patient history course was uneventful. After surgery, resistance in the artery and “steals”
32-year-old female suffered from inter- no more seizures were noted during blood flow from the right side to the
mittent partial seizures with secondary medical treatment. left PCA and makes the TTP of left PCA
tonic and clonic generalization for shorter. After surgical removal of the
5 years under regular medical treat- Comments AVM (Fig. 2), the AV shunts are deleted
ment. The seizure frequency increased DSA with syngo iFlow post-processing and the pressure gradient is no longer
recently. The deteriorated seizure con- quantitatively illustrates the peri-surgi- present. No more blood flow is needed
trol brought the patient back to hospital cal hemodynamic changes that related to compensate the pressure gradient.
to seek further treatment. to the AVM. Before surgery (Fig. 1), TTP Equalization of TTP (3.13 seconds) is
(time to peak opacification on DSA) of illustrated on left PCA and right PCA.
Diagnosis left PCA, the main feeding artery of
Left cuneus region S-M grade II arterio- AVM, is 2.83 seconds, which is shorter 2 After surgical removal of the AVM, the AV shunt is deleted and the pressure gradient is no longer
venous malformation (AVM). than the right PCA (3.83 seconds). The present. No more blood flow is needed to compensate the pressure gradient. The TTP of the left PCA
difference mainly results from the AV and right PCA are equalized (3.13 seconds).
Treatment shunts that occur in the AVM, where
Contact
Craniotomy with surgical removal of a pressure gradient of blood flow is
janina.beilner@siemens.com
the AVM was undertaken. The surgical present. The gradient decreases the

30 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 31
Angiography syngo DynaCT syngo DynaCT Angiography

Revascularization Treatment
of Acute Cerebral Stenosis
1 2
Supported by intra-arterial syngo Neuro PBV IR
Courtesy of Qiang Zhang, M.D.
Department of Diagnostic Radiology, Military General Hospital of Beijing PLA, China

Qiang Zhang, M.D.

is working with an
Artis zeego system
in his lab.

Patient history acquisition and injection protocol as injection. Although this protocol has 1 Pre-treatment: A severe stenosis in the M1 segment 2 Post-treatment: Right intracranial vasculature
A 47-year-old male patient with a in diagnosis in order to quantitatively not been approved systematically, we of the right MCA. was improved by stenting.
16-year history of hypertension and assess the quality of treatment. A signif- believe that intra-arterial syngo Neuro
onset of diabetes mellitus 5 years ago icant improvement of the CBV value of PBV IR measurement could have a large
presented with symptoms of paroxys- the right brain hemisphere could be application potential in conjunction
3 4
mal numbness and weakness in his left observed by the comparison pre- and with interventional treatment of cere-
extremities. post-stenting PBV imaging. brovascular diseases. Ongoing studies
are necessary to further approve the
Diagnosis Comments measurement with selective intra-arte-
Digital subtraction angiography (DSA) syngo Neuro PBV IR provides a mean to rial injection and to explore its clinical
demonstrates a severe stenosis (80 %) assess cerebral blood volume (CBV) in benefits.
in M1 segment of the right middle cere- the catheter suite. It is a powerful and
bral artery (MCA). A 3D intra-arterial convenient tool to visualize the revascu- Intra-arterial PBV
syngo Neuro PBV IR examination was larization with cerebral ischemia directly Examination protocol
performed to examine the viability of before and after intervention. Different
the right brain parenchyma. from the common syngo Neuro PBV IR Imaging protocol 8s DSA
examinations, in which an intra-venous Contrast quantity 16 cc (350 mg/cc)
Treatment injection protocol is used, in this case, diluted to 50 %
A 2.5 x 9 mm intracranial stent (Apollo, a selective intra-arterial injection pro- Injection rate 1 cc/s
MicroPort, China) was implanted tocol was adopted. The pre- and post- Injection duration 16 s
at the position of stenosis through treatment blood volume measurements X-ray delay 8s
balloon dilatation. The procedure was were restricted to the right brain, the Injection site right common
performed under general anesthesia. area that is supplied by the right com- carotid artery
DSA examination showed the morpho- mon carotid artery. This way, the effect Reconstruction preset Neuro PBV
logical improvement of the M1 segment of revascularization on the right MCA
of the right MCA. The stenosis was could be best presented. More impor-
reduced to less than 10 %. tantly, the usage of contrast agent in 3 Pre-treatment syngo Neuro PBV imaging of the right 4 Post-treatment syngo Neuro PBV imaging of the right
Contact
After stenting, a syngo Neuro PBV IR the intra-arterial injection was only 10 % brain hemisphere. brain hemisphere.
jingfeng.han@siemens.com
run was performed by using the same of the amount used in intra-venous

32 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 33
Cardiology Artis zee in EP Artis zee in EP Cardiology

“The ability to leave tags

Overlay of MRI Images at ablation sites gives us
confidence.

in Pulmonary Vein Isolation The clear demonstration

of anatomical variants of
the pulmonary veins is
really important as there
MRI images help the electrophysiologist to understand the anatomy and is no such thing as nor-
plan the right ablation strategy for pulmonary vein isolations. The 3D image mal left atrial anatomy –
is superimposed onto the live fluoroscopy und improves the guidance of the variation is the norm.”
catheter during ablation therapy in the EP lab.
R. Weerasooriya M.D.,
Department of Cardiology,
By Professor Rukshen Weerasooriya
Hollywood Private Hospital, Perth, Australia
Prof. Weerasooriya, M.D.
surrounded by his team.

Radio-frequency (RF) catheter abla- Figure 1 demonstrates the antero- temperature probe is also present. pulmonary veins (Fig. 1 and 2). with axial imaging and voxel size of the MR and fluoroscopic images at
tion of atrial fibrillation (AF) is highly posterior view of the position of the Using this technology, major aspects The MR images were obtained using 1.0 x 0.8 x 1.0 mm; TR/TE 2.91/1.1 msec; Hollywood Private Hospital in Perth,
dependent on an understanding of the circumferential mapping catheter and of anatomy such as the intervenous a Siemens 1.5T Avanto scanner. All flip angle 25 degrees; FoV 350 mm; Australia. Using this software, pulmo-
complex and variable anatomy of the the ablation catheter in the left superior ridges, venous calibre, early branch- sequences were acquired during a matrix 224 x 448. nary vein isolation can be undertaken
pulmonary vein (PV) – left atrial (LA) pulmonary vein. The fluoro overlay ing, accessory veins, roof pouches and breath-hold of 15-20 seconds. An initial Prior to the ablation procedure, a low in a safe and effective manner. Studies
junction. While CT 3D fluoroscopic involves a surface model generated appendage position can be appreciated. test bolus is given to assess transit time dose 5-second 3D rotational fluoro- are currently underway to carefully
overlay technique has been previously using syngo InSpace EP and syngo iPilot. The syngo InSpace EP software enables to the left atrium. Left atrial morphol- scopic imaging (syngo DynaCT) without evaluate the success and complication
described, we have investigated the Figure 2, on the other hand, offers a cross-sectional representation of the ogy was acquired after injection of contrast is performed with T6 to T9 in rates as well as radiation dose using
use of magnetic resonance (MRI) image view onto the right pulmonary veins. left atrial anatomy (Fig. 3); a type of 0.2 mmol/kg of gadolinium-diethylene the field of image. Using syngo InSpace this novel technology further. Initial
fluoroscopic overlay (with syngo iPilot) A decapolar catheter has been placed “endoscopic” fluoro overlay view, as triamine penta-acetic acid (injection 3D/3D Fusion, the syngo DynaCT and results of applying this new approach
which has the distinct advantage of within the coronary sinus via a long well as tagging of ablation points, rate 3-4 cc/sec) and appropriate time MR data are displayed fused together. to MR-guided PV isolation on a group of
lower exposure to ionizing radiation. curved sheath and an esophageal shown as pink tags at the ostium of the delay using a Flash 3D sequence The bony landmarks of the vertebral 43 consecutive patients with symptom-
column are used for alignment and atic AF have allowed us to perform the
registration of the MR data set to enable entire procedure without an EP mapping
accurate image overlay. During the abla- system. Despite removing the dedicated
1 2 1 Automated coregistra- 3
tion, the segmented left atrium from electroanatomical mapping system,
tion of 3D MRI of LA and
pulmonary veins. the MRI is displayed superimposed on cases are performed with similar fluoro
Intra-procedural overlay the live fluoro image using syngo iPilot. time, radiation dose to the patient,
during PV RF ablation. The MR-fluoro overlay image, derived and procedure time, while the prepara-
from the MR data set, is updated in tion time has been reduced. A further
2 Position marker of
real time to match the position of the improvement is the marked dose reduc-
ablated region on MRI-
based overlay during
angiography system maintaining an tion to the operator performing the case
ablation of right inferior accurate overlay. An internal view of the as the low dose 3D acquisition can be
pulmonary vein. left atrium is obtained using clip planes. performed with clinical staff out of the
3 Automated 1-click segmentation of the Ablation points can be recorded by room.
left atrium during ablation preparation placing a tag at the tip of the ablation
catheter. The tags are shown as part of
the MR fluoro overlay.
syngo InSpace 3D/3D Fusion, syngo
Contact
InSpace EP, and syngo iPilot software
anne-eloise.cournut@siemens.com
have enabled rapid and efficient fusion

34 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 35
 Cardiology syngo DynaCT Cardiac syngo DynaCT Cardiac Cardiology

Accurate Placement of Aortic Valves

Supported by syngo DynaCT Cardiac
Walters DL, M.D.1, Crowhurst J., Chief Radiographer1, and Aroney C., M.D.1,2
1
Cardiology Department, Prince Charles Hospital, Brisbane, Qld., Australia
2
Holy Spirit Northside Private Hospital, Chermside Qld., Australia

“Due to the increased

accuracy of valve placement
“We found that the use of syngo DynaCT with syngo DynaCT Cardiac,
Cardiac significantly reduces the overall
DynaCT Cardiac was used to determine this technique has become
contrast volume and radiation dose required the angle. Initial findings show the
for the TAVR procedures. It accurately average re-valving procedural contrast an integral part of all of the
determines the choice of valve deployment
volume for the pre-operative CT group
was 285 cc, versus 210 cc for the syngo
TAVI cases within our
position.” DynaCT group. As a comparison over
the combined CT + re-valving proce-
hospital.”
dure, the total contrast volume for the
J. Crowhurst,Chief Radiographer, Department of Cardiology, pre-operative CT group was 335 cc, ver- Darren Walters, M.D., Director of Cardiology,
Prince Charles Hospital Brisbane, Australia Prince Charles Hospital Brisbane, Australia
sus 210 cc for the syngo DynaCT group.
Not only does the use of syngo DynaCT
Cardiac result in the reduction of con-
trast required, it importantly also allows
us to achieve a significant reduction
in radiation dose. Indeed, through the
entire assessment and intervention
The emerging technique of Transcath- Method the amount of dose per patient was
eter Aortic Valve Replacement (TAVR), Patients enrolled in the TAVI program reduced on average from 255.5 CGy
is offering treatment options to many were separated into two groups. One with a pre-procedural CT to 214.2 CGy
patients who are ineligible for open group was studied with pre-operative when syngo DynaCT Cardiac is used 1 2

heart surgery due to frailty and other CT scans and the other underwent instead.
co-morbidities. peri-operative C-arm CT (syngo DynaCT
The success of this procedure is greatly Cardiac). Predicted C-arm angulations Conclusion
dependent on the alignment of the from both groups were decided using The treatment with peri-operative
valve prosthesis in the aortic root. Siemens syngo InSpace 3D software. C-arm CT with syngo DynaCT Cardiac
The valve must be profiled perfectly In all cases, the Artis zee system was significantly demonstrates a more pre-
perpendicular to the X-ray beam before positioned using the CT scan’s predicted cise angle of the C-arm when compared
deployment. This requires multiple angle. An aortogram was performed to to traditional pre-operative CT. As the
aortograms being performed which is confirm the accuracy of the predicted use of contrast media is critical for
time-consuming, inaccurate and uses profile. Total contrast volume was noted patients suffering from renal impair-
significant contrast media volumes. for the re-valving procedure including ment, the use of syngo DynaCT Cardiac
Performing a pre-operative or peri- contrast required for the syngo DynaCT indicated to be the system of choice as
operative CT scan can demonstrate the Cardiac. less contrast media and radiation dose
correct C-arm angle for placement of was delivered in comparison to pre-
the valve. The cardiology team at the Comments operative CT.
Prince Charles Hospital has compared In the pre-operative CT group, the
the effectiveness of pre-operative CT correct C-arm angulation was dem- 1 Aortic root segmentation result based 2 Overlay of anatomical information and landmarks onto live fluoro
Contact
against peri-operative C-arm CT for onstrated in less than 30 % of cases, on syngo DynaCT Cardiac 3D Volume. for image guidance during valve positioning.
anne-eloise.cournut@siemens.com
these procedures. versus 93 % of cases where syngo

36 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 37
 Cardiology Hybrid OR CARE Cover Story

Minimally Invasive Aortic

Valve Implantation Offers
New Hope to Stenotic Patients

Since 2008, the Angiografia de Occidente

cardiology group has performed 70
percutaneous aortic valve implantations.
Siemens Artis zee imaging equipment is
considered “indispensable” for the implants.
In Europe, the procedure is rapidly
becoming standard practice for elderly
patients unsuitable for open-heart surgery.
by Chris Kraul

The city of Cali in southwestern Colom- Food and Drug Administration, the rela- considered very helpful by the hospital the TAVI device. At first there was a lot of with great definition the anatomy the the time – and radiation – needed to
bia might not leap to mind as a hotbed tively new procedure is rapidly becom- for performing the 8,000 procedures – mispositioning, but with syngo DynaCT, way we have to see it,” said Bernardo make a diagnosis or place the implant.
of cutting-edge medical technology, but ing standard care in Europe, Canada, divided about evenly between diagnos- results have improved significantly over Caicedo, MD, Dager’s partner at Angio- Advanced features like automated selec-
Dr. Antonio Dager and his Angiografia and Latin America for elderly stenotic tic procedures and angioplasties – that the last three years,” Dager said. grafia de Occidente. tion of filters, dose free repositioning
de Occidente clinic are in the vanguard patients with comorbidities who are not Dager and three other interventional For pre-procedural TAVI planning Dager Adds Dager: “These systems are an of collimator blades and table as well as
of nothing less than a revolution in eligible for open-heart surgery because cardiologists at Angiografia de Occi- also makes use of computed tomogra- extension of your senses, your mind, low dose acquisition protocols reduce
minimally invasive cardiovascular pro- of their high-risk status. dente perform annually at seven loca- phy (CT). With the Siemens SOMATOM® and your thoughts about the patient’s the exposure. The upshot, says Angio-
cedures that is being helped along by Due to the relatively high volume of tions in Cali, Popayan, and Pereira. Definition CT scanner he is able to pre- condition. You can think out a case as grafia de Occidente radiology technician
Siemens Artis zee imaging systems. implants and Dager’s success rate of 96 Essential for the 45-minute TAVI pro- cisely determine size, morphology and you do the procedure, because the feed- Francisco Corredor, is that a typical
Since March 2008, Dager and his associ- percent, his clinic was named in Novem- cedure is his Artis zee system, which is position of the diseased aortic valve. back and capture are instantaneous.” angioplasty now requires significantly
ates have performed 70 transfemoral ber 2010 to participate in a Medtronic- equipped with syngo DynaCT Cardiac for Furthermore the distance of the coro- The systems also feature Siemens low- less radiation than a typical procedure a
aortic valve implants (TAVIs), more than sponsored study of angioplasty centers rotational angiography. It generates pre- nary ostia to the aortic annulus can be dose radiation technology that, for few years ago.
any other clinic in South America. In all worldwide that tracks the effectiveness cise three-dimensional images that can accurately assessed. several reasons, makes the procedures “Angiography systems used to disperse
cases, Artis zee equipment was used of aortic valve implants. Medtronic is be rotated, enabling him to see the aortic significantly safer for patients and radiation indiscriminately in a cone-
to help diagnose the disease, usually one of the principal manufacturers of root from all angles. “It’s better than life. The way we have to see it medical staff: Better images let Dager like path. Now, it is very targeted,”
aortic stenosis, and place the implants. the valves. The nine Siemens imaging It helps me pinpoint the exact place in “Without this equipment, our work see organs and the progress of the says Dager. He speaks English with a
Although not yet approved by the U.S. systems that Dager’s clinic uses are the inferior portion of the aorta to align would be impossible. It can show guidewire more clearly, which reduces faint Cajun accent, having spent some

38 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 39
Cardiology Hybrid OR Hybrid OR Cardiology

“Without this equipment, our

work would be impossible.
of his teenage years in New Orleans,
It can show with great
where his father was Colombian consul. definition the anatomy the
Dager’s day starts at 7:30 a.m. and
sometimes doesn’t end until 10 p.m. if way we have to see it.”
he has a “papa caliente” – Spanish for
“hot potato”, or emergency. On aver- Bernardo Caicedo, M.D., Department of Cardiology,
age, Dager performs ten diagnostic and Angiographia de Occidente Clinic, Colombia
interventional procedures per day, some
lasting a few minutes, some up to three
hours.
Among the 70 TAVIs he and his partners
have done were eight U.S. patients
who came to Dr. Dager’s clinic in Cali
at the insistence of cardiologists at the
University of Miami Miller School of
Medicine, with which Dager maintains
close ties. The referrals usually come, he
says, because the patients don’t qualify
for insurance reimbursement, and hav-
ing the implant done at Angiografia de “It’s better than life. It helps me pinpoint the exact place in
Occidente costs half as much as the cost
of the procedure at a U.S. clinic. the inferior portion of the aorta to align the TAVI device.
A dream come true At first there was a lot of mispositioning, but with syngo
Dager’s relations with the University of
Miami medical school date from 1985,
DynaCT, results have improved significantly over the last
when he was accepted as a four-year three years.”
cardiology and hemodynamics fellow
under the school’s William J Harrington Dr. Dager plans the next steps during the treatment by
checking the fluoroscopic image in the control room. Antonio E. Dager, M.D., Department of Cardiology, Angiographia de Occidente Clinic, Cali, Colombia
Program for Latin American medical
students and physicians. He cites the
program as the source of much of his
professional success and of his enduring
passion for following the state-of-the-
art in medical technology. By the time
Dager began his fellowship in Miami,
the Cartagena native had already spent Caicedo, a close friend who was his chief Dager says. Those who do not receive heart diseases. Lifestyles have changed ing degrees the world over), together younger patients, who are more likely
a decade in general and intensive care resident during his internship in 1974. implants have only a 50-percent sur- from home cooking and daily siestas to with the growing success rate in TAVI these days to receive implants via open-
practice in Cali after attending the Uni- vival rate one year after diagnosis and more junk food and stress. As a result, procedures, is why experts are project- heart surgery.
versidad del Valle medical school there. Better survival rates only 30-percent chances of survival we see lots more atherosclerotic and ing a rapid acceleration in percutaneous
Chris Kraul, a former foreign correspondent
But he had always hoped to specialize in Dager also gets referrals because the after two years. peripheral artery disease than we did 20 aortic valve replacements in coming with the Los Angeles Times, is now a freelance
cardiology, particularly after a beloved results of the TAVIs are so compelling. In their nearly four decades in medi- or 30 years ago. Stenoses get detected years. The procedures have already writer based in Bogota, Colombia.
uncle died of aortic stenosis in 1974, Patients in their 70s diagnosed with aor- cine together, Drs. Dager and Caicedo in patients’ 40s and 50s instead of their taken off in Europe, where more than
when the diagnosis was a virtual death tic stenosis who receive the implanted say, they have witnessed a demo- 60s and 70s,” says Dager. 20,000 TAVIs have been performed up
sentence. The UM Harrington fellow- valve have a 77-percent likelihood of graphic shift in patient population to now, up from only 1,000 in 2007,
ship helped him realize his dream. Upon surviving the first year and a 69-percent due to Colombia’s modernizing and Acceleration Dager says. He believes the need for
in procedures foreseen Contact
his return to Cali in 1989, he founded chance of surviving two years, results urbanizing population. “We’re in the aortic valve replacements will further
hanno.herrmann@siemens.com
Angiografia de Occidente with Dr. that roughly track a Canadian study, midst of an epidemic in diet-related That shift (which is in progress in vary- increase, and possibly also among

40 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 41
Surgery Hybrid Surgery Titel Kategorie

3D Imaging “We had angio

Brings a New suites, but we
Vision to didn’t have CT
Endovascular scanners in the
Surgery angio suite
until syngo
Alan Lumsden, MD, a leader in the
DynaCT.
field of endovascular surgery, is
Medical Director of the Methodist
Now we have a
Hospital DeBakey Heart and Vascular
Center Houston, Texas and Professor whole new set
and Chairman of the Department of
Cardiovascular Surgery at the
Methodist Hospital, Houston, Texas.
of imaging
Lumsden, who has received more
than $1.8 million in research funding
modalities that
and has contributed more than 300
papers to the medical literature, says we can work
3D imaging in the operating room,
robotic catheter guidance, and other
advanced technologies have the
from.”
potential to revolutionize endo-
vascular surgery by improving Alan B. Lumsden, M.D.,
Medical Director Methodist Hospital
accuracy as well as safety. DeBakey Heart and Vascular Center,
Houston, Texas, U.S.

By Sameh Fahmy, MS

42 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 43
Surgery Hybrid Surgery Hybrid Surgery Surgery

A look into the new hybrid OR

featuring Artis zeego.

Which early advances in imaging catheter robotics. Can we automate actually several branches coming out of not be able to do it along the entire
have been most consequential for parts of this? Because that same this aneurysm. It was marginal whether length, but in that critical terminal
surgeons? centerline that we’ve used down the we should be treating it or not and 10, 15 centimeters, can we build that
The single most important piece of middle of the aorta to measure a length we backed out of treating that patient capability? We can draw a centerline on
equipment was the portable C-arm. That for an endograft could be a guide path because we thought the risk/benefit syngo DynaCT, we can lay those lines on
has, in my opinion, transformed what we for a robot. And that’s not that far ratio was in favor of leaving it alone. the patient so we can see a virtual line,
could do. No hospital is going to invest away. We have the catheter robots and and we’re starting to have the ability to
three or four million dollars in building a are really interested in this interface Tell me about the use of syngo have that degree of accuracy in steering
hybrid room before you had significant between 3D navigation, which you DynaCT as a navigational aid. catheters. And those centerlines are just
patient volume and reimbursement to can pinpoint with a robot, and the 3D With the catheter robotics that are cur- a series of points in space with coor-
justify building that. The next level really imaging that Siemens provides. rently available, we have highly accu- dinates – and robots follow directions
was fixed imaging suites in the operat- rate control and can move millimeter pretty well.
ing rooms. Or I should also say, access to What are some benefits of the robotic by millimeter when we need to. The
fixed imaging, because not all of them movement of the Artis zeego? first human cases have been done in What kind of training needs to be
are in the operating room. Right now, I think it’s the ease of posi- relatively straightforward situations, the done for vascular surgeons to maxi-
tioning the patient. But in the future it’s femoral artery, but the benefit really mize the potential of 3D imaging?
Tell me about some of the more going to be in the speed of the rotation comes in some of the complex cath- When you see surgeons interacting with
recent milestones in imaging. of the image intensifier and detector, eterization capabilities, so for example imaging equipment, it’s not optimal.
I think the next one is syngo DynaCT although I think that’s going to have to branched aortic endografts. One of the The radiation safety aspects basically
image fusion; that’s the next revolution be done under an IDE (investigational advantages perhaps of these robots are not there; the image optimization
that’s about to take place. We had angio device exemption) with the FDA (U.S. is that when we’ve done the syngo is often not where it should be. Those
suites, but we didn’t have CT scanners Food and Drug Administration). The DynaCT and we know the location of are gaps that we need to be teaching.
in the angio suite until syngo DynaCT. faster we can acquire the images, the the renal artery is behind an endo- I think there is an enormous imaging
Now we have a whole new set of imag- fewer motion artifacts. It also may allow graft, where we can’t inject it with dye training opportunity, need actually, in
ing modalities that we can work from. you to start measuring flow in vascular directly, we can potentially with a robot the surgical world.
territories by looking at the speed in puncture that endograft over the renal
Can you give me an example in which they are being filled. So that’s artery and then gain access to the renal What do you see on the horizon for
which syngo DynaCT is particularly why the robotic component of the Artis artery. It adds a whole new conceptual the future of imaging in surgery?
beneficial? non-diagnostic, we’re going to stick a that 3D image and interact with it in zeego is pretty exciting. Right now we’re capability in how we’re going to man- Right now, I think that you’re beginning
Type II endoleak management is one scope in there, take a biopsy, and send 3D with tools that allow us to plan the really not using it to its maximal capabil- age those patients. to see vascular surgeons using these
example in vascular surgery. Another it to the pathologist. And if it’s a lung operation. We would then push it to the ity. A lot of these things are still under tools and beginning to present and talk
example would be for the thoracic cancer, it needs to be resected and it’s simulators and practice on Mrs. Smith’s development. What are some advantages of about them. But orthopedics, urology,
surgeon. Rather than having a patient going to happen right there. I think the renal artery angioplasty today. We could combining 3D imaging with robotic general surgery, and thoracic surgery all
undergo a needle biopsy, and possibly technology is transformational. then take that same data set and push it How do the 3D imaging capabilities of catheter guidance? have potential applications.
bringing the patient back for a scope if to the Artis zeego tomorrow, fuse it on syngo DynaCT improve your ability to Currently, when you take a catheter and
the needle biopsy is non-diagnostic and How can 3D imaging aid procedural top of the patient and do the procedure treat patients in the hybrid suite? navigate to the left coronary artery, you Sameh Fahmy, MS, is an award-winning free-
then having a third procedure to resect planning? having planned it three-dimensionally I think it can improve accuracy. I’ll give really don’t navigate anything. You have lance medical and technology journalist based
in Athens, Georgia, U.S.
the tumor, I think it could all be done in Let me give you a vision, although the in a cave environment and having prac- you an example of splenic and renal a series of wall interactions between the
one shot. You could import the initial CT pieces aren’t all necessarily meshing ticed on our simulator. Now you may artery aneurysms. There was a patient catheter and the wall of the aorta all the
scan, fuse it on top of the patient, use together yet. One of the advantages not have to do this in every case, but it’s recently whose CT scan I looked at in way up – and that’s where the compli-
something like syngo iGuide (integrated of syngo DynaCT is 3D reconstruction, the opportunity to do this on the more the office and it looked like this was a cations come from. So centerline navi-
needle guidance), stick a needle in it but we don’t look at it in 3D. We have sophisticated cases that’s significant. saccular aneurysm that was fairly easy gation is highly appealing. Can we get
Contact
for a biopsy, send it to the pathologist, a 3D rendering on a 2D model. We And the final part of this, and this is to treat. When we did the 3D recon- a catheter up there and never touch the
thomas.hartkens@siemens.com
keep the patient asleep, look at it. If it’s would really like to be able to look at several years away, is using flexible struction and looked at it, there were wall or minimize wall contact? We may

44 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 45
Surgery Thoracic Surgery / Pneumonology Thoracic Surgery / Pneumonology Surgery

Accuracy Far Beyond “I believe hybrid rooms are the future of

medicine. In such multi-level rooms, where
that syngo DynaCT can contribute to
doing so more precisely.”
Other types of ablation, such as RFA,

Conventional Pneumological
microwave and LITT or endoluminal
angiography and surgery take place on the brachytherapy also depend on exact
same table, cardiologists as well as pulmo- navigation. Depending on the tumor
size, these “total” local ablations are

Practice nologists, hepatologists and surgeons can

gain from the benefits of intraprocedural
expedient in the context of a therapy
using intratumoral chemotherapy,
since affected lymph tracts and lymph
one percent of cases. Those measuring imaging.” nodes can absorb the outflowing che-
8 to 10 millimeters have a 10 to 20 motherapeutic agent in significantly
percent chance of being malignant and higher concentrations than is the case
Worldwide, cancer is a leading cause of death, 50 percent of lesions over 20 millime-
Wolfgang Hohenforst-Schmidt, M.D., Department of Cardiology-Angiology-
with systemic administration. Undis-
Pneumology, Klinikum Coburg, Coburg, Germany
with lung cancer causing more deaths than ters are cancerous, making clarification covered residual tumors in lymph tracts
essential. and lymph nodes are not reached by
stomach, liver, colon and breast cancer. Taking the local ablation, however, they are
biopsies from small lung nodules to diagnose Challenge: Increase Accuracy reached by intratumoral chemotherapy.
of Tissue Samples
cancer at an early stage poses an opportunity However, Schreiber found out that the ceiling-mounted angiography system. shift”, says the lung specialist, “But the syngo DynaCT
and a challenge at the same time. The smaller accuracy of tissue samples taken from The syngo DynaCT application generates problem of false-negative results is still in the Hybrid Room
lesions of this size is relatively low: a CT-like dataset within a few seconds. conspicuous. To solve this, we want When asked which departments could
the nodule, the higher the survival rate of the 33 percent in the case of lesions less Real-time fluoroscopic images are to bring additional instruments, such benefit from angiographic imaging, the
patient, but the more difficult the biopsy. than 20 mm as opposed to 62 percent superimposed on this during the bron- as needles, brushes, suction-cytology lung specialist answers that it is mainly
for lesions over 20 millimeters. Small choscopy, facilitating navigation within and 20-Mhz-miniprobes to the lesion in suited to hospitals with a high patient
An efficient solution lies in guided navigation. pulmonary nodules (SPN) tend to be the bronchial tree. Hohenforst-Schmidt the near future. The expectation from circulation, in which at least 800-1,000
With no artificial contrast medium but air the benign rather than malignant, but ensures that the diaphragm remains in other studies is that the additional use bronchoscopies are performed annually.
they require more invasive treatment a fixed position via jet ventilation dur- of these instruments will bring another “I believe hybrid rooms are the future
tumor is clearly visible with syngo DynaCT. because conventional bronchoscopies ing deep sedation. He uses no artificial 10 - 15 % of detection rate.” of medicine. In such multi-level rooms,
on lesions of this size result in a low contrast medium but air to make the Hohenforst-Schmidt has also done sev- where angiography and surgery take
by Lena Schnabl accuracy rate. Thus tissue samples can tumor clearly visible with syngo DynaCT. eral transthoracic biopsies using syngo place on the same table, cardiologists
be false-negative. Dr. Wolfgang Hohen- According to the lung specialist, the DynaCT and syngo iGuide, the live and as well as pulmonologists, hepatologists
forst-Schmidt, Senior Physician at the major benefit of this approach is that it is integrated needle guidance software. and surgeons can gain from the benefits
According to the WHO the lung tumor A number of trials of low-dose CT Department of Cardiology, Angiology a real-time procedure. Both stages – the Tissue samples taken during transtho- of intra-procedural imaging.”
group is often diagnosed in the screening are currently underway in and Pneumology (Head of the Depart- acquisition of the syngo DynaCT dataset racic biopsies are usually bigger and
advanced stages, resulting in poor Europe. More lung screenings will most ment Prof. Dr. Johannes Brachmann) at and the bronchoscopy under fluoro- therefore more accurate diagnosis is Lena Schnabl is a social scientist and works in
prognosis. However, a study from the likely result in more positive findings, the Coburg Hospital in Germany says: scopic guidance – are performed at the possible. syngo DynaCT enables the ver- the editorial team of Siemens healthcare com-
munications. Among other topics, she writes
American Cancer Society shows that if such as the detection of a high number “This poses a real problem. If the tissue same time, in the same place and with ification of the correct needle position about early detection and diagnostics of cancer
discovered early enough the overall sur- of small nodules that make clarification sample proves to be malignant, I hit the the diaphragm in the same position. and thus makes transthoracic needle on a regular basis
vival rate is 88 %, making precautious, through biopsies necessary. lesion without doubt. But in the case procedures more effective. References
precise and reliable diagnosis essential. Taking biopsies from small lung nodules of benign results the main question
“The increase in the hit rate to Furthermore, the lung specialist has • American Cancer Society, Cancer Facts & Figures
In June 2011 the National Lung Screen- to diagnose cancer at an early stage is, if I ought to believe these results. around two thirds poses a demonstrated that it is possible to dye 2011; Intl. Early Lung Cancer Action Program

ing Trial (NLST) publicized its primary poses an opportunity and a challenge We urgently need an enhanced solution seismic shift.” small lesions so that they are more Investigators, 2006;
• The National Lung Screening Trial Research Team,
results. The trial was launched in 2002 at the same time. The smaller the for the diagnostic clarification of small, To date, the lung specialist has taken visible and easier to remove during The New England Journal of Medicine; Reduced
and compared two ways of detecting nodule, the higher the survival rate of peripherally located lung lesions in biopsies from over forty patients via subsequent surgical interventions. Addi- Lung-Cancer Mortality with Low-Dose Computed
lung cancer: low-dose helical computed the patient, but the more difficult the order to prevent false-negative results. syngo DynaCT-guided bronchoscopies tionally, Hohenforst-Schmidt believes Tomographic Screening, June 29, 2011

tomography (CT) and standard chest biopsy. The likelihood of a lesion being This is only feasible via navigation.” – with impressive results: During the syngo DynaCT can become a powerful • MacMahon H. et al., Radiology 2005; 237:395-400;
Guidelines for Management of Small Pulmonary
X-ray. The primary results show a 20 % malignant varies depending on age and According to Hohenforst-Schmidt, the proof-of-concept period the hit rate tool to make progress in local ablative Nodules Detected on CT Scans
decrease in mortality from lung cancer smoking behavior as well as its size: solution lies in guided navigation with was 80 % in lesions with an average therapy modalities like radiofrequency • Schreiber G. et al., Chest 2003
in the low-dose CT group as compared As published in the ‘Guidelines for Man- syngo DynaCT. As the pulmonary medi- diameter of 24x23x23 mm, and 58 % ablation, microwave ablation, laser
to the radiography group. The rate of agement of Small Pulmonary Nodules cine unit is located in the Department in very small nodules with an average induced thermotherapy or intratumoral
positive results was more than three Detected on CT Scans’, lesions measur- of Cardiology, Angiology and Pneumol- of 15x14x16 mm – only by forceps chemotherapy.: “Intratumoral chemo-
Contact
times higher with low-dose CT screen- ing less than 4 millimeters found in low- ogy the lung specialist has access to biopsies. “The increase in the hit rate therapy can considerably extend the
anne.figel@siemens.com
ing than with radiographic screening. risk individuals prove malignant in only an angiography suite equipped with a to around two thirds poses a seismic lifespan of patients and I am convinced

46 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 47
Surgery Thoracic Surgery / Pneumonology Thoracic Surgery / Pneumonology Surgery

Navigation in the Lung

Supported by syngo DynaCT Cardiac
Courtesy of Wolfgang Hohenforst-Schmidt , M.D.
Institute of Internal Medicine, Klinikum Coburg, Germany

1
1 3D volume of the lung (syngo DynaCT
Cardiac) with live fluoroscopy overlay
“Local ablative therapies like intratumoral (syngo iPilot).

chemotherapy may considerably extend

the lifespan of patients and I am convinced
that syngo DynaCT can contribute to doing
so more precisely in the future.”

Wolfgang Hohenforst-Schmidt, M.D., Department of Cardiology-Angiology-

Pneumology, Klinikum Coburg, Coburg, Germany

Patient History 1 The 3D volume is overlaid with live supports biopsies of even early-stage
A 70-year-old female. fluoroscopy. This way, the physician lung cancer. The open structure of the Please note:
the clinical images are
can see live the movement of the C-arm is well suited for interventions
from different cases.
Diagnosis biopsy forceps toward the tumor and and proves to be useful in the field of
The patient was diagnosed with moder- make sure the biopsy captures the pneumology.
2 3
ately differentiated lung adenomatous tissue (Fig. 1). The demonstrated case, shows that an
carcinoma four years ago and initially overlay of the tumor in the 3D data set
treated with chemotherapy. Currently 2 In addition to option 1, it is possible and the real-time fluoroscopy is very
the patient presents with multiple to manually mark a path through the precise due to the fact that the whole
intrapulmonary nodules, metastases bronchi as well as the volume of the procedure – 3D data acquisition and
in the sternum and multiple osteoplas- tumor on the workstation. This path bronchoscopy – is done in the same
tic metastases in the thoracic spine. can then again be overlaid and fol- suite at the same time and nearly in
Additionally the patient has cerebral lowed when advancing the forceps to the same position of the diaphragm,
metastases. the tumor (Fig. 2). guaranteed by the apnea under deep
The patient was admitted for an update sedation (not general anesthesia) and
to diagnose the response to chemo- 3 Another option is to do a virtual jet ventilation.
therapy. In general the patient suffers bronchoscopy. The software cur- We conclude that with syngo DynaCT
from moderate dyspnea. rently allows navigation up to the Cardiac rapid onsite navigation in the
9th debranching of the bronchial lung could soon be a routine applica-
Treatment tree (Fig. 3). tion in the bronchoscopy suite. syngo
A rapid data acquisition was performed DynaCT Cardiac has the power to be the
with syngo DynaCT Cardiac under deep Comments central part of a hybrid interventional
sedation and jet ventilation. In this Intra-procedural 3D imaging of the pneumology / thoracic surgery suite.
intra-procedural 3D data set the tumor bronchial tree with syngo DynaCT
is clearly visible. Navigation through Cardiac together with the other soft- 2 Manually marked path (syngo iGuide Toolbox) through the bronchi and 3 Virtual bronchoscopy based on syngo FlyThrough.
Contact
the bronchi is possible in different ware applications (syngo iPilot, syngo marked tumor volume.
anne.figel@siemens.com
ways: iGuide Toolbox and syngo FlyThrough)

48 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 49
Surgery Heart Valve Implantations Heart Valve Implantations Surgery

Heart Valve Replacement – Significant

Changes Thanks to Hybrid Surgery

Today, Japan’s popula-

tion is living longer
The machine enables intra-procedural to undergo open-heart surgery due to turn away many prospective patients a transapical insertion on a valve- when opened, hold the valve firmly
than ever, but that also imaging in 2D and 3D and helps multi- the risk that this procedure poses for due to their advanced age and physical mounted catheter, which is introduced in place. The Edwards valve does not
means a higher nation- functional teams of cardiac surgeons them. frailty. As a consequence, we can do through a surgical puncture into the require prior removal of the patient’s
and cardiologists to best perform their “For more than 30 years, we’ve relied only 70 open-heart surgeries a year at apex of the left ventricle. own valve, but instead is slid inside the
al incidence of elderly procedures. on open-heart surgery, and that Kurashiki Central.” Produced by Edwards LifeSciences, defective valve, permanently pushing
patients needing heart Doing heart valve replacements in a requires splitting the sternum,” Komiya
Catheter Delivery
based in Irvine, California, the pros- back its leaflets and immediately taking
hybrid room is also recommended in a explained. “Many patients with defec- thetic valves are based on an ingenious, over the function of maintaining one-
valve replacements. recent joint paper from the Society of tive heart valves are more than 70 years The Kurashiki heart team is focusing on yet simple design concept. They are way blood flow.
Siemens is collaborat- Thoracic Surgeons (STS) and the Ameri- old. Among the national population, two different options for catheter-deliv- bovine in origin and similar in size Catheter delivery minimizes or elimi-
can College of Cardiology (ACC), two of there are annually some 10,000 cases ered replacements of the heart valves, and shape to the natural valves in the nates the need for open-heart surgery
ing with surgeons at the most important cardiac surgical and of degenerative disease in the aortic transapical and transfemoral. The aortic human heart. These bio-valves are along with the trauma of opening large
Kurashiki Central Hospi- cardiological societies in the world. valve, but medical institutions must valve from Edwards is replaced through expandable wire-mesh stents which, parts of the thorax. The patient also

tal to introduce A multi-disciplinary team in a

multi-disciplinary room
lower-risk catheter-
“The methods for implanting heart Tatsuhiro Komiya M.D., Chief at the Cardiovascular Surgery Department of the Kurashiki Central Hospital, Kurashiki, Japan
based procedures that valves cannot be learned on one’s
own because close teamwork is essen-
eliminate the need for tial among the different specialists,
open-heart surgery in including interventional cardiologists,
echocardiographers, imaging special-
many of these cases. ists and heart surgeons like myself,”
says Tatsuhiro Komiya, MD, Chief of the
By Clark Shimazu
hospital’s cardiovascular surgery depart-
ment. “Since the launch of our joint
Kurashiki Central Hospital is among program with Siemens in May 2010,
three Japanese medical institutions each specialist has not only had to learn
whose multidisciplinary surgery teams his own specific skills but also gain
conducted clinical trials of catheter- some familiarity with other team mem-
delivered Edwards prosthetic valves bers’ tasks, because we have to work in
over the past year. The aim is to gain concert on the operation in a very short
approval from the National Health Min- period of time.”
istry for the innovative procedures. All The first round of clinical trials is espe-
of these institutions are equipped with cially important in Japan, where many
Siemens hybrid rooms – a conventional elderly people among the aging popula-
OR equipped with an angiography tion are outliving the normal duration
system to allow for both open and mini- of their heart valves. The aorta is the
mally invasive treatment in one room. biggest artery in the body; therefore, its
At Kurashiki Central Hospital, the room valve handles a larger flow than other
is equipped with a ceiling-mounted Artis heart valves. Seniors with a lot of co-
zee angiography system from Siemens. morbidities, however, are not indicated

50 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 51
Surgery Heart Valve Implantations Heart Valve Implantations Surgery

Lorem ipsum Dolor Team OR

functioning. The catheter and electrode immediately to open-heart surgery in

wire are retracted. The surgeon then our hybrid OR,” Komiya discloses.
removes the introducer sheath to close The aortic valve trials at Kurashiki
the puncture in the heart. Central have spurred development of
“This, for me, is the most stressful valves of smaller diameter that are more
moment, since any slip of the fingers suitable for Japanese patients who on
could have catastrophic consequences,” average are smaller than European or
says Komiya. “The heart is beating while American patients.
I close the thorax and skin incision.” More extensive research and develop-
The multiplicity of tasks was done ment on valve design must, of course,
within a total span of just 12 to 14 await ministry approval for the innova-
Kurashiki Central Hospital is famous for its innovative procedures.
minutes. tive valve replacement technique.
“Just like the American health system,
Positioning matters the Japanese one demands comprehen-
“A vast amount of planning precedes sive clinical trials on innovative proce-
spends far less time in surgery, and The Edwards Sapien valve is com- the operation,” Komiya states. “Echo- dures,” Komiya says. “Our reporting of
there is no longer a need for external pressed around a balloon catheter by a cardiograms and fluoroscopic images of data must be quite rigorous to satisfy
blood circulation with a cardiopulmo- crimper to a diameter narrow enough each patient are examined from differ- the strict requirements on testing medi-
nary bypass machine. to fit inside the patient’s aortic valve. ent angles so that the team can set the cal claims.”
Navigation of an Edwards valve into the Meanwhile, the cardiac surgeon uses a valve precisely into position.” Kurashiki Central and two other hos-
correct location demands orchestration scalpel to open an entry port between If an aortic valve is positioned just mil- pitals – in Osaka and Sakakibara – are
of many components, including several the two ribs directly above the apex. limeters off-center of the aortic annu- now tracking the recuperation phase
high-tech imaging modalities, intensive After completing the purse string lus, a stent-in-stent procedure must be of some 50 patients who volunteered
planning and preparation, real-time sutures, the surgeon punctures the api- done, by slipping in a second wire-mesh for the heart valve trials. Among this
monitoring, and multidisciplinary col- cal area for insertion of an introducer ring to hold the first one firmly in place. cohort, some received Medtronic’s
laboration in ensemble. sheath. A temporary pacemaker lead is “In one of our earlier operations, a valve CoreValve, an aortic valve that is being
placed in the heart. The valve-bearing was positioned slightly incorrectly,” says implanted via the femoral arteries
Taking a Balloon Ride catheter is introduced through the Komiya. “Since we had doubts about instead of the apex of the heart.
Komiya points out: “The single most sheath. Turning the control knob, the its ability to maintain a grip, the team “The technique is rapidly developing,
important step is to align the valve ring operator then maneuvers the flexible did a stent-in-stent insertion.” That and Japanese patients and physicians
on the aortic annulus between the left catheter, curving it toward and into has held ever since, with no ill effects are expressing enthusiasm,” Komiya
ventricle and the proximal ascending the left ventricular outflow tract. After for the patient. “If a valve were ever to concludes. “This is a new frontier for
aorta. The valve must be precisely posi- checking the alignment on screen the dislodge, that could be disastrous,” he medical science and surgical practice
tioned on this line, neither too far in nor temporary pacemaker stimulates the adds. “Our recourse then would be the worldwide and here in Japan.”
too short of the mark.” left ventricle with up to 200 beats per immediate start of open-heart surgery.”
Echocardiograms, pre-operative CT minute. The heart contracts so rapidly Which does not pose any technical prob- Clark Shimazu is an environmental and technol-
and intra-operative syngo DynaCT that the cardiac output is minimized. lems - due to the fact that the operating ogy writer based in Chiang Mai, Thailand.

images provide the heart team with The balloon swells to enlarge the stent, room is a hybrid OR. The combined
a three-dimensional schema of the locking the bio-valve into place. The heart-valve unit provides quick backup
target region. The valve must also be pacemaker is stopped; the balloon is in any unlikely event.
perpendicular to the X-ray projection to deflated. The heart again pumps. “Among our patients, in one case,
Contact
capture the best real-time images of the The team watches to determine a coronary was obstructed by the Dr. Komiya explains the placement of the prosthetic heart valve. anne.figel@siemens.com
catheter’s progression. whether the Edwards valve is firm and valve expansion, so we had to switch

52 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 53
Surgery Hybrid OR Hybrid OR Surgery

An Innovative
Setting –
Hybrid Room 3D
Imaging Delivers
Groundbreaking
Care

The hybrid operating room at St.

Joseph Hospital in Orange County,
California, USA, allows cardiologists
and surgeons to transition seamlessly
from minimally invasive to open-
chest surgical procedures in the same
environment. The interdisciplinary,
multi-functional room maximizes
patient care, improves overall
outcomes and shortens hospital
stays.
More and more hybrid rooms are installed
By Diana Smith In 2010, St. Joseph Hospital became that has a significant elderly popula- demographics, it became imperative to
in surgery departments. St. Joseph Hospital
decided to go with the Artis zee system one of the first facilities in the United tion, which is continuing to experi- design a universal room that would be
based on robotic technology. States to unveil a hybrid operating ence explosive growth. The California highly utilized and provide faster, better
room, used to treat heart and vascular Department of Aging estimates that and more cost-effective care.
disorders in adult and pediatric patients. in 2010, one in five residents was 60 Today, in St. Joseph Hospital’s fully
The 525-bed hospital completes more years of age or older. That number is equipped hybrid surgical suite, physi-
than 7,000 cardiac and vascular proce- expected to increase significantly – 38 cians perform open, minimally invasive,
dures per year. percent in the next ten years*. As the image-guided and/or catheter-based
Located in densely populated Orange hospital contemplated build-out of its procedures, or a combination of pro-
County, the facility is located in a state operating room, evaluating volume and cedures at the same time, in the same

54 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 55
Surgery Hybrid OR Hybrid OR Surgery

operating room. The hybrid room images of the heart and vascular sys- floor- or ceiling-mounted systems.
incorporates groundbreaking three- tem are created with Artis zeego and A major benefit of the system is its large
dimensional technology, and is staffed Siemens syngo DynaCT software, result- volume cross-sectional imaging, with up
by a specially trained team of nurses, ing in a highly accurate 3D model that to 47 cm in diameter offering broader
radiological technicians and cardiovas- can be rotated freely in space on the coverage of the anatomy. Additionally,
cular technicians. workstation. With the advanced tech- clinicians in the hybrid room can adjust
For patients requiring complex proce- nology, physicians can precisely assess the working height of the system, there-
dures or for high-risk patients, such as and measure structural defects in the fore reducing fatigue and backache
those over age 80 with valve disease chambers, walls and valves of the heart associated with fixed heights, heavy
or those who have had multiple heart as well as blockages in the major blood lead aprons and lengthy procedure
and vascular surgeries, the hybrid room vessels and/or arteries. times, an especially important factor
is an optimal setting. Because of the The extreme level of accuracy helps when repairs can stretch into multiple
high-resolution and highly accurate 3D reduce duration of procedure by simpli- hours.
imaging available in the hybrid room, fying navigation when treating defects While the hybrid room is the most tech-
many of these patients are able to in the heart or aneurysms of major nologically advanced operating envi-
undergo minimally invasive procedures, blood vessels. As a result, many patients ronment, it has also been a model for
rather than major surgery, resulting in can be treated using minimally invasive maximum efficiency and clinical work-
the highest degree of safety, improved procedures instead of open surger- flow. Because it is set up for all kinds
recovery time, and less time in the ies that would have previously been of patients, the hybrid room has a high
hospital setting. required. Additionally, physicians report utilization rate, optimizing efficiency
that they are able to use significantly and workflow. The room is scheduled
A New Level of Imaging less contrast and take fewer images every day and used for all types of
St. Joseph Hospital’s hybrid operating because the quality and clarity is excep- vascular and cardiac procedures, includ-
room is equipped with a robotic, state- tional. According to St. Joseph Hospital ing percutaneous pulmonary artery
of-the-art imaging system, Artis zeego, staff, imaging in 3D has resulted in valve (Melody™ valve) insertion, plus
which provides excellent image quality improved outcomes, faster recovery overflow from the catheterization labs,
for interventional cardiology and car- times and less physical and emotional and even STEMI (ST-segment elevation
diac surgery as well as flexible system stress for patients and their families. myocardial infarction) patients.
positioning for anesthesiologists. The
system has an unrestricted positioning Multiple Capabilities, Diana Smith is a freelance writer specializing
ratio and acquires even three-dimen- Increased Efficiency in medical topics. She is based in Liberty Hill,
Texas, USA.
sional images. The exceptional imaging St. Joseph Hospital chose the Artis
technology allows physicians to perform zeego system for its exceptional tech- * Source: California Dept. of Aging,
www.aging.ca.gov/stats/
the most complex adult and pediatric nology, but the physicians and staff also oldest_old_population.asp
open heart surgeries as well as mini- enjoy the benefits of other features.
mally invasive procedures. It is one of Inspired by advances in automated
the few hybrid operating rooms in the manufacturing, the Artis zeego system
country with this capability. can be positioned exactly the way it is
Contact
To enhance clinical decision-making in needed and controlled with far greater
anne.figel@siemens.com
the hybrid OR, high-resolution, dynamic ease and precision than traditional

56 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 57
Customer Care Congresses and Events Congresses and Events Customer Care

Upcoming Congresses 2011 / 2012

Title Location Short Description Date Contact

Vascular & Endovascular

Charing Cross London, UK Apr 14 - 17 www.cxsymposium.com
Consensus Update
Annual Meeting,
We always would like to give you the the latest technological advances. You below you will find information on
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opportunity to get in “touch” with the will have the chance to experience our various events where we offer you the
Neurological Surgeons
real system and learn more about sys- technology at international congresses, opportunity to meet AX.
China International
tem handling to keep you in step with trade fairs, and workshops. In the list CMEF Shenzhen, China Apr 16 - 20 en.cmef.com.cn
Medical Equipment Fair
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Seoul,
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Title Location Short Description Date Contact South Korea
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Assembly and Annual Conference on Interventional
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of North America CIRSE)
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USA
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Symposium and Technologies
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Boston AF Boston, USA Jan 12 - 14 www.afsymposium.com/ Annual Scientific
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VE
Johannesburg, Healthcare Exhibition
Healthcare Exhibition Africa Health May 14 - 16 www.africahealthexhibition.com
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& Congress
EuroPCR Paris, France Cardiovascular Course May 15 - 18 www.europcr.com
Live Course, The Leipzig
LINC Leipzig Leipzig Jan 25 - 28 www.leipzig-interventional-course.de Deutscher Rönt- Hamburg, Congress, Deutsche
Interventional Course May 16 - 19 www.roentgenkongress.de
genkongress Germany Röntgengesellschaft
Annual Meeting,
Fort Lauderdale, www.sts.org/education-meetings/ Annual Meeting, Association
STS The Society of Thoracic Jan 30 - Feb 1
USA sts-annual-meeting AEPC Istanbul, Turkey for European Paediatric and May 23 - 26 www.aepc2012.org/index.php
Surgeons
Congenital Cardiology
Annual Conference,
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Germany SPINEWEEK organized by several spine May 28 - June 1 spineweek2012.com/
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associations
Annual Congress, European
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Annual Meeting, European
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WORLD CONGRESS Cardiac
Thoracic Surgery
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San Francisco,
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USA UKRC Manchester, UK UK Radiological Congress Jun 25 - 27 www.ukrc.org.uk
Radiology
Munich, Ger- Annual Congress, European
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Cardiology Annual Congress, Asian Ocea-
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nian Society of Radiology
Annual Conference, Deutsche
Mannheim, Gesellschaft für Kardiologie Annual Congress, Cardio-
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Germany -Herz- und Kreislaufforschung
e.V. Radiological Society of Europe

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© 2011 by Siemens AG, Berlin and Munich, All Rights Reserved
quickly find information relevant to your needs.
Publisher Antonio E. Dager, M.D., Tatsuhiro Komiya M.D.,
Siemens AG Bernardo Caicedo, M.D., Department of the Kurashiki Central
Medical Solutions Department of Cardiology, Hospital, Kurashiki, Japan
Medical Solutions Angiography & Interventional Angiographia de Occidente Clinic,
Innovation and trends eNews X-Ray Systems Cali, Colombia Darren Walters, M.D.,
in healthcare. The Our latest topics Siemensstr. 1, J. Crowhurst,
magazine, published such as product 91301 Forchheim, Germany Dario Echeverri, M.D., Department of Cardiology,
three times a year, is news, reference Miguel Ronderos, M.D., Prince Charles Hospital Brisbane,
designed especially stories, reports, Responsible for contents Department of Cardiology, Brisbane, Australia
for members of hos- and general Heinrich Kolem, Ph.D Fundación Cardioinfantil,
pital management, interest topics Bogotá, Colombia Rukshen Weerasooriya M.D.,
are always Chief editor Department of Cardiology,
administration per-
available at: Nadine Meru, Ph.D. Brendan Erskine, Hollywood Private Hospital,
sonnel, and heads of
www.Siemens.com/ nadine.meru@siemens.com Elissa Marshall, Perth, Australia
medical departments.
healthcare-news Department of Radiology,
Co-editor
The Alfred Hospital, Qiang Zhang, M.D.,
Sabine Wich
Melbourne, Australia Department of Diagnostic Radiology,
sabine.wich@siemens.com
Military General Hospital of Beijing PLA,
Editorial board Wan-Yuo Guo, M.D., Ph.D., Beijing, China
Anne Figel, Vera Jünnemann, Department of Radiology,
Taipei Veterans General Hospital, Production
Dirk Sunderbrink, Andrea Beulcke,
Taipei, Taiwan Michael Brumme
Thomas Hartkens, Anne-Eloise Cournut
Siemens Healthcare
Contributors to this issue David L. Lacey, M.D.,
Layout and editorial staff
Heike Theessen, Jingfeng Han, Department of Radiology,
Satzwerker – Jäger & Tuppi
Janina Beilner. Iowa Methodist Medical Center,
Karlsruhe, Germany
All at Siemens Healthcare Des Moines, Iowa, USA
Printer
Division of Vascular and Interventional Alan B. Lumsden, M.D., Rotaplan Offset Kammann Druck GmbH
Radiology Methodist DeBakey Hofer Strasse 1
Heart and Vascular Center, 93057 Regensburg, Germany
Anne Marie Cahill, M.D., The Methodist Hospital,
AXIOM Innovations MAGNETOM Flash SOMATOM Sessions Imaging Life Department of Interventional Radiology, Houston, TX, USA AXIOM Innovations on the net:
Everything from the worlds Everything from the world Everything from the world Everything from the world Children’s Hospital of Philadelphia, www.siemens.com/
of interventional radiology, of magnetic resonance of computed tomography. of molecular imaging Phiadelphia, PA, USA healthcare-magazine
Wolfgang Hohenforst-Schmidt, M.D.,
cardiology, and surgery. imaging. The magazine With its innovations, clini- innovations. This bi-annual
Institute of Internal Medicine,
This semi-annual magazine presents case reports, cal applications, and vision, magazine presents clinical
Klinikum Coburg, Coburg, Germany
is primarily designed for technology, product news, this semiannual magazine case reports, customer
physicians, physicists, and how-to’s. It is primarily is primarily designed for experiences, and product
researchers, and technical designed for physicians, physicians, physicists, news and is primarily Note in accordance with § 33 Para.1 of the Federal erally distinguishable from existing pathology. As “AXIOM Innovations” are cited. The editors request
personnel. physicists, and technical researchers, and technical designed for physicians, Data Protection Law: Dispatch is made using an referenced above, healthcare practitioners are ex- that two copies be sent to their attention. The con-
personnel. personnel. hospital management and address file which is maintained with the aid of an pected to utilize their own learning, training and sent of the authors and editors is required for the
automated data processing system. We remind our expertise in evaluating images. complete reprint of an article. Manuscripts submit-
researches.
readers that, when printed, X-ray films never dis- Partial reproduction in printed form of individual ted without prior agreement as well as suggestions,
close all the information content of the original. contributions is permitted, provided the customary proposals and information are always welcome;
For current and older issues and to order the magazines, please visit www.Siemens.com/healthcare-magazine Artifacts in X-ray, CT, MR and ultrasound images are bibliographical data such as author’s name and title they will be carefully assessed and submitted to the
recognizable by their typical features and are gen- of the contribution as well as date and pages of editorial board for review.

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