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08
www.siemens.com/healthcare-magazine Issue Number 8/October 2008
08
Siemens S.A., Medical Solutions
Editorial board
Monika Böhmer
Oslo, Norway
John P. Harris, MD
Charles E. Winn, MD
Basel, Switzerland
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2 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine 49
Editorial
Dear Reader,
Dr.-Ing. Norbert Gaus
President AX Division
To be ahead of the game, you have to the high risks involved. Also, after a cal experiences in interventional imag-
spot upcoming trends early enough to minimally invasive procedure patients ing and X-ray await you in this edition
act on them. This goes without saying do not need to stay in intensive care as of AXIOM Innovations.
both for you, our customers, and for us long as they do after normal surgery.
at Siemens Healthcare. So the Artis zee family for interven- I hope you enjoy reading this issue.
At Siemens, we like to keep you on the tional imaging is finding its way into I can tell you I did.
forefront of technology so you can zee the OR. But that is not all you can read
more and therefore do more. about in this edition of AXIOM Inno-
One fast growing trend is minimally vations. Recently, Siemens acquired a
invasive surgery performed in so-called new company and further extended
hybrid rooms, where high-end imaging our product portfolio. Together with Dr. Norbert Gaus
and surgery come together. Surgeons the technology and the products of
have already recognized this and are CAS Innovations, we are now able to
active in bringing minimally invasive offer electro-magnetic needle guid-
procedures with interventional imaging ance. Now it is possible to precisely
to their operating rooms. This combina- place electrodes or biopsy devices and
tion enables procedures that give hope guide them to the region of interest
to a lot of very sick patients who could very accurately and without radiation.
not undergo surgery before because of These and many more topics, e.g clini-
14 22
Content New Treatment Possibilities
for Cardiac Surgery
Electromagnetic Needle Guidance
14 Special
Treatment Methods
Cover
Percutaneos Nephrostomy
for an Obstructed Ectopic 49 Imprint
Pelvic Kidney
Courtesy of Warren Swee,
MD, MPH
26 38
Improved Efficiency Pediatric Imaging
in the EP Lab with AXIOM Luminos TF
24 State-of-the-Art Imaging
Technology in South America- 38 Therapeutic Relief of Sigmoidal
Neurosurgery Institute of Santiago Volvulus under Fluoroscopy
in Chile installs first biplane system Clinical case
with high-end 3D imaging
Artis zeego
Robotic Technology
with Human Benefits
With the introduction of the Artis zeego, the first
multi-axis C-arm system based on robotic tech-
nology from Siemens Healthcare, physicians at
Oslo’s Rikshospitalet are achieving new levels of
flexibility, efficiency and 3D imaging quality in
a wide range of clinical environments, from cardi-
ology, body and neurointerventional radiology
suites to high-end imaging in the OR.
By Nils Lindstrand
Rikshospitalet: A Leader in
Medical R&D
have bought an LED system designed hitting the lamps.” full support of the C-arm wherever they
for follow-spots in the theater. This al- The lighting system is not yet complete- need to move around the patient.
lows us to place the operating lamps at ly finished; the software still has to be “Surgeons have been striving for many
a greater distance, thus giving ourselves further developed. But when the project years to get better access to the patient
and the C-arm a better chance to move is finished, the surgeons will finally be when operating,” says Fosse. “With Artis
without blocking the light, and avoiding able to get both good lighting and the zeego and the new lighting system, we
“Surgeons have
been striving for
will really have come a long way expertise and technology are scattered,
towards the optimal solution.” you always are at risk of losing precious many years to get
time if something needs to be adjusted.
The Artis zeego decreases that risk.”
better access to
Artis zeego: A Versatile Tool The Artis zeego C-arm offers better sup- the patient when
port for physicians across any clinical
Artis zeego could be considered the environment, from body and neuroint- operating. With
ultimate technological answer to the erventional radiology suites to ORs and
development of new procedures and hybrid rooms. The adjustable isocenter Artis zeego and
new working environments like the
hybrid room. When hospitals bring radi-
enables off-center rotational angiogra-
phy for all parts of the body. 3D imaging
the new lighting
ology and cardiology together with the
surgeons, the flexibility and imaging ca-
techniques include Siemens technolo-
gies like syngo DynaCT, syngo iPilot and
system, we will
pacities of the Artis zeego provides the syngo iGuide. really have come a
optimal support for the team at work. syngo iPilot enables faster and more
“The new technologies help us to create precise catheter navigation through 3D long way towards
better hybrid rooms,” says Fosse. “Well-
functioning hybrid rooms mean we can
roadmapping that superimposes 3D re-
constructions onto live 2D fluoroscopy
the optimal
save lives, and allow us to always
choose the least invasive procedures.
images, 2D roadmaps or digital subtrac-
tion angiography (DSA). The application
solution.”
This means less risk for the patient and provides real-time updates of C-arm and
Erik Fosse, MD, Head of the Interventional
shorter hospitalization as well as huge table movements, as well as changes in Center, Rikshospitalet, Oslo, Norway
cost savings for society.” zoom and source-to-image distance.
Radiologists and cardiologists have been syngo iGuide is designed to bring nee-
performing more and more advanced dle procedures back into the interven-
interventions, and even though they tional suite, allowing them to be execut-
perform them well, this means greater ed faster and with greater confidence.
risks if the planned procedure needs to All in all, the Artis zeego C-arm has re-
be changed for any reason. moved numerous obstacles for the doc-
Hol is equally positive about working in tors at Rikshospitalet in their pursuit of
the hybrid room, and agrees that the the ideal environment for invasive pro-
new technologies such as Artis zeego cedures. It’s a happy combination of ad-
mean new ways to improve procedures. vanced technology that benefits physi-
“By combining knowledge and technolo- cians and patients alike.
gies from radiology, cardiology and sur-
gery, we may even develop new tailor- Nils Lindstrand is a freelance business, medical
made procedures and techniques,” he and technology writer based in Stockholm,
Sweden.
says. “It is also a major improvement
that the advanced imaging systems can
give you immediate confirmation that Contact
the procedure was performed correctly georg.nollert@siemens.com
and gave the expected results. When
Surgery
Opens up to
New Treatment
Methods
Recent developments in cardiac
surgery have led to new therapies
integrating surgical procedures
with skin incisions and interventions,
e.g. transcatheter techniques with the
puncture of a vessel. For these proce-
dures, integrated operating rooms are
needed. In addition to surgical equip-
ment, these hybrid operating rooms
need high-end imaging equipment
equivalent to the angiography devices
used in interventional radiography
and cardiology.
By Prof. Dr. Georg Nollert
Imaging devices have been used in operating theaters for a long time.
Mobile C-arms, ultrasound, and endoscopy are standard of care for many
operations. However, complex transcatheter techniques demand high
powered equipment to visualize thin guidewires, quantify small vessel
diameters, and evaluate delicate anastomoses. Because of their size and
complexity, these integrated endovascular suites or hybrid ORs require
special consideration, planning, and design as well as new skills to be
learned by the surgical team.
Basics of the hybrid room If a fixed C-arm system is being consid- tween pediatric cardiology and pediatric
ered, 45 m2 space is the lower limit. cardiac surgery, currently the strongest
There is no doubt that an interdisciplin- Lead shielding (2-3 mm) will need to be driver for hybrid therapies is transcathe-
ary team of surgeons, interventionalists, built into existing rooms. In some coun- ter replacement of the stenotic aortic
anesthesiologists, and other associated tries, special training for the use of valve.
specialists should plan and run such a X-ray devices may be required.
facility. Centers in close proximity to in- In general, all members of the team
tervention rooms and ORs probably have need access to all important informa- Trends in pediatric cardiac
better prerequisites than hospitals with tion. Therefore, multiple moveable and surgery
the classic separation that placed inter- flexible booms need to be installed in
ventional rooms in the internal medicine the operating room. If there are two Surgery remains the treatment of choice
building and operating theaters in the booms to be installed, a boom on every for most congenital cardiac malforma-
surgery building. In this situation, it is side of the OR table serves the opera- tions. But interventional cardiology ap-
recommended to install the hybrid room tive team. Collision of the ceiling- proaches are increasingly being used in
in the surgical wing, where all OR equip- mounted displays with operating lights simple and even complex lesions. The
ment and personnel (e.g. heart-lung or other ceiling-mounted equipment percutaneous approach can be challeng-
machine and perfusionists), anesthesia should be avoided. A dedicated ceiling ing due to low patient weight or poor
and surgical intensive care are readily plan with all ceiling-mounted compo- vascular access. The passage of large
available. Reasonable proximity of the nents including air conditioning should catheters through the heart in small in-
hybrid room to other imaging systems be drawn to ensure the function and fants may result in rhythm disturbances
like computed tomography scanning or usability of all devices. and hemodynamic compromise. Diffi-
magnetic resonance imaging should cult and complex anatomy such as in
also be taken into consideration. double-outlet right ventricle or transpo-
A hybrid OR should be larger than a New therapies have emerged sition of the great arteries, or acute
standard OR and the basic principle for turns or kinks in the pulmonary arteries
planning is “the larger the better”, be- Pediatric hybrid operations, hybrid coro- in tetralogy of Fallot patients can make
cause not only the imaging equipment nary revascularization, transcatheter percutaneous procedures challenging if
needs sufficient space. Staff calcula- valve replacement and repair, or stent- not impossible. Surgery also has its limi-
tions have shown that in hybrid proce- graft placement in the thoracic aorta tations, when it comes to operative clo-
dures up to 18 people need to be in the are new developments that are ideally sure of multiple apical muscular ventric-
hybrid room. Experts recommend 70 m2 performed in a hybrid operating room. ular septal defects, adequate and lasting
for new ORs being built. Additional Although hybrid therapies were first de- relief of peripheral pulmonic stenosis, or
space for a control room is mandatory. veloped in a close collaboration be- management of a previously implanted
1 2 3 4
stenotic stent. Furthermore, in some tion of the aorta, which reduces the creased transfusions. Six-month angio-
complex malformations, the presence of chance of potentially fatal emboli, and graphic vessel patency and major
multiple ventricular septal defects in- the low surgical trauma by using mini- adverse cardiac events were similar in
creases the mortality risk, because they mally invasive techniques. Hybrid revas- the hybrid and off-pump coronary
are difficult to access by surgery. Com- cularization is currently performed only artery bypass groups. These clinical ad-
bining interventions and surgery into a in a few centers worldwide. One reason vantages will probably lead to a spread
single therapeutic procedure reduces is the real challenge regarding logistics, of hybrid revascularization techniques
complexity, cardiopulmonary bypass because an interventional and surgical when hybrid rooms become more com-
time, risk, and improved outcomes. team have to work together, and the en- monly available.
vironment in which to perform this
therapy – a hybrid room – is scarce. But
New possibilities for heart in the end, a higher number of repeat Trends in transcatheter
patients interventions compared with off-pump valve therapy
coronary artery bypass grafting was
Surgical and percutaneous coronary ar- seen, because the stented vessels had a Transcatheter valve therapies are cur-
tery interventional revascularization are higher occurrence of restenoses. How- rently developed for the most common
traditionally considered isolated op- ever, with the advent of drug-eluting valve diseases: mitral valve regurgita-
tions. A simultaneous hybrid approach stents, the reintervention rate de- tion, aortic stenosis, and – in children –
may allow an opportunity to match the creased. A recent feasibility study from pulmonary valve disease. For repair of
best strategy for a particular anatomic the University of Maryland evaluated 13 mitral regurgitation, more than 30 de-
lesion. Revascularization of the left an- patients with multi-vessel coronary ar- vices are currently under investigation
terior descending artery with the left in- tery disease who underwent left inter- and await market approval. Experimen-
ternal mammary artery is by far the best nal mammary artery-to-LAD minimally tally, prostheses for mitral und tricuspid
treatment option in terms of long-term invasive direct coronary bypass per- valve replacement are under develop-
results. Integrating this therapy with formed through a lateral thoracotomy, ment and certainly will be available
percutaneous coronary angioplasty of- followed by stenting of non-LAD le- within the next several years.
fers multi-vessel revascularization sions, in a fluoroscopy-equipped operat- Aortic stenosis is the most frequent ac-
through a mini-thoracotomy. Particular- ing room. These patients had a more quired heart valve lesion in developed
ly in high risk patients, morbidity and than 40% decreased length of stay and countries. Conventional aortic valve
mortality decreases compared to con- a more than 90% decrease in intubation replacement for aortic stenosis is based
ventional surgery. Reasons are the times. Despite aggressive anticoagula- upon standardized guidelines with ex-
avoidance of cardiopulmonary and its tion and confirmed platelet inhibition, cellent outcomes particularly in younger
bypass-related morbidity, no manipula- the patients had less blood loss and de- patients at relatively low risk. Advanced
5 6
age and severe co-morbidities lead to an nary artery ostia, and a wide mesh transapical valve implantations using
increased surgical risk. Cardiologists are allowing for unobstructed coronary an oversizing technique were published
reluctant to refer these patients to sur- flow. The Edwards Sapien prosthesis in summer 2006. When both tech-
gery, because they are considered to be has a 14 – 16 mm balloon-expandable niques are compared, stroke risk was
‘too sick’, although conservative treat- straight-tube steel stent, mimicking a demonstrated to be lower with the
ment of aortic stenosis carries a fatal standard stented bioprosthetic valve. It transapical approach, which could be
prognosis. Low-risk, minimally invasive is strictly deployed within the aortic an- related to less aortic manipulation. A
techniques are needed to treat these nulus and sits in a subcoronary position second important complication of TAVR
very high-risk patients. in vivo. With regard to the leaflet cusps, is the high incidence of AV block, which
the CoreValve device is constructed is obviously valve-dependent and re-
of porcine pericardium, whereas the ported to be higher with the CoreValve.
Transcatheter aortic valve Edwards Sapien device utilizes bovine ATS, JenaValve, Sorin, and Ventor,
replacement (TAVR) pericardium. Three generations of the among other companies, are currently
CoreValve device have been implanted, conducting experimental evaluations
In 2002, Cribier reported the first the 24F, 21F, and now the 18F prosthe- and are on the verge of clinical implan-
human transcatheter aortic valve re- ses. Two inflow diameters, 26 and tations. Further systems for TAVR includ-
placement (TAVR) using a transfemoral, 29 mm, are available, allowing for suffi- ing the Lotus, AorTx, the Direct Flow
antegrade, transseptal approach. cient oversizing. With the Edwards Sapi- Medical valve and the PercValve are un-
Subsequently two valves were intro- en valve, diameters of 23 and 26 mm der development and further systems
duced to the market, i.e., the CoreValve are offered. A 29 mm prosthesis is un- will follow.
and the Edwards Sapien prostheses der development. Current sheath diam- For TAVR, valve positioning remains the
(Fig. 1 and 2)1 . eters for transfemoral implantation are most critical part of implantation with
Both valves have some similar funda- 22F and 24F, with smaller versions on the risk of coronary artery obstruction
mental design features, including xeno- the horizon. Implantations have been and the risk of paravalvular leak. Exact
genic pericardial valve cusps and a performed using both the transfemoral positioning, optimal imaging during im-
compressible stent suspending these and the transapical route with each de- plantation and an experienced team
cusps allowing for transcatheter deliv- vice. Up to now, more than 1,000 pa- performing the procedure are critical.
ery. There are, however, significant tients have received a CoreValve or an TAVR requires some specific equipment.
differences. The CoreValve prosthesis Edwards Sapien prosthesis. In parallel A hybrid operative theater is the ideal
has an approximately 50 mm long self- with the development of the transfem- setting for TAVR and is recommended by
expanding nitinol stent, with a tubular oral technique (Fig. 3), the direct, the European Association for Cardio-
‘hour glass’ shape that can deploy in the antegrade, transapical technique was Thoracic Surgery. The hybrid OR offers
aortic root, above the level of the coro- explored (Fig. 4). The first successful the sterile environment with emergency
7 8
7 Flexibility and whole body coverage is provided by the 8 Flexible park positions, variable iso-center and new 3D
Artis zee ceiling-mounted solution. imaging capabilities are possible only with Artis zeego.
back-up measures and the angiographic ventional surgery with cardiopulmonary its flexible patient access, outstanding
imaging technology needed in the cath- to the less invasive catheter techniques. 3D imaging capabilities and its variable
eterization laboratory. Excellent imag- iso-center make Artis zeego an ideal
ing capabilities are the most important A whole new spectrum system for imaging in the OR.
criterion for exact valve positioning and of therapies
thus optimal patient outcome. The over- References
all setting of a hybrid operative theater The hybrid operating room facilitates a 1. Walther T, Chu MW, Mohr FW. Transcatheter
is of specific value most importantly whole new spectrum of cardiac surgical aortic valve implantation: time to expand?Curr
Opin Cardiol. 2008 Mar;23(2):111-6.
when emergency cardiopulmonary by- therapies and will therefore become an
pass or conversions to conventional sur- essential resource of every cardiac cen- 2. Vahanian A, Alfieri OR, Al-Attar N, Antunes
gery are required. This life-saving effect ter. The trend towards hybrid tech- MJ, Bax J, Cormier B, Cribier A, De Jaegere P,
Fournial G, Kappetein AP, Kovac J, Ludgate S,
has certainly been demonstrated in niques is more a revolution than an evo- Maisano F, Moat N, Mohr FW, Nataf P, Pierard L,
some of the current studies. In addition lution. Stanford University is already Pomar JL, Schofer J, Tornos P, Tuzcu M, van
to the environment, a dedicated team of including catheter techniques into train- Hout B, von Segesser LK, Walther T. Transcathe-
ter valve implantation for patients with aortic
cardiologists, cardiac surgeons, anes- ing of cardiovascular surgeons. Within stenosis: a position statement from the Europe-
thetists, scrub nurses, and technicians only two years the majority of all Ger- an Association of Cardio-Thoracic Surgery
are necessary for successful TAVR. In man heart centers started planning a (EACTS) and the European Society of Cardiology
(ESC), in collaboration with the European Asso-
some centers the same integrated team hybrid OR. Cardiac surgeons around the ciation of Percutaneous Cardiovascular Inter-
performs both transfemoral and world emphasize that cardiac surgery is ventions (EAPCI). Eur J Cardiothorac Surg. 2008
transapical approaches. moving rapidly towards the hybrid pro- Jul;34(1):1-8.
TAVR is not a mature method yet; expe- cedure and that the change is now, not 3. Reicher B, Poston RS, Mehra MR, Joshi A,
rience with it is limited and long-term in 5 years. Odonkor P, Kon Z, Reyes PA, Zimrin DA. Simulta-
neous “hybrid” percutaneous coronary interven-
results lacking. The clinical value has to Siemens Healthcare has recognized tion and minimally invasive surgical bypass
be proven in a randomized, controlled these trends in surgery and offers a grafting: feasibility, safety, and clinical out-
trial. Without the results of such a com- complete portfolio of high-end angiog- comes. Am Heart J. 2008 Apr;155(4):661-7
parison, the excellent long-term results raphy systems for imaging in an OR en- 4. Bacha EA, Marshall AC, McElhinney DB, del
of conventional aortic valve replace- vironment. From a semi-mobile system Nido PJ. Expanding the hybrid concept in con-
genital heart surgery. Semin Thorac Cardiovasc
ment make this therapy the gold stan- for smaller ORs to the flagship of inno- Surg Pediatr Card Surg Annu. 2007:146-50.
dard. Patients with an acceptable risk vation Artis zeego, the new angiogra- Review.
profile should therefore continue to un- phy system based on robotic technology,
dergo the standard therapy. However, Siemens delivers floor- and ceiling-
Contact
in the long run, valve therapy – for all mounted systems dedicated to surgery
georg.nollert@siemens.com
valves - will certainly change from con- procedures. Especially Artis zeego with
Patient history
46-year-old morbidly obese female
presented with high fevers, chills and
lower abdominal pain. Her condition
rapidly worsened to include lethargy
and hypotension.
Diagnosis
Pyelonephritis and urosepsis. The etiolo-
gy was found to be ureteral obstruction
of an ectopic right pelvic kidney on a
multidetector CT scan of the abdomen
and pelvis. An attempt to treat the
obstruction using cystoscopy resulted in
inadvertent ureteral perforation with
placement of a double J ureteral stent
outside of the collecting system. The
patient’s condition continued to deterio-
rate requiring urgent placement of a
percutaneous nephrostomy tube under
general anesthesia.
Treatment
Multiple Large volume syngo DynaCT
acquisitions with Artis zeego were per-
Dr. Warren Swee and the new Artis zeego multi-axis system at UVA
formed to guide a 22-gauge Chiba nee-
dle into the posterior calyx of the ecto-
pic pelvic kidney. The ectopic position
πof the kidney left only a narrow win- Comments Acknowledgements
dow for percutaneous access requiring Following nephrostomy tube placement I would like to thank Zachary Ryan, R.T.
passage through the psoas muscle to a and medical management, there was (R) for his assistance in image acquisi-
depth of 20 cm. After access was ob- complete resolution of the patient’s uro- tion.
tained, fluoroscopy was used to position sepsis.
Contact
a 10 French nephrostomy tube within
gerald.sandridge@siemens.com
the renal pelvis.
1 A+B Axial Large Volume syngo DynaCT images demonstrate a narrow window to access the ectopic pelvic
kidney (Kid) between the spine and liver (Lv). Fig 1 shows the first needle pass to be directed laterally
toward the liver capsule. Fig 2 shows successful redirection of the needle along the intended course through
the psoas muscle (PM). Due to massive percutaneous fat issue, a Large Volume syngo DynaCT acquisition is
extremely helpful.
1A 1B 2 A+B Axial and sagittal MIP (maxi-
mum intensity projection) recon-
structions of a Large Volume syngo
DynaCT acquisition to demonstrate
successful access to the renal collect-
ing system. A previously placed mal-
positioned double J ureteral stent is
also seen. (*)
2A 2B
3A 3B
Radiofrequency Ablation
of a Large Vertebral Metastasis
Using iGuide CAPPA
Electromagnetic Needle Guidance
Prof. Martin Skalej, MD, Oliver Beuing, MD, Anja Lenz, MD
Department of Neuroradiology, University of Magdeburg, Germany
1 2a
1 T1-weighted image without gadolinium enhancement 2 a+b The electromagnetic tracking shows progression
demonstrates large metastasis with intraspinal growth of the needle into the soft tissue mass.
and extension to the lungs, the aortic arch, the trachea
and the esophagus.
Patient history
68-year-old female with known renal nal and paravertebral infiltration quency ablation and subsequent radia-
cell carcinoma first diagnosed in 1996 and slight compression of the myelon tion therapy was planned. For radio-
with worsening pain in the upper (Fig 1). The lesion extends to the frequency ablation, first imaging with
thoracic spine. Patient showed discrete trachea and the aortic arch ventrally syngo DynaCT was performed.
paresis of the left arm, but no other and the lungs laterally. No other spinal The electromagnetic tracking system
neurologic deficit. metastases were detected. iGuide CAPPA, which superimposes the
puncture needle on the syngo DynaCT
Pre-treatment Imaging Treatment data set, was used for precise place-
MRI of the spine revealed a large metas- The patient was considered inoperable ment (Fig. 2 a + b). Then the electrodes
tasis with destruction of the second concerning tumor resection and verte- were introduced through the puncture
thoracic vertebra and extensive intraspi- bral body replacement. Thus radiofre- needle. The final position achieved
2b 3
Comments
according to the electromagnetic track- The electromagnetic tracking system in ther imaging is necessary during the
ing system was confirmed by another combination with syngo DynaCT allows intervention. X-ray exposure to the
syngo DynaCT run (Fig. 3) and the abla- precise placement of electrodes or bi- examiners is reduced when compared
tion was conducted with a total energy opsy devices even in regions that are to interventions performed under CT-
of 40 kJ. The patient tolerated the inter- difficult to evaluate with fluoroscopy or fluoroscopy guidance. If wanted, a
vention without any complication, pain where critical anatomic structures not control scan can be performed to docu-
improved immediately after the proce- visible with fluoroscopy alone must be ment the final position.
dure. avoided. The tracking system provides
excellent depiction of the progression
Contact
of the needles and anatomic detail is
vera.juennemann@siemens.com
provided by syngo DynaCT. Also no fur-
during a neuroradiological intervention, Improved patient care institute hosted a workshop with 37
so we can see the same pathology in Latin American neuro-interventionalists
two different planes, which provides us Among advanced imaging capabilities, focusing on syngo DynaCT and how its
with a 3D view of millimetrical struc- AXIOM Artis dBA brings other advantag- soft tissue imaging capabilities can dis-
tures for greater safety in our work and es to the facility. Dr. Bravo is very satis- play details that no other angiography
minor risk for the patient.” fied with the new system, mainly be- system on the market can offer. These
The other great benefit is that it enables cause it is the first in a public hospital in details range from hemorrhages in the
the physician to see complications in South America and because of the fi- brain to stent visualization. Many live
the treatment of patients in the same nancial benefits. “Working with the bi- cases were discussed with the partici-
room without moving the patient to an- plane system reduces the expenses for pating radiologists who also confirmed
other imaging modality. “Without mov- contrast agent and speeds up the proce- the high clinical value of syngo DynaCT.
ing the patient, it is possible to see any dure because it is not necessary to
kind of complication during treatment change C-arm positioning during the
in a very user-friendly way”, affirmed procedures,” he explains.
Contact
Bravo. At the end of February 2008, the same
antonio.carlos@siemens.com
At the University Hospital Gast- Image integration for ablation ed with 3D mapping systems. The Uni-
huisberg in Leuven, Belgium syngo of atrial fibrillation versity Hospital Gasthuisberg pioneered
DynaCT Cardiac has become a useful integration of 3D models with real-time
application during ablation therapy. Pre-procedural imaging and three-di- biplane fluoroscopic imaging to guide
The team in the cardiology depart- mensional (3D) reconstruction of the catheter navigation and ablation.2 Image
ment describes their experiences left atrium and pulmonary veins is per- integration is usually based on cardiac
with the system and how it contrib- formed in the majority of centers before CT or MRI images that are acquired prior
utes to an efficient workflow and atrial fibrillation (AF) ablation proce- to the procedure, and reconstructed
excellent results. dures.1 Detailed anatomical information into a 3D model for treatment planning.
can help achieve a more effective and One drawback of this approach is the
successful ablation and may prevent possibility of changes in the left atrial
procedure-related complications. Pa- geometry between imaging and the
tient-specific 3D models can be integrat- ablation procedure due to differences in
cardiac loading conditions, resulting in per second during a single 5-second ro-
1A Ungated syngo DynaCT Cardiac
inaccurate image integration during the tation and were automatically trans-
acquisition (after ATP)
procedure. Moreover, an additional am- ferred to the Siemens Workplace for 3D
bulatory hospital visit or earlier hospital- reconstruction to axial images and fur- 1B 2D Slice Reconstruction
ization is often required for the patient ther 3D processing (Fig. 1 A-C). Whereas
1c 3D Volume Rendering
to acquire the images necessary for 3D contrast administration for left atrial
syngo DynaCT Cardiac: (LA: left atrium, LV: left
reconstruction. This leads to extra logis- syngo DynaCT Cardiac examinations is ventricle, RIPV: right inferior pulmonary vein,
tical overhead. conventionally performed in the pulmo- LSPV: left superior pulmonary vein, RSPV: right
syngo DynaCT Cardiac now offers the nary artery, we developed a new ap- superior pulmonary vein, ap: anterior papillary
possibility of CT-like imaging of the left proach in which diluted contrast agent muscle, pp: posterior papillary muscle, LAA: left
atrial appendage)
atrium and pulmonary veins during the is directly injected into the left atrium.
ablation procedure. At the beginning of To obtain optimal contrast filling and to
1A
2008, we evaluated a new workflow in reduce cardiac motion artifacts, contrast
which syngo DynaCT Cardiac images injection and syngo DynaCT Cardiac ac-
were acquired during AF ablation proce- quisition were performed after adminis-
dures and reconstructed into a 3D mod- tration of adenosine-triphosphate (ATP)
el for integration with biplane fluoro- to induce transient ventricular asystole
scopic imaging. Catheter navigation and (Fig. 2 A) or during rapid right ventricu-
ablation were guided solely by syngo lar pacing to reduce cardiac output and
DynaCT Cardiac-based 3D-fluoroscopy cardiac motion (Fig. 3 A-B). This ap-
integration, without the use of a 3D proach resulted in high quality 3D re-
mapping system. Our goal was to devel- constructions of the left atrium and pul-
1B
op a workflow resulting in high quality monary veins, using only a limited dose
3D reconstructions of the left atrial of ionizing radiation and contrast agent.
anatomy with the lowest possible pa- Given the excellent quality of syngo
tient radiation exposure, eliminating the DynaCT Cardiac, pre-procedural imaging
need for additional pre-procedural im- with Cardiac CT or MRI is no longer con-
aging and improving image integration sidered necessary for clinical use in our
accuracy. center.
syngo DynaCT Cardiac offers the possi- In our opinion, one of the most impor-
bility for both ungated image acquisi- tant advantages of syngo DynaCT
tion with a single 5-second C-arm rota- Cardiac lies in the new possibilities for
tion over 200°, and an ECG-gated image 3D image integration. AF ablation pro-
acquisition using 4 sequential 5-second cedures are performed in our center
rotations with retrospective ECG gating. under general anesthesia. As a result, no
To reduce patient radiation dose, we patient movements occur and patient
opted for the ungated acquisition proto- position is identical during syngo DynaCT
col. Images are acquired at 60 frames Cardiac acquisition and fluoroscopic im-
2A 2B
3A
4A 4B
4 A+B Integration of syngo DynaCT Cardiac-based 3D model of the left atrium with fluoroscopy
using Siemens syngo iPilot. Left: fluoroscopic image in the right anterior oblique view showing the
ablation catheter (Abl) and circumferential mapping catheter (Lasso). Right: after syngo iPilot
image integration of the syngo DynaCT Cardiac-based 3D model, the position of the ablation and
mapping catheters at the ostium of the left superior pulmonary vein can be accurately determined.
(Abl: ablation catheter, Lasso: circumferential mapping catheter, LA: left atrium, RSPV: right supe-
rior pulmonary vein, RIPV: right inferior pulmonary vein, LSPV: left superior pulmonary vein, LAA:
left atrial appendage)
5A 5C
5B 5D
5 A+B RAO view visualized with LARCA (Leuven Augmented Reality for Catheter Ablation) software
Contact
erik.busch@siemens.com
Left to right: Prof. H. Heidbüchel, MD, J. Ector, MD, PhD, S. de Buck, PhD
Unlike other medical disciplines there tion, treatment plans have evolved that With this system combination, workflow
has been a long and productive relation- utilize the unique attributes of what at is streamlined, all anatomical data is
ship between the pediatric cardiologist first may seem like competitive special- available prior to the surgery and the
and cardiovascular surgeon, together ties, but have come together, as Taussig complete treatment can be done under
focusing on improving the lives of chil- did with Blalock, to develop new tech- the same anesthetic. The MIYABI con-
dren with congenital heart lesions. This niques and management strategies. The cept offers flexibility for system usage,
cooperative spirit found its origins, case presented on the following pages as both systems can be operated sepa-
when in November 1944, Dr. Alfred Bla- is one such contemporary example, that rately as well. But when used together,
lock, encouraged by Dr. Helen Taussig, of management of the newborn with they become a very powerful high-per-
performed the first arterial shunt, set- hypoplastic left heart syndrome. The formance interventional system. The
ting the stage for a revolution in cardiac treatment algorithm was bilateral pul- availability of two imaging technologies
care. That spirit continues today in very monary artery banding and placement during interventional procedures and
specialized centers dealing with con- of a ductal stent in a hybrid surgical an- the convenient way to move the patient
genital heart disorders like The Hospital giography suite, with prior cardiac MR from one system to the other quickly
for Sick Children in Toronto, Canada. imaging, and transfer on Siemens Miya- and easily supports an optimized treat-
With the development of percutaneous bi system from the MRI scanner to the ment and gives seriously ill children
techniques for cardiovascular interven- hybrid room for angiography. new hope.
Patient history
3-day-old baby boy, weight 2.5 kg. a hybrid procedure. Because of the child’s stent into the arterial duct through the
size it was determined that the hybrid main pulmonary artery was successfully
Diagnosis procedure would be a better option. performed.
Hypoplastic left heart syndrome.
Treatment Comments
Therapy planning The child was anesthetized and under- The child recovered well, was extubated
At three days of life, after consultation went a pre-procedural MRI to define the on day three following the procedure
with the family, the management deci- anatomy. (Fig. 3) Following the MRI, and returned home on day seven.
sion was to follow single ventricle pallia- the child was moved into the angiogra-
tion towards an eventual Fontan proce- phy suite while under the same anes-
dure. The first stage of palliation was thetic. A bilateral pulmonary artery Contact
either a standard Norwood operation or banding procedure and insertion of a dirk.sunderbrink@siemens.com
Treatment at the biplane AXIOM Artis dBC angiography system with the C-arm in park position for best patient access.
3 MR image of hypoplastic
left heart syndrome before
hybrid treatment.
3 4
4 Banded pulmonary arter-
ies, Patent Ductus Arterious
injection.
5 6
The Hospital for Sick Children (SickKids), affiliated with the University of Toronto, is Canada's most
research-intensive hospital and the largest center dedicated to improving children's health in the country.
Its mission is to provide the best in family-centered, compassionate care, to lead in scientific and clinical
advancement, and to prepare the next generation of leaders in child health.
www.sickkids.ca
Pediatric Fluoroscopy
with Digital Radiography
Expedites Clinical Outcomes
AXIOM Luminos TF, the proven system for fluoroscopy,
has many features to ease workflow and facilitate system
handling. Together with the mobile digital flat detector it
becomes even more versatile, producing excellent results
in pediatric care.
Tailored for optimal Fast diagnosis same patient folder and displayed in the
patient care by the patient’s side order of acquisition.
With mFD
Patient
Exposure Repositioning Exposure
positioning
With CR cassettes
Patient Insert Exchange Reposition Remove Scan Read out Images available
Exposure Exposure
positioning cassette cassette Patient cassette cassette cassette for review
1 Compared to CR cassettes, working with the mFD is faster and requires fewer steps. Furthermore there is no need to leave the examination
room for cassette processing, thereby increasing quality of patient care.
2 Fully digital imaging with the mobile Flat Detector enhances 3 Convenient and efficient system handling
flexibility and efficiency. for a smooth procedure.
2 3
Dr. John Harris and his team at the AXIOM Luminos TF. North Colorado Medical Center, Greeley, CO, USA.
Patient history
A 13-year-old female presented to the 1
1 Delayed radiograph
emergency department with sudden
taken 10 min. after
nausea, vomiting and abdominal pain. the therapeutic relief
No history of surgery or injury given. started.
Diagnosis
The initial X-ray radiograph of the abdo-
men showed a large bowel ileus with
some mild dilatation. The repeat radio-
graph and a subsequent CT scan two
hours later confirmed a persistent,
progressive air-filled distention to the
sigmoid colon and the large bowel.
As these findings are very suspicious for
a volvulus of the sigmoid colon a gastro-
grafin enema was considered for further
validation with the possibility of imme-
diate therapeutic relief to ensure the
blood flow to the intestine.
Treatment
2 The treatment initially began in the
2 Gastrografin enema
SIMMs position where the patient is lay-
validating the volvulus
ing on the left side with the right knee
at the rectosigmoid
junction. brought up to the chest. The introduc-
tion of the contrast agent was conduct-
ed under fluoroscopy control. At the
junction of the rectosigmoid, a volvulus
could be verified. Very slight hydrostat-
ic pressure was utilized before draining
the contrast back. This procedure was
repeated several times under fluorosco-
py. Within about 20 minutes of starting
this process, contrast was seen to enter
the more proximal portion of the sig-
moid colon and the patient began feel-
ing relieved of symptoms.
An additional delayed radiograph
showed contrast agent passing into the
3 Delayed radiograph approx. 20 min. after procedure started showing contrast left and the transverse colon. The co-
passing into the descending and transverse colon. lon was of more normal caliber. The
following delayed images indicated fur-
3
ther evacuation. There was still some
dilatation to the sigmoid colon but the
patient showed considerable improve-
ment in symptoms.
The patient was observed in the emer-
gency department for an additional two
hours and could be released with no
residual pain or symptoms. A follow-up
with abdominal imaging in three months
time was recommended.
Comments
With the Siemens AXIOM Luminos TF
fluoroscopy system and its mobile Flat
Detector for digital radiographic imag-
ing, the therapeutic relief of the volvu-
lus and overhead delayed images could
be completed within 23 minutes due to
less processing time and well organized
workflow. The radiographs acquired
with the mobile flat detector were avail-
able within seconds and allowed the
technologist to remain with the patient
at all times. Patient care was perceived
to be of higher quality.
Contact
kelly.obrien@siemens.com
barbara.reber@siemens.com
Virus Protection
at the University Hospital Basel,
Switzerland
The University Hospital in Basel provides a good example of broad-based
virus protection for medical technology systems. With Siemens Virus
Protection, the hospital proactively protects most Siemens modalities against
potential attacks.
In the University Hospital Basel, on a Providing operating security the hospital’s internal operating net-
daily basis, about ten thousand patient for the systems work. The systems are increasingly
images – corresponding to a volume of threatened by viruses stemming from
18 gigabytes – are processed and regis- Given the high level of system utiliza- data exchange, for example through
tered in the network of the radiological tion, equipment reliability is crucial. And USB devices and network-connected lap-
image storage system. Currently, the security considerations play an increas- tops or from files downloaded from
entire quantity of stored image data ingly important role in providing this the Internet. For the University Hospital
amounts to about 32 terabytes, which is reliability. On the one hand, networked Basel, the safety and protection of medi-
equivalent to the contents of over 5,000 communications and the exchange of cal technical systems with their enor-
kilometers of file shelves. data worldwide brings the risk of con- mous volumes of data have top priority.
tamination by malicious software, such Professor Wolfgang Steinbrich, MD,
as viruses, worms, and Trojan horses. Director of the Institute for Diagnostic
On the other hand, the systems need to Radiology, explains: “Today our capacity
be protected from risks resulting from is configured in such a way that the de-
vices always have to be functioning. through Siemens Virus Protection. The tomer is even aware of the virus on-site
That’s why in addition to system quality, service consists of virus detection and and before the virus can cause any dam-
operational security is our most impor- elimination as well as prevention. age. Professor Steinbrich values this as-
tant goal.” Through the installation of a virus scan- pect in particular: “It’s our responsibility
To achieve this, the University Hospital ner and connection of the systems to to safeguard and protect our image
Basel installed full-scale protection Siemens Remote Service (SRS), remote data. Due to new technologies, new
against malicious attacks – the first hos- updates with relevant hotfixes are im- dangers have arisen that we must elimi-
pital in Switzerland to take this step. To ported proactively to protect the sys- nate. I was very positively impressed by
protect against viruses, worms, and Tro- tems against attacks from every type of Siemens’ proactive approach with Virus
jan horses, most imaging systems from known virus. Should a virus infection Protection. That’s why I strongly sup-
Siemens are equipped with Siemens nevertheless occur, the Siemens experts ported this solution.”
Virus Protection. can frequently detect this very early – The director of Medical and Operational
The University Hospital currently has 27 thanks to remote monitoring via SRS – Technology, Christian Kluth, attaches
Siemens modalities that are secured and take suitable action before the cus- special importance to ensuring that all
Improved efficiency
large-scale equipment in the University cal diagnostic equipment has become cludes: “Although the different networks
Hospital Basel is equipped with virus highly developed – from the original are physically decoupled, they are con-
protection. As he says, a complete solu- precision mechanical systems with ana- nected through the exchange of infor-
tion of this kind is a highly feasible ap- log electronics to computer-controlled mation. In order to prevent the misuse
proach for providing comprehensive instruments with complex software for of personal data at the interfaces and to
protection against virus attacks: “Just digital imaging. Second, the stand-alone avert threats, for example, from Trojan
one insecure site would be one too workstation systems of former times are horses or viruses, comprehensive inno-
many. Only the installation of Virus Pro- today interconnected and networked vative protection systems are required –
tection in all equipment offers the pro- with the image viewing units of image such as Siemens Virus Protection.”
tection that we prefer to help ensure storage networks. In addition, a high-
the operating reliability of our machines performance link to the radiological in-
and systems.” formation system and to the hospital- Contact
Professor Steinbrich attributes the dan- wide network of the clinical information birgit.munz@siemens.com
www.siemens.com/virus-protection
gers to two principal causes: “First, clini- system is planned.” Steinbrich con-
AX-Z1089-2-7600
Customer Care.Life Learning with and from the Experts
Learning With
and From the Experts
Siemens offers intensive hands-on training for interventional
cardiology using state-of-the-art simulation technologies
Siemens Presents
New Light and SoundConcept*
Many patients are anxious or even especially in children. Interventional should remain out of view. To work
scared prior to a catheterization proce- treatment becomes faster and more effectively in this light environment,
dure and need to be calmed down with effective when the patient is calmer and Siemens offers the TRAXON ™ Nano
sedatives. Various studies revealed that more at ease. Liner, a white light for clinical use to
sound and light effects in the room can For these reasons, Siemens created a provide adequate table lighting during
help take away that fear and anxiety, new light and sound concept which can the procedure. And with the BOSE ™
be individually designed for the custom- sound system connected to an iPod®
ers’ needs. It creates a soothing light Touch, the whole sound and light
Components of the light
environment consisting of various ele- environment can be operated with a
and sound concept ments the customer can choose from. syngo-like user interface.
Skylight LED tubes on the wall can create a For the light and sound installation dif-
LED Wall lightening warm light with different soft and fluid ferent themes like landscapes or special
French Window – colors that can also be coordinated with images for children are also available.
music. A skylight with a customized im-
artificial door/window
age can be tailored to any room size,
TRAXON Nano Liner * Siemens light and sound concept is currently only
even with a ceiling-mounted system, to available in Europe.
for patient table lighting
create the impression of a large and airy
BOSE Sound System
room. Another highlight is the artificial
with iPod Touch connection Contact
French door which is ideal to simulate
markus.rossmeier@siemens.com
daylight or to cover up objects that
Upcoming Congresses
& Workshops 2008 / 2009
We always would like to give you the the latest technological advances. You below you will find information on vari-
opportunity to get in “touch” with the will have the chance to experience our ous events where we offer you the op-
real system and learn more about sys- technology at international congresses, portunity to meet AX.
tem handling to keep you in step with trade fairs, and workshops. In the list
TCT Washington DC, USA Transcatheter Cardiovascular Oct. 12 – 17, 2008 www.tctconference.com
Therapeutics
ISHAHD Beijing, China International Symposium on Hybrid Oct. 18 – 20, 2008 www.hybridheartbeijing.org
Approach to Heart Diseases 2008
JFR Paris, France Journées Francaise de Radiologie Oct. 24 – 28, 2008 www.jfrexpo.com
AOCR Seoul, South Korea 12th Asian Oceanian Congress of Oct. 24 – 28, 2008 www.aocr2008.org
Radiology
CMEF Suzhou, China Medical Trade Fair Oct. 29 – Nov. 1, 2008 www.cmef.com.cn
AHA New Orleans, LA, USA American Heart Association Nov. 9 – 11, 2008 www.americanheart.org
RSNA Chicago, IL, USA 94th Annual Meeting Nov. 30 – Dec. 5, 2008 www.rsna.org
APCC Taipei, Taiwan 16th Asian Pacific Congress of Dec. 13 – 16, 2008 www.apcc2008.org
Cardiology
AF Symposium Boston, MA, USA 13th Annual Meeting Jan. 15 – 17, 2009 www.afsymposium.com
STS San Francisco, CA, USA Annual Meeting of the Society Jan. 26 – 28, 2009 www.sts.org
of Thoracic Surgeons
CCT Kobe, Japan Complex Catheter Therapeutics Jan. 29 – 31, 2009 http://cct.gr.jp
DGHTG Innsbruck, Austria 38th Jahrestagung der dt. Gesellschaft Feb. 15 – 18, 2009 www.dgthg.de
für Thorax-, Herz- und Gefäßchirugie
ECR Vienna, Austria European Congress of Radiology Mar. 6 – 10, 2009 www.ecr.org
SIR San Diego, CA, USA Annual Scientific Meeting Mar. 7 – 12, 2009 www.sirmeeting.org
CIT 2009 Beijing, China China Interventional Therapeutics Mar. 18 – 22, 2009 www.citmd.com
2009
JCS Osaka, Japan Japanese Circulation Society Mar. 20 – 22, 2009 www.j-circ.or.jp
ACC Orlando, FL; USA 58th Annual Meeting Mar. 29 – 31, 2009 www.acc09.acc.org
JRS Yokohama, Japan Japan Radiological Society April 17 – 19, 2009 www.radiology.jp
Medical Solutions
News
Innovation and trends
Our latest topics
in healthcare. The
such as product
magazine, published
news, reference
three times a year, is
stories, reports,
designed especially
and general
for members of hospi-
interest topics are
tal management, ad-
always available at
ministration per-
www.siemens.com/
sonnel, and heads of
healthcare-news
medical departments.
AXIOM Innovations
The Magazine for Interventional Angiography and Cardiology,
Radiography and Fluoroscopy
New Trends
in Surgery
Cardio-vascular surgery
opens up for new treat-
ment methods
Page 14
Efficiency
in the EP
syngo DynaCT Cardiac
enhances ablation therapy
Page 26
AXIOM
Luminos TF
Pediatric imaging
in fluoroscopy
Page 36
Virus protection
at the University Hospital
Basel, Switzerland
Page 40
08
with Artis zeego
More anatomical coverage with Large Volume syngo DynaCT
For current and older issues and to order the magazines, please visit www.siemens.com/healthcare-magazine
Editorial board
Monika Böhmer
Oslo, Norway
John P. Harris, MD
Charles E. Winn, MD
Basel, Switzerland
Note in accordance with § 33 Para.1 of the from existing pathology. As referenced above, pages of “AXIOM Innovations” are cited. The
Federal Data Protection Law: Dispatch is made healthcare practitioners are expected to utilize editors request that two copies be sent to their
using an address file which is maintained with their own learning, training and expertise in eva- attention. The consent of the authors and editors
the aid of an automated data processing system. luating images. is required for the complete reprint of an article.
We remind our readers that, when printed, X-ray
films never disclose all the information content Partial reproduction in printed form of individual Manuscripts submitted without prior agreement as
of the original. Artifacts in X-ray, CT, MR and contributions is permitted, provided the custo- well as suggestions, proposals and information are
ultrasound images are recognizable by their ty- mary bibliographical data such as author’s name always welcome; they will be carefully assessed and
pical features and are generally distinguishable and title of the contribution as well as date and submitted to the editorial board for review.
2 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine 49
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Phone: +49 9131 84-0 Radiography and Fluoroscopy
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www.siemens.com/healthcare-magazine Issue Number 8/October 2008
08
Siemens S.A., Medical Solutions