R obertY.R hee,M DR obertY.R hee,M DChief,VascularandEndovascularS urgery

Director,AorticCenter

M aim onidesM edicalCenter

BrooklynBrooklyn

Houston Aortic Sy m p osium 2017

• W L Gore:consultant,researchsupport,principalinvestigatorinvestigator

• Cook:researchsupport

M edtronic:researchsupport• M edtronic:researchsupport

• BostonS cientific:researchsupport,M AB• BostonS cientific:researchsupport,M AB

• GEHealthcare:consultant,researchsupport

Decem ber1948

Dr.R udolphN issen,chairm anofsurgery atM M C (1945-52),laterfam edforfundoplicationsurgery… .operatedonAlbertDr.R udolphN issen,chairm anofsurgery atM M C (1945-52),laterfam edforfundoplicationsurgery… .operatedonAlbertEinsteinforaAAA (w rappedtheaneurysm w ithcellophane)… … survived5yearspostopcellophane)… … survived5yearspostop

“ Dow hatyou can,w ithw hatyou have,w hereyou are”

~T heodoreR oosevelt~T heodoreR oosevelt

How tom akeendovascularproceduresm oresaferandeffectivem oresaferandeffective

T heFuture… 3D im agingforinterventions

W illbethestandardofcarew ithin5 years

HighDefinitionversusS tandardDefinitionHighDefinitionversusS tandardDefinition

9

FusionofpatientCTFusionofpatientCTintosim ulationunitintosim ulationunit

S im ulatedS im ulatedEVAR

T roubleshootbeforetheT roubleshootbeforetheoperation/procedure

2002 Ph illip sHOR ce iling m ount2002 Ph illip sHOR ce iling m ountUPMC, Pittsb urgh

2006 GE Innova HOR floorm ountUPMC, Pittsb urgh

Se im e nsArtisZ e e goSe im e nsArtisZ e e go

GE Discove ry 740

FusionGuidedEVAR /T EVAR

3D P recisionininterventions3D P recisionininterventions

R adiationDoseR eductionw ithCT A fusionR adiationDoseR eductionw ithCT A fusiontechniquestechniques

3D overlayCT Angio fuse d into p roce dure

P lannedL andingzones

O stium outline

O ptim izedC-armangulations

T ranslum barT ype2 endoleaktreatm ent

•70% ofallvascularproceduresperform edw ith70% ofallvascularproceduresperform edw ithendovascularapproach

•15% ofallO P EN vascularproceduresrequire•15% ofallO P EN vascularproceduresrequireim aginginconjunction

•FU T U R E...U pto90% ofallvascular•FU T U R E...U pto90% ofallvascularinterventioncouldbeendovascularinterventioncouldbeendovascular

•Hybrid O R is“ requiredequipm ent”

Geoffrey W hite R oy Greenberg

R educedDoseandContrastw ithIm ageFusion… .655

112.5

177.5 189159

312L illestudy

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S ailerAM etal.

44-47

105-120

150-205

45.5

112.5

65

Dose(DA P Gy.cm 2) Contrast(m l) P roceduretim e(m in)

44-47

Dose(DA P Gy.cm 2) Contrast(m l) P roceduretim e(m in)

L AO 13°-CAU 27°L AO 5°-CR A 25°

HaqqaniJVascS urg 2012

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A B C

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100%

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IQ +N orm al…

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R DL +N orm al…

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R DL +L ow …

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Interm ofdose,1 DS A im age ~ 100 fluoroim ages1 DS A im age ~ 100 fluoroim ages

45

• Standard EVAR (85 p atie nts)

• 6 ce nte rsworldwide

• Brooklyn• Brooklyn

• Lille, Toulouse

• Be lgium , Jap an, UK

• GE Discove ry IGS

• Each ce nte rh asre ce ive d a dose and

fusion im aging training b e fore e nrolling

p atie nts

• Monitoring dose and p ractice via• Monitoring dose and p ractice via

Dose watch , cloud-b ase d tracking

sy ste m

46GE Title orjob num b e r

2/25/2017

P restudy R esult:T heIm portanceofpracticefeedbacks

AfterP racticeanalysisand dedicated training…Number OfCases 8

30 Irradiated

Collimation(% of estimated collimated area per FOV)

Cases 8

Me an DAP 16.5Gy.cm ²

Me an AK 0.105Gy 30

0% 20% 40% 60% 80% 100%

Irradiated

Collim ated

Me an AK 0.105Gy

Me an Fluoro Tim e 14.05m in

Me an SID 1.15m

100%8%

18%

Acquisition Type(% of Total DAP)

Frame Rate(% of Total DAP)

Angulation(% of Fluoro Time & DAP)

FOV

(% of Total DAP)

32%

68%

100%19%

81%

68%

Fluoro DS A7.5

100%

30

74%

M edianA irKerm a M edianDA P M edianFluorotim e

S ite3

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M edianA irKerm a(m Gy)

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S ite4

M edianFluorotim e(sec)

0 50 100 150 200

S ite1

S ite2

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0 1000 2000 3000

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Achieving consistentlow doseresultsacrosssitesM edianAK< 110 m Gy,DAP < 15 Gycm 2M edianAK< 110 m Gy,DAP < 15 Gycm 2

• M ultim odality advancedim agingprovidestheinterventionalist a3Droadmap forinterventionroadmap forintervention

• S uccessofendovascularinterventions:P L AN N IN G andS IM U L AT IO N

• Integratedw orkflow ofplanningandintra-operative3D guidance• Integratedw orkflow ofplanningandintra-operative3D guidance

– DecreasesR adiation(topatientandoperater)

– DecreasesContrastU se

– DecreasesO R tim e(increasesO R efficiency)

– Decreasestim erequired forvascularinterventions

– S AFER forpatientsandstaff– S AFER forpatientsandstaff