DOI:10.2214/AJR.07.2469
AJR 2007; 189:W357-W364
© American Roentgen Ray Society
Live 3D Guidance in the Interventional Radiology Suite
John M. Racadio1,
Drazenko Babic2,
Robert Homan2,
John W. Rampton1,
Manish N. Patel1,
Judy M. Racadio1 and
Neil D. Johnson1
1 Department of Radiology, Division of Pediatric Interventional Radiology,
Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati,
OH 45229-3039.
2 X-Ray Department, Philips Medical Systems Nederland B.V., Best, The
Netherlands.
Received April 27, 2007;
accepted after revision June 6, 2007.
Address correspondence to J. M. Racadio
(john.racadio{at}cchmc.org).
The Department of Radiology, Division of Interventional Radiology, at
Cincinnati Children's Hospital Medical Center has a scientific collaborative
research partnership with Philips Medical Systems Nederland B.V. The
department is also a development site for the evaluation of Philips hardware
and software prototypes.
John M. Racadio has attended a Philips Medical Advisory Board meeting and
has had his travel expenses paid by Philips for two Philips-sponsored speaking
engagements. He is not paid by Philips, nor does he have any stock options or
receive any other financial compensation from Philips.
WEB This is a Web exclusive article.
Abstract
OBJECTIVE. The development of a C-arm cone-beam CT unit coupled with
flat detectors has markedly increased anatomic visualization capabilities for
interventional radiology procedures. We present technology in which
fluoroscopy and 3D imaging from a cone-beam CT-flat-detector C-arm unit are
combined with an integrated tracking and navigation system. A description of
the technology and representative clinical cases are presented.
CONCLUSION. This new combination further increases interventional
radiologic capabilities because it provides real-time procedural evaluation
and tracking.
Keywords: 3D imaging • CNS • cone-beam CT • CT guidance • fluoroscopy • interventional radiology • needle guidance • real-time imaging • vertebroplasty
Introduction
As imaging technology improves, the scope of interventional
radiology procedural capabilities increases. Currently, maximizing anatomic
visualization and improving procedural guidance are both areas of active
research. We describe the clinical use of a real-time tracking and navigation
system integrated into a cone-beam CT angiography-interventional C-arm
unit.
Background
The interventional radiologist traditionally has had to choose between
procedural guidance with CT (in a conventional CT scanner) or fluoroscopy (in
an interventional suite). The primary benefit of CT is the 3D spatial
understanding of bones and soft tissues together. The drawbacks are lack of
patient access and lack of real-time visualization of the procedure, including
monitoring needle advancement. Although there are CT scanners that are
equipped with "CT fluoroscopy," they allow real-time visualization
of only a thin slice of anatomy. The advantage of fluoroscopy is the live,
real-time visualization of a wide field of view of anatomy. However, it
provides only a 2D view with poor soft-tissue contrast resolution.
A new technology coupling flat-detectors with cone-beam CT within an
angiography-interventional C-arm has recently emerged
[1,
2]. Three-dimensional image
acquisition (cone-beam CT) and real-time procedural evaluation (fluoroscopy)
can be performed in one room without having to move the patient. Cone-beam CT
has been shown to provide adequate bone and soft-tissue resolution to assist
minimally invasive head and neck surgery in a preclinical investigation
[1]. In a small series in
humans, cone-beam CT in the angiography suite (DynaCT, Siemens Medical
Solutions) enabled immediate detection or exclusion of intracranial hemorrhage
without the need for patient transfer to a separate CT scanner
[3]. Although the 3D
soft-tissue spatial resolution of cone-beam CT may be adequate for
preprocedure evaluation and postprocedure verification, it lacks the advantage
of an accurate, real-time tracking and navigation system.
The newly developed system coupling cone-beam CT technology and integrated
tracking and navigation (XperCT and XperGuide, FD20 angiography-interventional
system, Philips Medical Systems) vastly increases the procedural capabilities
in an interventional radiology suite.
Technology
XperCT has evolved from 3D rotational angiography. Three-dimensional
isotropic soft-tissue volumes are reconstructed from rotational acquisitions.
Live fluoroscopy is coregistered with the 3D data set and superimposed on it.
This coregistration is integrated with the movement of the C-arm such that the
projection of the 3D CT-like data set changes as the C-arm moves in various
oblique angles. This 3D data set can be viewed and manipulated both in the
control room and at tableside in the procedure room.
XperCT technology at our institution has been integrated into the
single-plane X-ray flat-detector-based system FD20. The speed of the
rotational movement and the number of acquired images depend on the technique
used. The 3D rotational angiography technique is based on 120 rotational
images acquired along 240° of circular trajectory, and XperCT scanning is
based on 310 images (optional 620) along the same 240° of movement.
Patient dose of XperCT (CT dose index [CTDI] of 12.5 mGy for abdominal XperCT
scan) is comparable to conventional helical CT (Homan R, written
communication, March 2007).
Flat-detector-based angiography systems, characterized by higher contrast
resolution and an improved imaging chain than conventional angiography
systems, produce soft-tissue data sets with high spatial and contrast
resolution. Depending on the resolution matrix and the field of view used, the
spatial resolution can go down to 30 µm (0.4 mm) with a contrast resolution
of 5 H at a slice thickness of 10 mm.
Recently, a 3D road-mapping technique was developed
[4]. This technique provides
realtime coupling of 2D fluoroscopic imaging and 3D reconstructions created
from rotational acquisitions. As both of the data sets are acquired with the
C-arc in the calibrated space, they are superimposed in real time with high
matching accuracy. The relation between the 2D and 3D data sets is maintained
during C-arm movements (angulations and rotations), changes in source-image
distance, and modifications of image size. Because all of these data sets
(CT-like data, 2D fluoroscopy, and 3D reconstructions) are acquired inside the
same calibrated space, it is possible to register and display them as one
imaging entity.
The XperGuide technique allows X-ray-based real-time 3D imaging-guided
interventions to be performed in the interventional suite. It provides rapid
and interactive definition of the skin entry point and the internal anatomic
target point (pathology) and connects the two points with virtual graphics.
The virtual graphics show the ideal needle trajectory, as established by the
user, to provide the easiest access to the target while minimizing patient
trauma (i.e., avoid puncturing vessels and vital anatomy).
The needle trajectory is drawn on a selected slice or on a slice reformat
in 3D. Once the virtual graphic is established, the entire imaging geometry is
programmed to calculate the optimal imaging projections, thereby enhancing the
ability to monitor the needle's progress in real time. The virtual 3D graphic
is mapped onto the fluoroscopic image that is superimposed onto the 3D data
set; therefore, the needle path graphic is always visible on the fluoroscopic
image independent of the C-arm geometry location.
The two viewing directions that are most helpful during needle insertion
are the "entry point" view, which is looking down the needle axis,
and the "progression" view, which is looking perpendicular to the
needle. These viewing directions are automatically calculated from the
user-defined planned path and can be selected by the interventionalist at
tableside. If the C-arm is positioned to the entry point view, the entry point
and target point will be directly superimposed on each other. The guidance
graphic is visible as a dot, representing the entry point of the needle,
surrounded by a small circle on the fluoroscopic images.
The needle is initially aligned and inserted using a distance holder with
the needle tip positioned on the entry point using the bull's eye approach
(Fig. 1A). A table-mounted
laser plane can then be aligned with the needle shaft to maintain the proper
needle angle while the C-arm is rotated into the progression view.
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Fig. 1A —Fluoroscopic images after placement of needle into phantom along
graphics of planned path. Purple circle enhances visualization of skin entry
site (purple dot) A, whereas green circle enhances
visualization of target site (green dot). Rot = rotation, Ang =
angle. Entry point view (A), progression view (B), and random
C-arm position (C) are shown.
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Needle advancement along the planned path is monitored in the progression
view. The guidance graphic is visible as a ruler on the fluoroscopy images
(Figs. 1B and
1C). To confirm the position of
the needle, one or more XperCT acquisitions can be obtained during the
procedure. Lead shutter collimation can be performed (cranially and caudally)
to decrease patient dose (i.e., creating a thinner slice).
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Fig. 1B —Fluoroscopic images after placement of needle into phantom along
graphics of planned path. Purple circle enhances visualization of skin entry
site (purple dot) A, whereas green circle enhances
visualization of target site (green dot). Rot = rotation, Ang =
angle. Entry point view (A), progression view (B), and random
C-arm position (C) are shown.
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Fig. 1C —Fluoroscopic images after placement of needle into phantom along
graphics of planned path. Purple circle enhances visualization of skin entry
site (purple dot) A, whereas green circle enhances
visualization of target site (green dot). Rot = rotation, Ang =
angle. Entry point view (A), progression view (B), and random
C-arm position (C) are shown.
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Multiple graphics for multiple targets and needle trajectories are
supported with this technique. In addition to the superimposition of the
guidance graphics on the fluoroscopic data, it is possible to superimpose the
graphics onto slice data or volume data. This view provides a better
understanding of the needle position with respect to the surrounding
soft-tissue structures that are not visible on the fluoroscopic images.
A limitation of both XperCT and XperGuide is that the patient must remain
still during the procedure. XperCT requires the patient to stay still for 21
seconds. XperGuide needle trajectory requires that the patient continue to be
still so that the virtual CT data set remains coregistered with the true
anatomy (same limitation as with CT guidance, although the 3D update takes
more than 1 minute, compared with seconds for the CT update).
Clinical Cases
The following clinical cases show the unique benefits of XperCT and
XperGuide.
Case 1: Pars Interarticularis Injections
XperCT and XperGuide allowed precise 3D planning and real-time needle
guidance in one technique (Fig.
2A,
2B,
2C,
2D,
2E,
2F,
2G,
2H).
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Fig. 2A —14-year-old boy with chronic back pain and bilateral pars
interarticularis defects. XperCT (FD20 angiography-interventional system,
Philips Medical Systems) image with graphics shows planned needle path
(green) into left-sided pars defect. Purple line is actually purple
circle indicating skin entry site, which on 90° tangent (progression view)
appears as a line.
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Fig. 2C —14-year-old boy with chronic back pain and bilateral pars
interarticularis defects. Live fluoroscopy images obtained with C-arm in entry
point position can be superimposed over XperCT slice (C) or over XperCT
volume (D). Purple and green circles, which enhance visualization of
skin entry site and target site, respectively, are superimposed.
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Fig. 2D —14-year-old boy with chronic back pain and bilateral pars
interarticularis defects. Live fluoroscopy images obtained with C-arm in entry
point position can be superimposed over XperCT slice (C) or over XperCT
volume (D). Purple and green circles, which enhance visualization of
skin entry site and target site, respectively, are superimposed.
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Fig. 2E —14-year-old boy with chronic back pain and bilateral pars
interarticularis defects. Interventional radiologist uses needle holder to
position needle so that both needle tip and hub are superimposed in center of
XperGuide (FD20 angiography-interventional system, Philips Medical Systems)
graphic circle. Table-mounted laser plane (white line) can then be
aligned along shaft of needle to serve as guide for needle advancement.
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Fig. 2F —14-year-old boy with chronic back pain and bilateral pars
interarticularis defects. Interventional radiologist places C-arm in
progression view position to advance needle along XperGuide graphics. Keeping
needle shaft properly aligned with laser plane (white line) ensures
that there is no deviation of needle in anteroposterior and transverse
dimensions.
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Fig. 2G —14-year-old boy with chronic back pain and bilateral pars
interarticularis defects. In this progression view, live fluoroscopy is
superimposed over XperCT volume, and needle has been advanced along XperGuide
graphics (purple and green).
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Fig. 2H —14-year-old boy with chronic back pain and bilateral pars
interarticularis defects. XperCT slice image obtained after advancement of
both needles into bilateral pars defects shows small amount of contrast
material that was injected to confirm needle tip placement and proper
distribution of steroid and anesthetic agent. Calibrated green line shows
user-defined needle path. Purple line is actually purple circle indicating
skin entry site, which on 90° tangent (progression view) appears as a
line. Green line is actually green circle indicating target site, which on
90° tangent (progression view) appears as a line.
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Case 2: Transgluteal Pelvic Abscess Drainage
XperCT allowed precise planning of the approach to ensure an
infrapyriformis trajectory, which is better tolerated by patients, and to
avoid sciatic nerve injury. Although this part of the procedure could have
been readily accomplished under conventional CT, live fluoroscopy helped
direct tract dilatation without kinking the wire and helped ensure final
positioning of the pigtail catheter in an appropriate position that would not
irritate the bladder (Fig. 3A,
3B,
3C,
3D,
3E,
3F).
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Fig. 3A —11-year-old boy with perforated appendiceal abscess in pelvis. With
patient in right-side-down decubitus position, XperCT (FD20
angiography-interventional system, Philips Medical Systems) allows precise
planning for transgluteal pelvic abscess drainage via infrapyriformis approach
away from course of sciatic nerve. Calibrated green line shows user-defined
needle path. Purple line is actually purple circle indicating skin entry site,
which on 90° tangent (progression view) appears as a line. Green line is
actually green circle indicating target site, which on 90° tangent
(progression view) appears as a line.
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Fig. 3B —11-year-old boy with perforated appendiceal abscess in pelvis. With
C-arm in entry point view, live fluoroscopy superimposed over XperCT slice
allows identification of proper skin entry site (tip of hemostat,
circle).
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Fig. 3C —11-year-old boy with perforated appendiceal abscess in pelvis. With
C-arm in progression view, needle is advanced under live fluoroscopy
(superimposed on XperCT slice) along user-defined trajectory graphics
(purple and green).
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Fig. 3D —11-year-old boy with perforated appendiceal abscess in pelvis. With
C-arm lateral to patient, J-tipped guidewire is advanced under live
fluoroscopy superimposed on XperCT slice. Purple and green show trajectory
graphics.
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Fig. 3F —11-year-old boy with perforated appendiceal abscess in pelvis. After
aspiration of 300 mL of pus, pigtail catheter is repositioned posteriorly
within abscess cavity so it will not irritate bladder, which is more
anteriorly located in relation to abscess cavity. Purple and green show
trajectory graphics.
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Case 3: Sacroiliac Joint Injection
Differentiating between the anterior and posterior joint spaces under
fluoroscopy can be difficult. XperCT and XperGuide enabled this
"CT-guided" procedure to be performed in the interventional
radiology suite (Fig. 4A,
4B).
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Fig. 4A —16-year-old girl with chronic back pain for 1 year since motor
vehicle crash. After XperGuide (FD20 angiography-interventional system,
Philips Medical Systems) placement of needle into left sacroiliac joint,
XperCT (FD20 angiography-interventional system, Philips Medical Systems) slice
(A) and XperCT volume (B) show close correlation of needle
placement over path planned by XperGuide graphics (purple and
green).
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Fig. 4B —16-year-old girl with chronic back pain for 1 year since motor
vehicle crash. After XperGuide (FD20 angiography-interventional system,
Philips Medical Systems) placement of needle into left sacroiliac joint,
XperCT (FD20 angiography-interventional system, Philips Medical Systems) slice
(A) and XperCT volume (B) show close correlation of needle
placement over path planned by XperGuide graphics (purple and
green).
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Case 4: Discogram
Three-dimensional XperCT spine reconstruction was easily manipulated on the
3D workstation to open the disk space so that the optimal needle trajectory
could be planned and precisely executed (Fig.
5A,
5B,
5C).
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Fig. 5A —14-year-old girl with chronic back pain and equivocal disk
abnormality on MRI. XperCT (FD20 angiography-interventional system, Philips
Medical Systems) slice with user-defined graphics (purple and
green) of planned needle path.
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Fig. 5B —14-year-old girl with chronic back pain and equivocal disk
abnormality on MRI. Three-dimensional XperCT volume in entry point view
looking down barrel of planned needle path. Purple dot indicates skin entry
site (center of bull's eye) for needle placement; purple circle
enhances visualization of dot.
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Fig. 5C —14-year-old girl with chronic back pain and equivocal disk
abnormality on MRI. In progression view, live fluoroscopy is superimposed over
XperCT slice after advancement of needle over XperGuide (FD20
angiography-interventional system, Philips Medical Systems) graphics
(purple and green).
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Case 5: Translumbar Direct Inferior Vena Cava Central Line Placement
Although planning the needle path and directing the needle into the
inferior vena cava is possible with conventional CT, the super-imposition of
live fluoroscopy with XperCT was invaluable in allowing real-time
visualization of advancement of guidewires, dilators, and the central catheter
(Fig. 6A,
6B,
6C).
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Fig. 6A —10-year-old boy with small-bowel transplant and occluded subclavian,
jugular, and femoral veins who needs central venous access for total
parenteral nutrition. XperCT (FD20 angiography-interventional system, Philips
Medical Systems) planned needle path (calibrated purple line) in
off-axial projection ensures safe trajectory to inferior vena cava (IVC)
avoiding kidney, bowel, renal vein, and ureter. Purple and green ellipses
indicate skin entry site and target site, respectively.
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Fig. 6B —10-year-old boy with small-bowel transplant and occluded subclavian,
jugular, and femoral veins who needs central venous access for total
parenteral nutrition. Progression view of planned needle path (calibrated
green line) ensures cranial angulation, so subsequent guidewire and
catheter will naturally advance into superior portion of IVC toward right
atrium rather than inferiorly toward pelvis. Purple line is actually purple
circle indicating skin entry site, which on 90° tangent (progression view)
appears as a line.
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Fig. 6C —10-year-old boy with small-bowel transplant and occluded subclavian,
jugular, and femoral veins who needs central venous access for total
parenteral nutrition. Fluoroscopy image is superimposed over off-sagittal
XperCT slice after needle advancement into IVC. Note how needle course is
slightly superior to dotted XperGuide (FD20 angiography-interventional system,
Philips Medical Systems) graphics (calibrated green line). This is
because skin entry site (purple) on patient had to be moved slightly
superiorly because interventional radiologist did not account for
cartilaginous lip of iliac wing when determining planned needle path.
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Case 6: Lumbar Sympathetic Ganglion Block
Contrast material was injected under live fluoroscopy, documenting
real-time spread and ensuring that there was no flow into the retroperitoneal
vasculature. If this injection had been performed under conventional CT
guidance alone, intravascular needle tip position could not be excluded (Fig.
7A,
7B,
7C,
7D,
7E).
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Fig. 7A —16-year-old boy with vascular malformation of left thigh and chronic
neuropathic lower leg and foot pain. Axial XperCT (FD20
angiography-interventional system, Philips Medical Systems) shows predefined
needle path (purple) as well as contrast material, which was injected
to confirm needle tip position and show spread of steroid and anesthetic
agent. Green line is actually green circle indicating target site, which on
90° tangent (progression view) appears as a line.
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Fig. 7B —16-year-old boy with vascular malformation of left thigh and chronic
neuropathic lower leg and foot pain. Multiplanar projections show precise
correlation of needle and planned path of XperGuide (FD20
angiography-interventional system, Philips Medical Systems) graphics
(purple and green) and document distribution of injected
contrast material, steroid, and anesthetic agent.
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Fig. 7C —16-year-old boy with vascular malformation of left thigh and chronic
neuropathic lower leg and foot pain. Multiplanar projections show precise
correlation of needle and planned path of XperGuide (FD20
angiography-interventional system, Philips Medical Systems) graphics
(purple and green) and document distribution of injected
contrast material, steroid, and anesthetic agent.
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Fig. 7D —16-year-old boy with vascular malformation of left thigh and chronic
neuropathic lower leg and foot pain. Multiplanar projections show precise
correlation of needle and planned path of XperGuide (FD20
angiography-interventional system, Philips Medical Systems) graphics
(purple and green) and document distribution of injected
contrast material, steroid, and anesthetic agent.
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Fig. 7E —16-year-old boy with vascular malformation of left thigh and chronic
neuropathic lower leg and foot pain. Multiplanar projections show precise
correlation of needle and planned path of XperGuide (FD20
angiography-interventional system, Philips Medical Systems) graphics
(purple and green) and document distribution of injected
contrast material, steroid, and anesthetic agent.
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Case 7: Epidural Steroid Injection
Live fluoroscopy during steroid injection ensured that no contrast material
entered the vascular system or thecal sac (Fig.
8A,
8B,
8C,
8D).
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Fig. 8A —16-year-old girl with back pain and radicular symptoms localizing to
left L5-S1 level. XperCT and XperGuide (FD20 angiography-interventional
system, Philips Medical Systems) graphics (purple and green)
show planned needle path for epidural injection (A). After needle
advancement using XperGuide graphics under live fluoroscopy, small amount of
contrast material was injected to confirm needle tip location in epidural
space in axial (B), sagittal (C), and 3D (D)
projections.
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Fig. 8B —16-year-old girl with back pain and radicular symptoms localizing to
left L5-S1 level. XperCT and XperGuide (FD20 angiography-interventional
system, Philips Medical Systems) graphics (purple and green)
show planned needle path for epidural injection (A). After needle
advancement using XperGuide graphics under live fluoroscopy, small amount of
contrast material was injected to confirm needle tip location in epidural
space in axial (B), sagittal (C), and 3D (D)
projections.
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Fig. 8C —16-year-old girl with back pain and radicular symptoms localizing to
left L5-S1 level. XperCT and XperGuide (FD20 angiography-interventional
system, Philips Medical Systems) graphics (purple and green)
show planned needle path for epidural injection (A). After needle
advancement using XperGuide graphics under live fluoroscopy, small amount of
contrast material was injected to confirm needle tip location in epidural
space in axial (B), sagittal (C), and 3D (D)
projections.
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Fig. 8D —16-year-old girl with back pain and radicular symptoms localizing to
left L5-S1 level. XperCT and XperGuide (FD20 angiography-interventional
system, Philips Medical Systems) graphics (purple and green)
show planned needle path for epidural injection (A). After needle
advancement using XperGuide graphics under live fluoroscopy, small amount of
contrast material was injected to confirm needle tip location in epidural
space in axial (B), sagittal (C), and 3D (D)
projections.
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Conclusion
XperCT combines the most valuable interventional features of CT and
fluoroscopy into one technology. It allows real-time visualization of
interventional procedures using 3D CT-like images. The XperGuide ensures
accurate needle advancement following user-defined trajectories; this results
in more confident anatomic navigation. These new techniques expand the
procedural capabilities of interventional radiologists and should thus improve
patient care and outcomes.
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Abstract
Introduction
