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Enhanced Virtual Bronchoscopy Using the Pulmonary Artery: Improvement in Route Mapping for Ultraselective Transbronchial Lung Biopsy

¹ Department of Radiology, Hokkaido University School of Medicine, North 15 West 7, Kita-Ku, Sapporo 060-8638, Japan.
² First Department of Medicine, Hokkaido University School of Medicine, Sapporo 060-8638, Japan.

View larger version (94K): [in a new window]   Fig. 1A. —Images in 37-year-old healthy male volunteer show definition of enhanced virtual bronchoscopy using pulmonary artery. At farthest point on virtual bronchoscopy (A), next branch was unclear at any threshold, but peripheral bronchus was open and clear on CT scans (B and C).

View larger version (141K): [in a new window]   Fig. 1B. —Images in 37-year-old healthy male volunteer show definition of enhanced virtual bronchoscopy using pulmonary artery. At farthest point on virtual bronchoscopy (A), next branch was unclear at any threshold, but peripheral bronchus was open and clear on CT scans (B and C).

View larger version (166K): [in a new window]   Fig. 1C. —Images in 37-year-old healthy male volunteer show definition of enhanced virtual bronchoscopy using pulmonary artery. At farthest point on virtual bronchoscopy (A), next branch was unclear at any threshold, but peripheral bronchus was open and clear on CT scans (B and C).

View larger version (103K): [in a new window]   Fig. 1D. —Images in 37-year-old healthy male volunteer show definition of enhanced virtual bronchoscopy using pulmonary artery. At beginning of enhanced virtual bronchoscopy (D) of pulmonary artery reconstruction for peripheral branch, virtual endoscopic lumen is still clear. Tip of virtual endoscope was moved from bronchus to pulmonary artery on same bronchovascular bundle (E and F).

View larger version (145K): [in a new window]   Fig. 1E. —Images in 37-year-old healthy male volunteer show definition of enhanced virtual bronchoscopy using pulmonary artery. At beginning of enhanced virtual bronchoscopy (D) of pulmonary artery reconstruction for peripheral branch, virtual endoscopic lumen is still clear. Tip of virtual endoscope was moved from bronchus to pulmonary artery on same bronchovascular bundle (E and F).

View larger version (165K): [in a new window]   Fig. 1F. —Images in 37-year-old healthy male volunteer show definition of enhanced virtual bronchoscopy using pulmonary artery. At beginning of enhanced virtual bronchoscopy (D) of pulmonary artery reconstruction for peripheral branch, virtual endoscopic lumen is still clear. Tip of virtual endoscope was moved from bronchus to pulmonary artery on same bronchovascular bundle (E and F).

View larger version (124K): [in a new window]   Fig. 1G. —Images in 37-year-old healthy male volunteer show definition of enhanced virtual bronchoscopy using pulmonary artery. At end of enhanced virtual bronchoscopy (G), enhanced virtual bronchoscopy using pulmonary artery reached target at subpleural region. H is axial CT magnified image focused on periphery. Blue track in B, E, and H indicates road map.

View larger version (123K): [in a new window]   Fig. 1H. —Images in 37-year-old healthy male volunteer show definition of enhanced virtual bronchoscopy using pulmonary artery. At end of enhanced virtual bronchoscopy (G), enhanced virtual bronchoscopy using pulmonary artery reached target at subpleural region. H is axial CT magnified image focused on periphery. Blue track in B, E, and H indicates road map.

View larger version (41K): [in a new window]   Fig. 2A. —45-year-old man with primary lung adenocarcinoma in left lower lobe. Virtual bronchoscopy images (beginning at A and ending at C [but excluding B]) failed at fourth bronchial order. Images from enhanced virtual bronchoscopy using pulmonary artery (D) were successful in route mapping to tumor (seventh bronchial order). Images from actual bronchoscopy (beginning at B and ending at E [but excluding C and D]) show correlation with virtual bronchoscopy and enhanced virtual bronchoscopy. All arrows show next routes where virtual bronchoscopy or actual bronchoscopy is inserted.

View larger version (29K): [in a new window]   Fig. 2B. —45-year-old man with primary lung adenocarcinoma in left lower lobe. Virtual bronchoscopy images (beginning at A and ending at C [but excluding B]) failed at fourth bronchial order. Images from enhanced virtual bronchoscopy using pulmonary artery (D) were successful in route mapping to tumor (seventh bronchial order). Images from actual bronchoscopy (beginning at B and ending at E [but excluding C and D]) show correlation with virtual bronchoscopy and enhanced virtual bronchoscopy. All arrows show next routes where virtual bronchoscopy or actual bronchoscopy is inserted.

View larger version (45K): [in a new window]   Fig. 2C. —45-year-old man with primary lung adenocarcinoma in left lower lobe. Virtual bronchoscopy images (beginning at A and ending at C [but excluding B]) failed at fourth bronchial order. Images from enhanced virtual bronchoscopy using pulmonary artery (D) were successful in route mapping to tumor (seventh bronchial order). Images from actual bronchoscopy (beginning at B and ending at E [but excluding C and D]) show correlation with virtual bronchoscopy and enhanced virtual bronchoscopy. All arrows show next routes where virtual bronchoscopy or actual bronchoscopy is inserted.

View larger version (31K): [in a new window]   Fig. 2D. —45-year-old man with primary lung adenocarcinoma in left lower lobe. Virtual bronchoscopy images (beginning at A and ending at C [but excluding B]) failed at fourth bronchial order. Images from enhanced virtual bronchoscopy using pulmonary artery (D) were successful in route mapping to tumor (seventh bronchial order). Images from actual bronchoscopy (beginning at B and ending at E [but excluding C and D]) show correlation with virtual bronchoscopy and enhanced virtual bronchoscopy. All arrows show next routes where virtual bronchoscopy or actual bronchoscopy is inserted.

View larger version (23K): [in a new window]   Fig. 2E. —45-year-old man with primary lung adenocarcinoma in left lower lobe. Virtual bronchoscopy images (beginning at A and ending at C [but excluding B]) failed at fourth bronchial order. Images from enhanced virtual bronchoscopy using pulmonary artery (D) were successful in route mapping to tumor (seventh bronchial order). Images from actual bronchoscopy (beginning at B and ending at E [but excluding C and D]) show correlation with virtual bronchoscopy and enhanced virtual bronchoscopy. All arrows show next routes where virtual bronchoscopy or actual bronchoscopy is inserted.

View larger version (67K): [in a new window]   Fig. 3A. —Agreement of route map with biopsy path is shown in images from 65-year-old woman with lung cancer in right lower lobe. Image from virtual bronchoscopy shows most distal point reached.

View larger version (133K): [in a new window]   Fig. 3B. —Agreement of route map with biopsy path is shown in images from 65-year-old woman with lung cancer in right lower lobe. CT image with road map (blue) shows route of virtual bronchoscopy.

View larger version (148K): [in a new window]   Fig. 3C. —Agreement of route map with biopsy path is shown in images from 65-year-old woman with lung cancer in right lower lobe. Flouroscopic CT images show tips of ultrathin bronchoscope and bioptome reaching target lesion, which coincided with road map image.

View larger version (145K): [in a new window]   Fig. 3D. —Agreement of route map with biopsy path is shown in images from 65-year-old woman with lung cancer in right lower lobe. Flouroscopic CT images show tips of ultrathin bronchoscope and bioptome reaching target lesion, which coincided with road map image.

View larger version (18K): [in a new window]   Fig. 4A. —Results of statistical analysis of three radiologists shown as mean (•) ± 2 SD (whiskers). A, B, and C are qualified radiologists. Radiologist A is highly experienced in 3D building, B and C are not. Br = conventional virtual bronchoscopy, PA = enhanced virtual bronchoscopy using pulmonary artery. Graph shows no significant difference in luminal diameters among three radiologists regarding limit of bronchus diameter, which was 1.5 mm. Significant difference was found in reconstructed diameter among radiologist A (0.75 mm), radiologist B (1.1 mm), and radiologist C (0.9 mm). Significant differences were found in luminal diameters between bronchus and pulmonary artery among radiologists.

View larger version (18K): [in a new window]   Fig. 4B. —Results of statistical analysis of three radiologists shown as mean (•) ± 2 SD (whiskers). A, B, and C are qualified radiologists. Radiologist A is highly experienced in 3D building, B and C are not. Br = conventional virtual bronchoscopy, PA = enhanced virtual bronchoscopy using pulmonary artery. Graph shows no significant difference among three radiologists regarding limit of bronchial order, average of which was 7.5. Significant difference was found between radiologist A and other two radiologists regarding limit of pulmonary arterial order: 11.8 order, radiologist A; 9.8 order, radiologist B; and 9.2 order, radiologist C.

View larger version (12K): [in a new window]   Fig. 5. —Graph shows maximum bronchial order in clinical cases. For virtual bronchoscopy, maximum was sixth branch. For enhanced virtual bronchoscopy enhanced using pulmonary artery, maximum was eighth branch. Results are shown by median (•) and 25th and 75th percentile values (whiskers). Significant difference was found between virtual bronchoscopy and enhanced virtual bronchoscopy using pulmonary artery for median limit of branch order.

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