from siemens

1. 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

2. Editorial
“Keeping image quality
high and radiation
dose low is one of the
key drivers in the
development of our
imaging portfolio.”
Dr. Heinrich Kolem,
CEO of the Angiography & Interventional X-Ray Business Unit (AX)
at Siemens Healthcare
2 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

3. Editorial
Dear Reader,
Dr. Heinrich Kolem
CEO AX Division
Earlier this year, I had the opportunity to patients. They are also key drivers for possibility especially for high-risk
attend the Cardiovascular and Interven- our development. We know that our patients who cannot undergo open sur-
tional Radiological Society of Europe’s customers carry a lot of responsibility gery. New innovative applications such
(CIRSE) annual conference in Munich. for each individual patient they treat. as syngo Aortic ValveGuide* help sur-
The CIRSE is one of the most renowned In return, it is our responsibility to offer geons and cardiologists replace calcified
conferences for interventional imag- reliable systems to support our cus- aortic heart valves with more guidance
ing. There were approximately 6,000 tomers worldwide. We are constantly and a new automated workflow.
attendees eager to learn about the lat- exploring new possibilities to reduce
est technologies and advances in their dose without compromising image qual- 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
how many visitors were interested in line of thought, “Low Dose - High Prin- to present to you this issue of AXIOM
our products and solutions. For the first ciples.” Our dose saving initiative with Innovations. You can read more about
time, we showcased how “The Future is CARE (Combined Applications to Reduce CARE technology, new functionalities in
Flexible” with the Artis zeego, our multi- Exposure) and CLEAR (an imaging tech- endovascular and thoracic surgery, and
axis C-arm system based on robotic nology to enhance visualization with many other innovative topics. Enjoy!
technology. We introduced the Hybrid IR X-ray) not only reduces radiation dose
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.
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 3

4. Content
26
16 Enhanced Endoleak
Content Radiation Reduction
is Key in Pediatrics
Treatment Through
Improved Navigation
10 A long-term commitment 3 Editorial
to reduce radiation dose
Siemens has long been a leader in
addressing the need to provide opti-
mal images at the lowest possible 6 News
radiation dose following the ALARA
principle. Many institutions world-
wide working with Siemens angio-
graphy systems use the CARE 10 Cover Story
applications in their daily routine
when imaging patients of all ages. Low Dose, High Principles:
It is most importatnt to them to Cardiac CARE for All
keep radiation dose low, especially A Report from Fundación
for children and also their own staff. Cardioinfantil in Colombia
A Pediatric Radiologist's Approach
to Radiation Reduction
Interview with Dr. Anne Marie
Cahill, Children's Hospital of
Philadelphia
Treatment of Complex Head and
Cover Neck Malformation in an Infant
Clinical Case
Imaging of temporal
mandibular joint with
reduced radiation dose. CAREposition
Courtesy of Anne An Evaluation of Radiation-Free
Marie Cahill, M.D.,
Department of
Positioning
Interventional
Radiology,
Children´s Hospital
of Philadelphia, 61 Imprint
Pennsylvania, USA
4 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

5. Content
32 42
syngo Neuro PBV IR Helps During Advanced Technology Revolutionizes
Revascularization Treatment Endovascular Surgery
Angiography 38 Minimally Invasive Aortic Valve 54 An Innovative Setting –
Implantation Offers New Hope to Hybrid Room 3D Imaging Delivers
26 Endoleak Treatment: Stenotic Patients Groundbreaking Care
Enhanced Visualization Meets Interview with Dr. Antonio Dager St. Joseph Hospital in California
Enhanced Navigation at Angiographia de Occidente in chooses an interdisciplinary
syngo iGuide facilitates better Colombia approach to maximize patient care
Workflow
30 Quantitative Evidences of Surgery Customer Care
Hemodynamic Improvement of
Brain Arteriovenous Malformation 42 3D Imaging Brings a New Vision 58 Upcoming Congresses &
after Surgical Intervention to Endovascular Surgery Workshops
Clinical case Interview with Dr. Alan Lumsden,
Director of the Methodist Hospital 60 Subscription & Information
32 Revascularization Treatment DeBakey Heart and Vascular Center
of Acute Cerebral Stenosis in Houston
Clinical case
48 Accuracy Far Beyond Conventional
Pneumological Practice
Cardiology Dr. Hohenforst-Schmidt pioneers
new navigation techniques in
34 Overlay of MRI Images pneumology
in Pulmonary Vein Isolation
A clinical evaluation 48 Navigation in the Lung
by Prof. Rukshen Weerasooriya Clinical Case
36 Accurate Placement 50 Heart Valve Replacement –
of Aortic Valves Significant Changes Thanks to
Clinical case Hybrid Surgery
Dr. Tatsuhiro Komiya talks about
new surgical procedures
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 5

6. News
Less Radiation During
Catheter Interventions
Siemens’ Artis zee® angiography system has
recently integrated the MediGuide Technology
from St. Jude Medical, a medical positioning
system that visualizes the position of a catheter
without radiation.
Like a GPS system, the MediGuide Technology
locates the catheter during cardiac interventions
and projects its precise position in real time on
a previously acquired fluoroscopy image of the
patient. During electrophysiological interventions,
a miniaturized sensor integrated into the catheter
can be located by receiving electromagnetic posi-
tioning signals from the MediGuide transmitters,
which are incorporated into the detector housing
of the Artis zee system. The MediGuide Technology
then calculates the respective position and orien-
tation of the catheter and displays it in real time
on fluoroscopic images of the patient that were
recorded earlier. The technology also compensates
for patient movement caused by respiration and
heart motion.
The MediGuide Technology provides significant
benefits especially during complex electrophysi-
ological procedures. The electrophysiologist no
longer has to take fluoroscopic images of the
patient each time the catheter is re-positioned.
As a result, less radiation and less contrast agent
use is expected.
The Heart Center Leipzig, Germany, has already
performed the first interventions with Artis
zee and the MediGuide Technology. “The low-
radiation, precise localization of the catheter tip
onto the pre-recorded fluoroscopy image is a most
impressive function, because the system is able to
compensate the motion from the heart beat and
breathing,” said Professor Dr. Gerhard Hindricks,
Director of the Rhythmology Department. “For my
team and me, this is clearly the future in electro-
physiology.”
Localization of the catheter supported by MediGuide Technology
and EnSite Velocity Mapping System.
6 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

7. News
Integrated FFR Calculation Saves
Space and Time
The measurement of fractional
flow reserve (FFR) helps to deter-
mine the hemodynamic signifi-
cance of a coronary stenosis and
to guide balloon and stent place-
ment. FFR is being measured by
comparing the blood pressures
distal (behind) and proximal (in
front) to a lesion. Once this ratio
reaches 0.75 or below, a stenosis
is considered hemodynamically
significant and a stent placement
is recommended.
The FAME study published
in 2009 (N Engl J Med 2009;
360:213-224) evaluated FFR-
guided CAD treatment and
clearly found an increase in
patient survival of 30 % while at
the same time treatment costs
decreased by 30 %.
St Jude Medical and Volcano
offer FFR measurement solu-
tions in the cath lab that now
have been fully integrated with
the Siemens AXIOM Sensis XP
recording system, which offers
simple plug&play connectivity
and makes using an external
workstation obsolete.
For getting the new FFR mea-
surement capabilities, AXIOM
Sensis XP software must be
upgraded to the latest software
version due for release at the
end of 2011. The FFR option can
already be ordered today and will
become available with the new
software version.
All systems in the field currently
running software version VC10
will be upgraded free of charge to
VC11 starting in spring 2012. AXIOM Sensis XP running VC11 software and FFR option.
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 7

8. News
A New Era: Hybrid Operating Rooms
in the American Hospital
As one of the most modern hospitals where TAVI (Transcatheter Aortic Valve
not only in Turkey but the entire region, Implantation) procedures have recently
the American Hospital in Istanbul begun to be performed with the use
continues its leading role in hybrid of the Artis zeego system and Siemens
operating room practices with the syngo DynaCT Cardiac software,
recently installed Siemens Artis zeego procedures can be completed more
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
Dr. Genco Yücel, Department of Cardiology, recording system (Siemens AXIOM in high regard not only in Turkey but in
in front of the department’s new Artis zeego. Sensis XP), etc., are used. At the center neighboring countries as well.
Hybrid OR With Trumpf Table Opened
at Clinical Center Ludwigsburg
Since 2010, Siemens optionally delivers Artis zeego or Artis
zee ceiling with the TruSystem 7500 OR table by Trumpf.
In May 2011 another hybrid operating room with Trumpf´s
OR table and Siemens Artis zeego went live at the clinical
center Ludwigsburg, Germany – meanwhile this is the sixth
installation worldwide that combines an Artis system with a
Trumpf OR table. The room at the clinical center Ludwigsburg
is located in a brand new building as part of a 35 million euro
project to build one of the most modern surgical centers in
Germany with altogether 9 fully digital connected operating
rooms. With this new hybrid OR, patients will benefit from
fewer shifts during the procedures, less radiation because of
faster and fewer acquisitions, and fewer complications since
the success of the intervention can be verified right in the OR
at the end of the procedure.
Siemens is also going to offer a similar integration of the
Artis zeego and Artis zee ceiling with Maquet OR tables in View of the new hybrid operating room in Ludwigsburg with the Trumpf
early 2013. TruSystem 7500 OR table and Siemens Artis zeego.
8 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

9. News
Siemens Integrates
Maquet’s Magnus OR Table
for Hybrid ORs
1 2
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
top supports complex procedures in advanced positions. in endovascular procedures.
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-
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.
three fully integrated table systems. This It flexibly adjusts to even complicated Of course Siemens will continue to
means synchronized C-arm and OR table positions of the segmented table top. offer the tried-and-true family of fully
movements, 2D and 3D imaging, all with This flexibility also allows free access integrated Artis zee tables. They are
a single integrated operation module. from any side, with a comfortable space available in three different versions: the
And the right table for surgical require- for the anesthetist and his equipment. standard table, table with tilt, and the
ments in the hybrid OR. If open procedures without imaging OR table with tilt and cradle. The carbon
The key benefit of the new solution is equipment are performed, Artis zeego’s table tops allow for high-end imaging,
the multidisciplinary use of the hybrid multiple park positions allow for maxi- including 3D. The Artis table family is
OR – which means it will allow for both mum space in the OR field. the solution of choice for cardiac and
interventional imaging and for open Equipped with an additional floating vascular procedures providing an exten-
procedures where extremely flexible carbon table top, the integrated solu- sive longitudinal travel range, full body
patient positioning may be required. tion enables full cath lab functionality. coverage and a free floating radiolucent
The Magnus OR table is fitted with The table top provides 360° radio- table top.
exchangeable table tops – a fully radio- translucency for superb X-ray images,
lucent carbon top (Fig. 2) as well as a including 3D. A transport system
highly flexible, segmented table top ensures the easy exchange of the table
(Fig. 1). The latter allows surgeons the tops. The patient can be prepared and
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
including complicated positions, induction area ensuring ahead of time available in the U.S., and its future availability cannot
occurring especially in orthopedics maximum efficiency for the OR. be ensured.
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 9

10. Cover Story CARE
Low Dose,
High Principles:
Cardiac CARE for All
10 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

11. CARE Cover Story
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
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 11

12. Cover Story CARE
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
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
sistent ductus arteriosis, a congenital using Siemens’ state-of-the-art “low
condition that, without a procedure to dose” interventional imaging technol-
close the ductus, would have proved ogy. The hospital has four Siemens Artis
fatal by her mid-teens. systems that – with their advanced
Nelsy, whose mother and ten-year old software and imaging innovations – can
brother both died of heart disease, will dramatically cut the radiation exposure
be brought to Bogotá free of charge of patients like Nelsy, compared with
from her home 300 miles away, a poor what they would have received a few
fishing village on Colombia’s southwest- years ago.
ern Pacific coast. She and her father will Each system is bundled with Siemens’
be put up in the clinic’s housing and, proprietary CARE (Combined Applica-
despite the fact that they have no way tions to Reduce Exposure) applica-
to pay the hospital bills, Nelsy will be tions that can help to decrease typical
“The Siemens given the kind of care that has made exposure in catheterization labs. It does
engineers have Fundación Cardioinfantil a private,
nonprofit institution, a beacon of car-
that by providing a broad range of dose
saving applications, enhanced monitor-
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
giving individual throughout the Caribbean and Cen- allows doctors at Fundacion Cardioin-
tral America, and from as far away as fantil to tailor treatment to a patient’s
training to our Florida and Peru. It also takes on scores specific age, weight and diagnosis.
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
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,”
minimizing the Making the Safety Factor a
said Dr. Ronderos. Additionally he states
the better the imaging, the less time he
radiation used in High Priority spends diagnosing the condition and
The procedure in the hospital’s heart placing coils, stents and heart valves.
a given exam catheterization lab to close the ductus That reduces the patient’s and the medi-
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
additional pneumonia in the coming years and for the operator as well as the patient.
give her a good chance of leading a Medical staff who administer the pro-
measures of long, healthy life, says Miguel Ronde- cedures are concerned about their own
ros, MD, a cardiologist who trained at risk as well.
radiological University of Alabama-Birmingham and Making angiography safer has been a
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
12 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

13. CARE Cover Story
A Vision of Improved Healthcare Access
Fundación Cardioinfantil’s history began in brigades – teams of a half-dozen doctors and
1971 when two Colombian doctors, brothers nurses – to seek out sick children in remote,
Reinaldo and Camilo Cabrera, returned home poverty-stricken areas of the country. Now,
from completing their medical training at the about eight times a year, the brigades hold
Texas Heart Institute in Houston determined two-day cardiovascular clinics at partner
to address the inequalities of their country’s hospitals from one end of the country to the
healthcare. High on their list of concerns was other where young patients in need gather.
the incidence of congenital heart defects, Two months prior to each visit, the founda-
affecting one in every 100 babies. In devel- tion’s community relations department starts
oped countries, such defects are easily getting the word out via radio announce-
diagnosed and treated, but they too often ments and posters that any family who has
proved to be death sentences in Colombia. a child with possible heart problems will be
Poverty and difficult geography make access examined for free. It was in one such brigade
to quality medical care an impossible dream visit held at Pasto’s Hospital Los Angeles in
for much of the population. May that Ronderos diagnosed Nelsy, one
With the help of ex-president Carlos Lleras of 400 young people who lined up for an
Restrepo, the new physicians opened the pre- examination, and put her on the list of kids
decessor of today’s foundation in a corner of to be brought to Bogotá. She and her father
Bogotá’s Misericordia Hospital, a charity clinic traveled eight hours by boat and four hours
for children, specifically to offer cardiovascu- by bus to get to the examination site.
lar care to poor youth in the urban area. They Fundación Cardioinfantil’s staff examine
relied on donations of services, equipment, about 4,000 poor young people per year
cash and eventually land from the city of during these outreach clinics. Of those,
Bogotá, where the current 300-bed hospital 250 children and adolescents, or about
is situated. 20 percent of all the children examined,
As it grew, the clinic broadened its mission to are subsequently brought to the hospital
include children who could pay for treatment for heart surgery or angiography at the
as part of a scheme by which paying patients bustling Bogotá hospital, free of charge.
helped subsidize care for the poor. Later, as For their service to Colombia, the Cabrera
the clinic’s reputation for quality care spread, brothers were decorated in July 2010 by
adult heart patients were admitted, also to then-president Alvaro Uribe with the Order
help subsidize treatment for poor children. of Boyaca, the highest national honor
Adults now comprise about 70 percent of the attainable by a Colombian civilian. One of the
caseload. doctors, Reinaldo Cabrera, died in November
In 1986, the Cabrera brothers decided to pro- 2010, but his brother Camilo continues to
vide care to young patients for whom a trip to be active and currently is the director of the
Bogotá for life-saving treatment was impos- foundation.
sible. The hospital began organizing outreach
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 13

14. Cover Story CARE
Combined Applications to Reduce Exposure:
An Integrated Answer to Dose Reduction the imaging and visibility of devices.
CAREvision: pulsed fluoroscopy application that provides extremely Over the last five years, Siemens syngo
low frequencies to meet individual dose-saving targets. Pulses can DynaCT has made soft tissue imaging
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
reduction is achieved. additional soft tissue information in
the interventional suite and thus get a
CAREfilter: a variable CU-filter (0.1 mm – 0.9 mm) is automatically set better understanding of the structure of
according to the current transparency of the object/C-arm angulation, the vessels and organs they are dealing
without any necessary interaction from the user. Dose reduction: up with.
to 50 %. Dr. Dario Echeverri, who heads Funda-
CAREposition: positioning without repeated fluoroscopy. The feature cion Cardioinfantil’s catheterization lab
is especially needed during long-lasting neurointerventions that can and who is also the current president
take several hours as the provider can control patient positioning of the Latin American Society of Inter-
without the need for additional fluoroscopy. ventionist Cardiology, said the CARE
application “CAREguard” is especially
CAREprofile: radiation-free adjustment of collimators as well valuable because it tracks radiation skin
as radiation-free semitransparent filter parameter setting. Dose dose thresholds of patients and medical
reduction: Up to 9 %. staff and sounds a warning if they are
CAREguard: a new real-time application that monitors skin dose exceeded.
exposure and allows for effective skin dose control. Three separate “It allows us to do a continuous follow-
thresholds can be defined with warning indicators that alert up of the radiation dispersed by the
for length of exposure time. The feature reduces exposure for machines and helps us reduce exposure
radiologists, technicians, and patients. to patients and MDs, nurses and techni-
cians working in the lab,” Echeverri said.
Low Dose Acquisition: additional low dose protocols that can be
Cognizant of the importance of low
accessed hands free, directly from a footswitch. These tools can
dose imaging, Siemens sends a free
reduce radiation dose by 67 %.
update of the latest software VC14
Low Dose syngo DynaCT: an optional feature, offers CT-like 3D including all CARE (Combined Applica-
imaging for radiosensitive patients and others. As an example, 5 sec tions to Reduce Exposure) and CLEAR
protocol can be done at 0.1 µGy/frame instead of 0.36 µGy/frame, (image quality) features to all customers
which results in a 72 % reduction. of its Artis zee angiography systems
around the world.
CAREreport: a structured dose report that contains all patient Siemens’ advances now enable doctors
demographics, procedure, and dose information. Using commercially to reduce the number of times a typical
available programs or in-house software, this information can be heart patient has to undergo imaging
filtered for further processing, such as dose analysis. exams. A decade ago, Nelsy might have
had to undergo three different proce-
dures during her stay at Cardioinfantil:
one to diagnose, a second to treat her
limiting dosage while enhancing image quality images are now captured at disease, and a third to confirm success.
quality. Improved safety is doubly criti- 7.5 frames per second, down from 30 But the likelihood now is that a single
cal because of the expanding range of frames previously, making possible a procedure will suffice.
diagnoses and treatments for which 75 percent reduction in radiation dur- “Nowadays, we must be much more
angiography is now used, going far ing the procedure. CAREreport offers a careful with our exams in arriving at a
beyond its original cardiovascular appli- running account of radiation dispersed diagnosis,” Dr. Ronderos said. “Each day
cation to include neuro and abdominal along with the patient’s demographics, we are more aware of the importance to
interventions and surgeries. procedure and dose information. health of the cumulative dose of radia-
The low dose equipment is achieving tion over the course of a lifetime and,
that goal with a variety of innovations. A Two-Way Flow of Information with the Siemens technology we have,
Proprietary technology pulses radia- But there is more than that to low combined with our understanding and
tion instead of emitting continuous dose. Efficiency gains from powerful quality of the imaging, we can minimize
fluoroscopy. With CAREvision, high new Siemens software have improved exposure in a given exam.”
14 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

15. CARE Cover Story
Fewer procedures also mean a patient says Echeverri, because he, Ronderos
receives fewer injections of contrast and other medical staff operate the
agent, which if overused can damage machines themselves without specially
kidneys. trained technicians.
As one of a dozen Siemens “reference “We want the relationship with Siemens
sites” at leading hospitals in Latin to go far beyond buying and selling
America and the Caribbean, Fundación equipment. We want Siemens to help us
Cardioinfantil has become a key prov- in an integral way with training, market-
ing ground for Siemens’ low dose ing and advice, a friend who will help
imaging initiative in the region. The distinguish the foundation. The Low
clinic also has become an incubator for Dose Workshop with Siemens was very
more intensive relationships between encouraging, and it produced concrete
Siemens product managers and the results,” says Echeverri.
medical professionals who use the In exchange for going the extra mile,
company’s equipment. The company Siemens is allowed to bring prospec-
and its clinical customers see such close tive clients to Cardioinfantil to see
relationships as a necessity, given the the systems in action, and even bring
high stakes in cardiovascular care: the in doctors and nurses from foreign
life-saving benefits of cutting-edge ther- countries to receive training on the
apies as well as the potential hazards of machines. Siemens also gets important
the imaging devices. feedback that is incorporated into the
“Over the last year, a real two-way flow systems’ software and design. A bonus
of information with Siemens has begun, for Siemens is its association with one “CAREguard
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
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
token, we offer suggestions on design prematurely. follow-up of the
improvements to better protect the Attesting to Fundación Cardioinfan-
patients and people who work in the til’s high standards is its cooperation radiation
room.” Those suggestions have included
smaller tables to accommodate child
arrangement with the Cleveland Clinic,
which sends medical staff to Bogotá
dispersed by the
patients and design changes for protec-
tive clothing.
once a year to conduct professional
seminars.
machines and
The advances of the Artis zee system “Most companies just want to sell helps us reduce
give Dr. Echeverri added flexibility in machines and there is usually a discon-
devising different protocols “according nect between the sales and technical exposure to
to the patient and his or her condition, staff of these companies. Siemens is
instead of using the same program for changing that trend. Together we are patients and
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
Ronderos: “The Siemens engineers have “We have come to a nice arrangement.” technicians
helped a lot in giving individual train-
ing to our personnel with the goal of Chris Kraul is a freelance writer based in Bogotá, working in the
minimizing the radiation used in a given Colombia, covering stories a wide range of top-
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
of radiological protection.” Bureau Chief at the newspaper’s Bogotá office.
In February, Siemens brought in experts Dario Echeverri, M.D.,
to the clinic from Germany to lead a Department of Cardiology, Fundación
dose and radiation workshop on safe Cardioinfantil, Bogotá, Colombia
Contact
operation of the angiography sys-
vera.juennemann@siemens.com
tems. That was an important gesture,
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 15

16. Cover Story CARE
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

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

18. Cover Story CARE
doses are constantly measured and has experienced three major benefits of only are fewer images necessary using
the user can set the parameters to site- the Siemens products in their ability to Overlay Reference, but the images are
specific values. If pre-defined skin dose image at the lowest possible radiation obtained at a lower radiation level.
levels are exceeded, an audible warn- doses: Store Fluoro, Overlay Reference, Therefore, radiation is decreased as
ing sounds, and a skin dose indicator and Low Dose syngo DynaCT. compared to traditional applications that
flashes on the live display. A warning Store Fluoro enables the user to store a relied upon traditional fluoroscopy.
pop-up is also prominently displayed on regular fluoro scene during a procedure During common vascular imaging, radia-
the touchscreen of the system’s table- for documentation instead of doing a tion dose is decreased because, as Cahill
side control, which is located within the new acquisition. Cahill explains that this states, “We can do an angiogram and
interventional radiologist’s view during functionality allows her to decrease the save a specific image and then overlay
the procedure. Radiation exposure lev- number of acquisitions she requires as that image onto the live fluoro. Later
els can be generated with CAREreport, compared to previous clinical methods. that image can be used to track smaller
and they can also be archived in the She can save images on the display arteries. This process saves radiation
PACS system along with the procedural monitor instead of obtaining further because we do not perform roadmaps
images. Cahill and her colleagues regu- images and exposing the patient – and (comprehensive tracking of blood flow
larly take advantage of this feature by staff – to additional levels of radiation. through the vasculature) as much as we
providing patients with radiation infor- Prior to having this capability, it would used to.”
mation when reviewing clinical results. have been necessary for her to acquire
additional images to assure she had all C-arm CT and Joint Injections
Clinical Applications of the information she needed before The Children’s Hospital of Philadelphia
for Low-Dose Imaging the patient left the interventional also uses syngo DynaCT to reduce radia-
Cahill has worked closely with Siemens radiology suite. tion exposure in patients who require
in developing C-arm CT protocols that Similar to Store Fluoro, Overlay Refer- imaging where the radiation dose is a
provide 3D information in the inter- ence can decrease the number of particular concern. C-arm computed
ventional radiation suite at very low images acquired as compared to previ- tomography permits joint injections
radiation doses. She reports that she ous clinical imaging methods. Not with the use of CT and fluoroscopy and
AVM nidus extending from T6 to L1 supplied by a left intercostal artery
1 2 3
1 Conventional intercostal artery angiogram 2 VRT (Volume Rendering Technique) 3 Embedded MPR Image of AVM nidus
18 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

19. CARE Cover Story
“Store Fluoro allows
us to decrease the
omits an additional dose of radiation latter is used to determine the relation-
number of acquired
from traditional CT. Cahill references her ship of the airway to the treated lesion images. With the
research using C-arm CT, which shows to help decide if the patient's breathing
that radiation doses can be significantly tube can be safely removed post proce-
Store Fluoro
decreased when treating and evaluat- dure. In vascular malformation therapy functionality we can
ing patients with temporal mandibular this helps clinicians determine whether
joint (TMJ) disorder. She explains that the breathing tube can be safely
save images on the
radiation savings are largely obtained by removed from patients who are asleep display monitor
reducing the need to acquire traditional under general anesthesia.
computed tomography examinations In addition, vascular anomalies are instead of obtaining
following interventional treatments. treated using Low Dose syngo DynaCT further images and
TMJ disorder commonly requires as well, and the radiation savings – also
patients to receive repeated injections about 50 percent of conventional CT – is exposing the patient,
once or twice a year, and the radiation largely obtained once again by omitting and staff, to
dose savings adds up during the course a post-procedural traditional CT. One of
of treatment. Pediatric TMJ patients are the major advantages of treating vascu- additional levels of
one specific group where imaging with lar anomalies in this fashion is that the radiation.”
the ALARA principle is crucial because success of the sclerotherapy procedure
of the repeated radiation exposure of a can be evaluated immediately after the
vulnerable area, the jaw, because of its procedure by the same interventional Anne Marie Cahill, M.D., Department
of Interventional Radiology, Children’s
proximity to the eyes and thyroid. radiologist at the same location, which
Hospital of Philadelphia, PA, USA
Joint injections are a common applica- is an efficient use of hospital resources
tion of C-arm CT because of the ability and an excellent means to improve
to image at very low dose. Dr. Cahill patient satisfaction to their clinical care.
estimates based on phantom studies The importance of dose savings –
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
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
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
Contact
vascular malformation therapy, whereby
heike.theessen@siemens.com
the intermittent imaging used in the
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 19

20. Cover Story CARE
Treatment of Complex Head and Neck
Lymphatic Malformation in an Infant
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
was diagnosed with a large neck mass the lymphatic malformation epithelium provided by the sclerotherapy agent we
on prenatal ultrasound. Prenatal MR that eventually leads to scarring and are able to reduce the dose provided
imaging was performed demonstrat- regression of the lesion. The second by our typical syngo DynaCT to 6 % of
ing a 5.7 cm by 2.7 cm left neck mass. and third sclerotherapy procedures used the manufacturer setting and 50 % of
The patient was delivered at CHOP Low Dose syngo DynaCT imaging to conventional CT.
via Caesarean section for concern of confirm sclerotherapy distribution in the In the future, syngo DynaCT can be
airway compromise. The baby boy lesion. The syngo DynaCT was acquired used to direct procedures. By identifying
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

21. CARE Cover Story
1
1 Axial T2 weighted MR image demonstrating
the macrocystic lymphatic malformation left neck.
2
2 Correlating axial syngo DynaCT image
demonstrating the distribution of the
sclerotherapy agent throughout the lesion
when compared to the MRI. Note the close
proximity of the sclerotherapy agent and
lesion to the airway guiding post-procedure
therapy, resulting in the patient remaining
intubated post-procedure.
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 21

22. Cover Story CARE
Evaluation of CAREposition:
Radiation-Free Positioning with
CAREposition Results in a Decrease
in Screening Times
Brendan Erskine, and Elissa Marshall from the Department of
Radiology, The Alfred, Melbourne, Australia have conducted a
study on the potential of CAREposition to reduce the fluoroscopic
screening time during various diagnostic procedures. The study
was presented as a paper: “Evaluation of Siemens CAREposition,
Radiation-Free Positioning For Angiography and Fluoroscopy” at
the ASMIRRT 2011 conference.
by Brendan Erskine and Elissa Marshall
Introduction savings, not to investigate dose minimi- Other techniques for reducing screening
CAREposition is a Siemens functionality zation. While a reduction in screening time,
that enables accurate repositioning of time will result in lower patient dose,
the patient under visual control without ultimately dose is a product of many • Last Image Hold (LIH) holds the last
radiation exposure. Guidance is pro- factors, beyond the scope of this study, fluoroscopic image on the viewing
vided by a centrally positioned crosshair such as: monitor and incorporates radiation-
marking the central beam while the free collimation and wedge filter
collimated field of view (FOV) is visually • Patient habitus placement
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-
• Detector quantum efficiency (DQE) ing the screening time, this software
Background • Pulsed fluoroscopy functionality may indirectly reduce
CAREposition functionality is aimed • Adaptive dose filtration by the screening time and patient dose by
purely at reducing fluoroscopic screen- application of copper/aluminum allowing the storage of fluoroscopic
ing time and therefore the primary prefiltration sequences instead of formal (higher
focus of this study was to quantify these dose) angiographic sequences
22 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

23. CARE Cover Story
Table 1: Screening Times Pre & Post CAREposition
30:00
Mean Screening Time (min)
25:00
20:00
15:00
pre CAREposition
post CAREposition
10:00
05:00
00:00
Aorto-femoral Angiography ERCP
Femoral Angiography PICC Line Insertion
AV Fistulography Gastrografin Swallow
AV Fistula – Interventional Defecating Proctography
Tunneled Line Insertion Pain Management
Jugular Vonoplasty Video Swallow
Erskine Brendan and Marshall Elissa, Dept. of Radiology, The Alfred, Melbourne, Australia
• Some fluoroscopic systems especially as the difficulty of laser visualization Methods
mobile image intensifiers (I.I.) incor- in brightly lit rooms and refraction Screening times from procedures per-
porate the use of I.I. mounted laser of the laser through plastic I.I. cov- formed on all angiographic and fluoro-
guidance to assist positioning without ers. Also, accurate positioning of the scopic machines were obtained over a
the need for radiation. This relatively laser is made more difficult on heavily six month period. At the trial midpoint,
cheap method of image guidance draped patients. three multipurpose fluoroscopic/angio-
suffers from many drawbacks such graphic machines were enabled with
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 23

24. Cover Story CARE
Table 2: Screening time measurements during diagnostic and interventional procedures
Procedure Case Numbers PRE CAREposition POST CAREposition
Endoscopic retrograde
94 04:52 03:42
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
Arterio-venous (AV) fistulography –
19 01:06 00:49
Diagnostic
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
wide spread of results. To obtain the results.
• Siemens AXIOM Artis MP most accurate data, only procedures
(fluoroscopy) (diagnostic or interventional) with Discussion
• Siemens AXIOM Artis MP standardized imaging and relatively […] CAREposition appeared most
(angiography) high case numbers were chosen. These beneficial in the scenario of sequen-
• Siemens AXIOM Artis dMP procedures along with results are dem- tial diagnostic imaging of peripheral
(fluoroscopy/angiography) onstrated in Table 1. vasculature, whereby accurate overlap
between acquisitions could be achieved
All machines employed remote (pedes- Study limitations with minimal fluoroscopy. Aorto-femoral
tal) C-arm/table controls ran exclusively Since we are primarily a teaching insti- diagnostic angiographic studies saw a
by the radiographer. Our main angio- tution, it is likely that even without the 7 % reduction in screening time (3:26
graphic machine, a Siemens Artis zee use of CAREposition we might have to 3:11 min), with single leg diagnostic
biplane, had CAREposition licensing observed a small reduction in screen- studies demonstrating a 21 % reduction
from installation and was therefore ing times given increasing experience (1:30 to 1:11 min). A similar result was
excluded from the trial. of both medical and allied staff. Also, demonstrated for diagnostic AV fistulog-
Although data from approximately despite the six month trial encompass- raphy, where a 26 % reduction (1:06 to
2,200 procedures were obtained, ing approximately 2,200 fluoroscopic/ 0:49 min) was observed. Several exam-
the variability of fluoroscopic and angiographic procedures, a greater ples for procedures are listed in Table 2.
angiographic procedures (particularly period of data collection would have When operators gain confidence in the
24 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

25. CARE Cover Story
1a 1b 1c
1 Utilization of CAREposition during three angiographic procedures:
a Trans-jugular liver biopsy
b Cerebral angiography
c Femoral angiography
accuracy of CAREposition functionality, ing time was demonstrated, however, lization of CAREposition has resulted in a
huge reductions in screening time could noting our case numbers were small. modest decrease in screening times for
be achieved. Such was highlighted when A much larger result was demonstrated a range of diagnostic procedures with
reliance exclusively on CAREposition for in jugular venoplasty procedures. This greatest benefit being demonstrated
guidance of angiographic positioning in interventional procedure was chosen when used in sequential diagnostic
three peripheral diagnostic studies com- because it provided the largest subject imaging of peripheral vasculature.
prising 19 separate acquisitions, were group of all the interventional proce-
achieved with totals of only 4, 6 and 8 dures and involved standardized imag- Thanks to the following angiographers for their
seconds fluoroscopy time […] ing of both internal jugular veins and assistance in compiling procedural data: Jane
Chow, Karen Patel, Alix Fell, Wayne Chan, Neal
[…] screening times in interventional azygos system with subsequent angio- Russell, Lisa Broadley.
procedures are heavily dependent on plasty of stenosed vessels, providing us
both the patient pathology and the with a more accurate reflection of the
skill of the clinician. Although difficult benefits of CAREposition.
to quantify, CAREposition appeared
extremely useful in complex and chal- Conclusion
lenging interventional procedures CAREposition provides radiation-free flu-
especially when multiple working oroscopic and angiographic positioning
projections were employed. In the with the use of graphic markers overlaid
Contact
angiographic intervention of AV fistulas on the fluoroscopic last image hold.
vera.juennemann@siemens.com
only a small reduction (5 %) in screen- Our study has demonstrated that the uti-
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 25

26. Angiography syngo iGuide
Endoleak Treatment:
Enhanced Visualization
Meets Enhanced Navigation
Diagnostic CT scan showes an Endoleak Type II. The CT images are fused with the syngo iGuide allows you to place target and
syngo DynaCT dataset. skin entry point on the CT image, which is
overlaid onto the syngo DynaCT.
1 2 3
syngo iGuide integrated needle guidance The endovascular repair of abdominal
aortic aneurysms (EVAR) with stent
enables vascular surgeons and grafts has surged in popularity over
interventional radiologists to efficiently, the past decade, dramatically reduc-
ing the amount of recovery time for
precisely, and effectively treat type II patients in comparison with open repair.
endoleaks, one of the most vexing However, approximately one-third1 of
patients who undergo EVAR will have
complications following endovascular an endoleak, a condition in which
abdominal aortic aneurysm repair. blood flows outside the lumen of the
endograft but within the aneurysm sac,
By Sameh Fahmy, MS potentially increasing the risk of rupture.
In type II endoleaks, aortic branches that
26 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

27. syngo iGuide Angiography
syngo iGuide
provides a
bull's eye
view and pro-
gression
views for
optimal nee- After reaching the target a catheter will be A DSA scene shows clearly all endoleak related
dle tracking. placed in the endoleak. vessels. The feeding vessels will be embolized
with various coils and Cordis Trufill n-Butyl
Cyanoacrylate glue.
4 5 6
have been excluded by the endograft, pital DeBakey Heart and Vascular Center syngo DynaCT, the solution frees up
such as the lumbar arteries and the in Houston, Texas, USA, and Professor of the hospital’s computed tomography
inferior mesenteric artery, perfuse the Cardiovascular Surgery at Weill Cornell (CT) scanners for routine diagnostic
aneurysm sac via retrograde blood flow. Medical College of Cornell University. imaging and enhances workflow by
Type II endoleaks are the most common In July 2010, Lumsden and his collea- eliminating the need to transfer the
endoleak and can have multiple feeding gues began using syngo iGuide inte- patient during the procedure. “The most
and draining vessels that make their grated needle guidance, a software important thing for us is that the aneu-
treatment challenging. “Sometimes solution that enables physicians to per- rysm stops growing,” says Lumsden,
when we get referred to these patients, form needle procedures more precisely who uses the multi-axis Artis zeego.
they may have had three or four trans- and efficiently using the Artis zee family “And in the majority of patients that
femoral attempts at blocking the en- of C-arm systems. Because the planning we have treated with syngo iGuide, the
doleak off,” says Alan Lumsden, MD, of the procedure is accomplished using aneurysm has stopped growing and the
Medical Director of the Methodist Hos- cross-sectional images acquired with endoleak has gone away.”
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 27

28. Angiography syngo iGuide
Interventional radiologists such as much shorter amount of time. Detailed
David Lacey, MD, at Iowa Methodist anatomical information is obtained with
Medical Center in Des Moines, Iowa syngo DynaCT, and the images are fused
report similar promising results. “I’m with a diagnostic CT that was obtained
more apt to be able to select small ves- earlier. To define the needle path, physi-
sels and embolize them, and our results cians mark the needle target point in
have been very good,” says Lacey, who the CT dataset and then mark the loca-
in 2008 became one of the first users of tion of the skin entry point. By scrolling
syngo iGuide in the USA. through the multiplanar reformations,
physicians can follow the needle path
Saving Time easily and verify that there are no vital
and Streamlining Workflow structures, such as the inferior vena
The two most common approaches cava, in the way of the planned path.
for treating type II endoleaks are the syngo iGuide automatically proposes
transarterial approach, often via trans- two needle progression views, in which
femoral access, and direct translumbar the planned path is graphically overlaid
puncture. The success rate of the tran- onto the fluoroscopic image. The needle
sarterial approach is low, with up to 80 is advanced under fluoro guidance, and
percent recurrence rate due to the com- an additional syngo DynaCT run is per-
plexity of endoleaks and the potentially formed in slab mode to check the final
circuitous route.2 position of the needle. Once the needle
“The transfemoral approach has been position is verified, the physicians per-
tried and largely has failed,” Lumsden form the embolization.
says. “The idea behind the translum- Lacey estimates that the use of syngo
bar procedure is that instead of going iGuide reduces the time it takes to per-
through multiple feeding branches, you form the procedure by an hour, while
go right where they all come together Lumsden notes that it may save even
and work into those feeding branches more time in particularly complicated
from inside that. The access in trying to cases. “The last one we did probably
“In the majority of go transfemoral or transmesenteric is took an hour,” Lumsden says. “Before, it
patients that we very long and torturous; some catheters probably took two to three hours.”
can’t even get to them.” In addition to the measurable reduc-
have treated with Lacey explains that before Iowa Meth- tion in time associated with the use of
syngo iGuide, the odist Medical Center began using syngo syngo iGuide, the elimination of patient
iGuide with its ceiling-mounted Artis transfer from the CT has the theoretical
aneurysm has zee, he and his colleagues would use a advantage of maintaining sterility, since
stopped growing translumbar approach and advance the physicians no longer have to transfer a
needle into the endoleak cavity using CT patient with a wire extending from the
and the endoleak fluoroscopy. After confirming that the aneurysm sac, out the patient’s back,
has gone away.” needle was in position by the pulsatile and to the outside world.
return of blood, the physicians would A CT scanner can be used for many
exchange the needle over a guidewire, diagnostic scans in the time it takes to
Alan B. Lumsden, M.D., Medical Director secure the wire with tape, and then complete a single needle procedure, so
Methodist DeBakey Heart and Vascular
transfer the patient to the interven- the elimination of the CT scanner for
Center, The Methodist Hospital,
Houston, TX, USA tional radiology angio suite. The patient needle guidance also has clear finan-
would then be re-prepped before physi- cial benefits. Lacey points out that the
cians used the guidewire to advance a increasing use of interventions such as
catheter under fluoroscopic guidance CT biopsies and CT ablations has put
into the endoleak cavity, where coils additional scheduling demands on the
and glue are used for the embolization. scanners at Iowa Methodist Medical
With the installation of syngo iGuide, Center, making any technology that
however, the entire procedure is per- reduces demand for the CT scanners
formed in the angio suite – and in a especially welcome.
28 AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine

29. syngo iGuide Angiography
Lacey points out several components of these feeding vessels.”
syngo iGuide that he says reflect a level The physicians say the power of the
of refinement not seen in similar needle technology is evident by the ease with
guidance systems. The ability to obtain which it handles challenging cases.
a control scan after the needle has been Lacey points out that he often encoun-
placed helps ensure accuracy by auto- ters aneurysm sacs that measure less
matically correcting for patient motion than a centimeter. The difficulty of
or even the deformation of tissues accessing them is compounded in larger
“The 3D overlay lets caused by the pressure of the needle on patients, who in many cases require a
the skin. The Artis zee ceiling-mounted 20-centimeter needle. “That’s a long
you look at any an- system he uses is equipped with an way to go to get an accurate placement
gle to figure out integrated laser crosshair that precisely with a needle, but it turns out to be
marks the skin entry point. This reduces pretty easy to do with this system,” he
how to best navigate radiation dose by eliminating the need says. “I’m always impressed that I can hit
the otherwise un- for fluoroscopy to match the needle tip that target, often in just one pass, using
with the path in the bulls-eye view and this system.”
predictable pathway improves ease of use. After acquiring The physicians say that long-term
into this lesion.” the initial syngo DynaCT scan to define follow-up and several additional cases
small structures, Lacey uses syngo will be required to quantify improved
DynaCT in low-dose mode to further patient outcomes using syngo iGuide,
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,
Once the endoleak site has been ising. Lacey says the success in treating
Des Moines, Iowa, USA
accessed, Lacey uses an additional tool type II endoleaks at Iowa Methodist
known as syngo iPilot to overlay a 3D Medical Center has already led to refer-
syngo DynaCT angiography image on rals. In one recent case, the referring
the live fluoro as he navigates the cath- physician tried and failed to treat the
eter. “The 3D overlay lets you look at any patient using conventional tools and
angle to figure out how to best navigate sent the patient to Iowa Methodist,
the otherwise unpredictable pathway nearly four hours away.
into this lesion,” Lacey says. “It allows Lacey adds that syngo iGuide is so easy
you to very quickly and easily pick off to use that it can give physicians who
the supplying vessels and really helps lack significant experience or confi-
you address the full extent of the leak.” dence with needle procedures the abil-
ity to successfully perform procedures,
Handling Challenging Cases including type II endoleak repairs, that
with Ease they might otherwise find challenging.
Lumsden says that using conventional Using syngo iGuide is so simple, he
techniques, most physicians are quite says, “It’s kind of like cheating.”
happy just to get the needle into the
aneurysm sac. The precision that syngo Sameh Fahmy, MS, is an award-winning free-
iGuide enables, however, allows physi- lance medical and technology journalist based
in Athens, Georgia, U.S.
cians to enter the aneurysm sac at a
location that maximizes their likelihood 1 Baum RA, et. al. Endoleaks after Endovascular
Repair of Abdominal Aortic Aneurysms J Vasc Inerv
of embolizing the vessels that are feed-
Radiol 2003; 14:1111-1117
ing the endoleak. 2 Baum et al. Treatment of type 2 endoleaks after
“If you have two lumbar arteries that are endovascular repair of abdominal aortic aneu-
rysms: comparison of transarterial and translumbar
feeding into the aneurysm and we enter techniques. J VascSurg 2002; 35:23–29.
right alongside one of them, we can’t
bend the catheters around to get to it,”
Lumsden explains. “So one of the things
we’re looking at is trying to choose
Contact
the trajectory that will give us the best
heike.theessen@siemens.com
opportunity to catheterize and block off
AXIOM Innovations · November 2011 · www.siemens.com/healthcare-magazine 29