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Results with intraoperative 3-D angiography
Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie
Universitätsklinik Heidelberg
Ärztlicher Direktor: Prof. Dr. D.Böckler
P. Geisbüsch, C. Schulz, D. Böckler
Disclosure
Research grant by Siemens AG
Speakers fee (Siemens AG)
Contrast enhanced cone beam CT
for EVAR evaluation
=
Completion „Dyna CT“
Dyna CT Aquisition
5s Protocol; 90 LAO - 110 RAO
Dyna CT Aquisition
5s Protocol; 90 LAO - 110 RAO
Dyna CT: Volume of Aquisition
19 cm
24 cm
19 cm
Standard EVAR ✔
FEVAR ✔
Iliac Side branch ✔
Branched Endografts ?
CTA DynaCT
Heidelberg experience
EVAR Patients: n=98, prospective patient cohort
Intraoperative Postoperative
DynaCT DSA CTA
Geisbüsch et al J Vasc Surg Submitted for publication
Study Objective
1. Detection of endograft related complications:
- Endoleaks
- Endograft limb stenoses
- Endograft limb thrombosis
2. Reduction of reinterventions
3. Radiation exposure (Phantom model)
4. Reduction of contrast agent
Detection of endoleaks
Endoleak Type DSA
(n= / %)
DynaCT
(n= / %)
CTA
(n= / %)
I 1
(1.0%)
2
(2.0%)
1
(1.0%)
II 15
(15.3%)
33
(33.7%)
21
(21.4%)
III - - -
total
(n=98)
16
(16.3%)
35
(35.7%)
22
(22.4%)
DSA DynaCT CTA Reintervention
Ia Ballooning Ia -
(Ia)* Ballooning Ia
(dorsal) Ballooning Ia
Endostapler
(neglected by patient)
II II II
Distal Stentgraft-
extension
(Typ Ib in CEUS)
*treated after DSA and not seen on control-DSA
Endoleak Typ I
DSA DynaCT CTA Reintervention
Ia Ballooning Ia -
(Ia)* Ballooning Ia
(dorsal) Ballooning Ia
Endostapler
(neglected by patient)
II II II
Distal Stentgraft-
extension
(Typ Ib in CEUS)
*treated after DSA and not seen on control-DSA
Endoleak Typ I
DSA DynaCT CTA Reintervention
Ia Ballooning Ia -
(Ia)* Ballooning Ia
(dorsal) Ballooning Ia
Endostapler
(neglected by patient)
II II II
Distal Stentgraft-
extension
(Typ Ib in CEUS)
*treated after DSA and not seen on control-DSA
Endoleak Typ I
DSA DynaCT CTA Reintervention
Ia Ballooning Ia -
(Ia)* Ballooning Ia
(dorsal) Ballooning Ia
Endostapler
(neglected by patient)
II II II
Distal Stentgraft-
extension
(Typ Ib in CEUS)
*treated after DSA and not seen on control-DSA
Endoleak Typ I
Endoleak Type DSA
(n= / %)
DynaCT
(n= / %)
CTA
(n= / %)
I 1
(1.0%)
2
(2.0%)
1
(1.0%)
II 15
(15.3%)
33
(33.7%)
21
(21.4%)
III - - -
total
(n=98)
16
(16.3%)
35
(35.7%)
22
(22.4%)
Endoleak Typ II
Endoleak Type DSA
(n= / %)
DynaCT
(n= / %)
CTA
(n= / %)
I 1
(1.0%)
2
(2.0%)
1
(1.0%)
II 15
(15.3%)
33
(33.7%)
21
(21.4%)
III - - -
total
(n=98)
16
(16.3%)
35
(35.7%)
22
(22.4%)
Detection of endoleaks
DSA DynaCT Intraoperative
Intervention CTA Reintervention
- 1 PTA -
- 1 Stentgraft
Implantation -
- 1 PTA 1 Stentgraft
Implantation
Endograft limb stenosis
DSA DynaCT Intraoperative
Intervention CTA Reintervention
- 1 Thrombectomy -
- 1 Thrombectomy -
- 1 Thrombectomy -
Endograft limb thrombosis
Reinterventionen Heidelberg Author (Year) Patients Protocol Radiation Dose
Intra-
operative
cDSA
Intervention
DynaCT
(n= / %)
Postoperative
Control
Method
Reinterven-
tions after
CTA / CEUS
Heidelberg1 n=98 5s, 200°2
248f3 40 x 30 cm4
43.7 ± 10.8
Gycm² X
7/98
(7.1%) CTA
2/98
(2.0%)
1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size
Literatur (Reintervention ceCBCT) Author (Year) Patients Protocol Radiation Dose
Intra-
operative
cDSA
Intervention
DynaCT
(n= / %)
Postoperative
Control
Method
Reinterven-
tions after
CTA / CEUS
Heidelberg1 n=98 5s, 200°2
248f3 40 x 30 cm4
43.7 ± 10.8
Gycm² X
7/98
(7.1%) CTA
2/98
(2.0%)
Hertault et al.
(2015)
Lille
n=54 8s, 200°
150f 30 x 30 cm
7 Gycm²
(5.25 - 8) -
17/54
(31.5%) CEUS
2/54
(3.7%)
Törnqvist et al.
(2015)
Malmö n=51
8s, 200° 397f
40 x 30 cm
70.6 Gycm²
(34.9 –
126.5)
X 4/59
(6.7%) CTA
3/51
(5.9%)
Dijkstra et al.
(2011)
Cleveland
n=19
8s 397f
-
0.55 ± 0.036
Gy -
6/19
(31.5%) CTA n.a.
Biasi et al.
(2009)
St. George’s
London
n=65 8s 200°
248f 40 x 30 cm
- X 5/65 (7.7%) CTA 0/65
1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size
Literatur (Reintervention w/o DSA) Author (Year) Patients Protocol Radiation Dose
Intra-
operative
cDSA
Intervention
DynaCT
(n= / %)
Postoperative
Control
Method
Reinterven-
tions after
CTA / CEUS
Heidelberg1 n=98 5s, 200°2
248f3 40 x 30 cm4
43.7 ± 10.8
Gycm² X
7/98
(7.1%) CTA
2/98
(2.0%)
Hertault et al.
(2015)
Lille
n=54 8s, 200°
150f 30 x 30 cm
7 Gycm²
(5.25 - 8) -
17/54
(31.5%) CEUS
2/54
(3.7%)
Törnqvist et al.
(2015)
Malmö n=51
8s, 200° 397f
40 x 30 cm
70.6 Gycm²
(34.9 –
126.5)
X 4/59
(6.7%) CTA
3/51
(5.9%)
Dijkstra et al.
(2011)
Cleveland
n=19
8s 397f
-
0.55 ± 0.036
Gy -
6/19
(31.5%) CTA n.a.
Biasi et al.
(2009)
St. George’s
London
n=65 8s 200°
248f 40 x 30 cm
- X 5/65 (7.7%) CTA 0/65
1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size
Literatur (Reintervention CTA) Author (Year) Patients Protocol Radiation Dose
Intra-
operative
cDSA
Intervention
DynaCT
(n= / %)
Postoperative
Control
Method
Reinterven-
tions after
CTA / CEUS
Heidelberg1 n=98 5s, 200°2
248f3 40 x 30 cm4
43.7 ± 10.8
Gycm² X
7/98
(7.1%) CTA
2/98
(2.0%)
Hertault et al.
(2015)
Lille
n=54 8s, 200°
150f 30 x 30 cm
7 Gycm²
(5.25 - 8) -
17/54
(31.5%) CEUS
2/54
(3.7%)
Törnqvist et al.
(2015)
Malmö n=51
8s, 200° 397f
40 x 30 cm
70.6 Gycm²
(34.9 –
126.5)
X 4/59
(6.7%) CTA
3/51
(5.9%)
Dijkstra et al.
(2011)
Cleveland
n=19
8s 397f
-
0.55 ± 0.036
Gy -
6/19
(31.5%) CTA n.a.
Biasi et al.
(2009)
St. George’s
London
n=65 8s 200°
248f 40 x 30 cm
- X 5/65 (7.7%) CTA 0/65
1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size
Literatur (Protokoll) Author (Year) Patients Protocol Radiation Dose
Intra-
operative
cDSA
Intervention
DynaCT
(n= / %)
Postoperative
Control
Method
Reinterven-
tions after
CTA / CEUS
Heidelberg1 n=98 5s, 200°2
248f3 40 x 30 cm4
43.7 ± 10.8
Gycm² X
7/98
(7.1%) CTA
2/98
(2.0%)
Hertault et al.
(2015)
Lille
n=54 8s, 200°
150f 30 x 30 cm
7 Gycm²
(5.25 - 8) -
17/54
(31.5%) CEUS
2/54
(3.7%)
Törnqvist et al.
(2015)
Malmö n=51
8s, 200° 397f
40 x 30 cm
70.6 Gycm²
(34.9 –
126.5)
X 4/59
(6.7%) CTA
3/51
(5.9%)
Dijkstra et al.
(2011)
Cleveland
n=19
8s 397f
-
0.55 ± 0.036
Gy -
6/19
(31.5%) CTA n.a.
Biasi et al.
(2009)
St. George’s
London
n=65 8s 200°
248f 40 x 30 cm
- X 5/65 (7.7%) CTA 0/65
1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size
Literatur (Protokoll) Author (Year) Patients Protocol Radiation Dose
Heidelberg1 n=98 5s, 200°2
248f3 40 x 30 cm4
43.7 ± 10.8
Gycm²
Hertault et al.
(2015)
Lille
n=54 8s, 200°
150f 30 x 30 cm
7 Gycm²
(5.25 - 8)
Törnqvist et al.
(2015)
Malmö n=51
8s, 200° 397f
40 x 30 cm
70.6 Gycm²
(34.9 – 126.5)
1Geisbüsch et al J Vasc Surg submitted for publication, 2rotation, 3f=frames, 4detector size
Phantom Model: Effective Dose
Dyna CT vs CTA
• RANDO Alderson Phantoms
Thermo-Luminescent Dosimeters
(TLD)
• BMI ≈ 22 kg/m² + BMI ≈ 30 kg/m²
• Same field of view (FOV) for both
modalities
Geisbüsch et al J Endovasc Ther. Submitted for publication
Single Phase
CTA, abdominal
FOV
Three Phase CTA,
Thoracoabdominal
FOV
DynaCT
BMI ≈ 22 kg/m² 2.0 9.6 3.5
BMI ≈ 30 kg/m² 2.1 10.1 5.1
All values are given in mSv according to IRCP 103
- 64 %
Phantom Model: Effective Dose
Dyna CT vs CTA
Geisbüsch et al J Endovasc Ther. Submitted for publication
Reduction of
„in hospital use of contrast“
Conclusion
Reliable detection of endograft related complications
Immediate correction of intraoperative complications in a
relevant proportion of patients (7%)
Potential to further reduce reintervention rates
Reduces in hospital use of contrast and radiation exposure
Optimal protocol needs to be defined
Conclusion
Standard Follow-Up
Completion
DSA
CTA
Secondary Reintervention
Conclusion
Standard Follow-Up Standard Follow-Up
Completion
DSA
Completion Dyna CT
CTA
Secondary Reintervention
Immediate Revision
Duplex / CEUS
+
-
Results with intraoperative 3-D angiography
Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie
Universitätsklinik Heidelberg
Ärztlicher Direktor: Prof. Dr. D.Böckler
P. Geisbüsch, C. Schulz, D. Böckler