Advanced 3D Guidance for EVAR Procedures - … · Advanced 3D Guidance for EVAR Procedures Gilles...
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Advanced 3D Guidance for EVAR Procedures
Gilles Soulez, MD, MSc
University of Montreal
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Disclosure & Acknowledgments
• Research Grants• Canadian Health Research Institute
• Canadian Fundation of Innovation
• Natural Sciences and Engineering Research Council
• Fonds Recherche Québec-Santé
• Siemens Medical
• Cook Medical
• CAE
• Patent licensing (Cook Medical)
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Current limitation of CT planning and 2D DSA guidance for EVAR
• Procedure planning performed on CTA
• DSA guidance• Radiation exposure and CIN
• Need to recreate ideal projection for each procedural step
• No visualization of thrombus to delineate landing zones
• Increasing incidence of complex EVAR
• Hostile neck
• Branched/Fenestrated
• Chimney
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Renal function & EVAR
• GFR ml/min• Stage 1 >90
• Stage 2 60-89
• Stage 3 30-59
• Stage 4 15-29
• Stage 5 < 15
Brown LC. An Surg 2010;251-966-975
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Irradiation
• EVAR & irradiation1
• Planning CT
• EVAR + CT FU at 1, 3, 6 and 12 months and annually
• 145-205 mSv on 5 years• 70-year-old = attributable cancer risk = 0.60% (1 in 170).
• 50-year-old = 1.03% (1 in 100)
• 30% of CT scan unnecessary 2
• Stochastic injuries due to staff exposition3
1.White HA. J Cardiovasc Surg 2010 51:95-104 2. Zhou W. J Vasc Surg 2010 3. Stecker MS-JVIR-2009
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• Alignment 3D and 2D projection
• Real time fluoroscopy with2D/3D overlay
• Synchronization of 3D rendering with C-arm angulation
Improve guidance 3Droadmap
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Per-operative 2D/3D Workflow
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Limitation of overlaying CT volume rendering and fluoro
• Thrombus outline is not seen
• Superposition of VR will mask guidewires, delivery device and stent markers
• Only a rigid registration can be performed since you do not have a mathematical geometric model (Mesh)
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How to improve volume overlay
• Fading in and out
• Stent boost
• Use vessel transparent dysplay
• Complete segmentation of AAA lumen and thrombus outlines
• Create a lumen and thrombus mesh
• Dysplay only the mesh
Dijkstra-ML-J-Vasc-Surg-2011Tacher-V-JVIR-2013
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AAA segmentation and modeling• Longitudinal view of the
AAA
• Outerwall segmentation from the celiac trunk to one selected iliac artery
• Segmentation plans defined on transverse section of the AAA
• 3D rendering of the AAA lumen and thrombus
• Automated D-Max and volume measurements
Kauffmann C et al. EJR 2011;77:502-8
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Automatic CT segmentation for lumen and thrombus
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Planning
• Define centerlines• Aorta, iliac, renal arteries• CT, SMA• Internal iliac arteries
• Propose and define the best working view for each procedural steps
• Orthogonal projection to target vessel centerline
• Adjust if needed for C-arm mechanical range
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3D/3D Registration
• Perform a CBCT• Before draping
• Automatic bone registration• Spine/spine
• Fine tuning of registration based on vascular
• Calcification alignement• Vessel ostia
• Projection of 3D CT mesh in the fluoroscopic spac
• Synchronization of C-arm, table, magnification with the new 3D/3D space
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Registration with Biplanar Fluoroscopy
• Separate VR of spine and aortic lumen from CT
• Spine fusion /biplanar fluoroscopy
• Replacement of spine by aortic lumen
• Advantage• Dose• Easy
• Drawback• Absence of precise vascular
alignement
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Rigid registration
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Live DSA correction
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Live DSA correction
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Registration accuracy
Registration renal arteries Error X axis
Error z axis
Before correction mm 10.6±11 7.4±5.3
Bone based correction mm 3.5±2.5 4.6±3.7
DSA correction mm 0.6±0.7 0.3±0.4
•3D/3D registration is generated at the onset of the procedure (before patient draping)
•Need to minimize patient motion
•Influenced by anesthesia
•Arm position
Kaufmann et al. JVIR 2015
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Optimization of overlay for bone correction
• Substraction of bone marrow to outline bone contours
• Manual bone based correction of the 3D/3D alignement during fluoroscopy
• Manual alignement optimization based on DSA
• Mean error on renal• 1.95 ±2.46 mm (0-7 mm)
Fukuda-T et al. Europ-J Vascular-Endovasc-Surg-2013
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Iliac artery
• Iliac centerline deviation• 38.3±15.6mm
• Ostia internal iliac artery• Ipsi lateral
• 5.6±2mm (x axis)
• 4.3±3mm (z axis)
• Contralateral• 6.1±3mm (x axis)
• 5.5±4.2 (z axis)
Kaufmann et al. JVIR 2015
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Vascular displacement is a concern
Deformation induced by endovascular devices
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Elastic registration with automated detection of endovascular devices
Lessard S et al. Med Eng Phys 2015
Device segmentation
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• Errors at the internal iliac ostia estimation after a mesh deformation, measured offline
• 28 patients (21 EVAR and 7 FEVAR)
• 43 measures
• Before correction mean error 11.3±7mm
• After correction 1.99±2.03 mm
• 19 no error
• Principal suspected causes of error
• External iliac high curvature
• High calcification score
Preliminary results
Lessard S et al. Manuscript in preparation
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Deformation influenced by calcification and curvature
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Ideal Workflow for minimizing misregistration
• AAA mesh creation > MIP or VR overlay
• CBCT > biplanar ?• Better alignment of vascular structure on CBCT (calcification)
• Continuous and automated process of bone correction to correct bone displacement
• Apply correction on CBCT/CT fusion model
• Update of vascular structure• Guidewire (geometric centerline alignement)• After each DSA
• Mechanical modeling (FEA)
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Clinical utility for standard EVAR
• 72 pts database /matching based on BMI
• 16 vessel navigator
• 16 conventional DSA
Stangenberg-L-J-Vasc-Surg-2015
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2D/3D interesting for complex EVAR
• Increasing proportion of EVAR in hostile neck anatomies
• Fenestrated/branched SG/chimney procedures
• Helpful to align fenestration and catheterize side vessels
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Fenestrated/branched EVAR
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Tacher-V et al JVIR 2013
Clinical utility
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Clinical utility: fenestrated, branched SG
• 72 patients FEVAR• 41 no CT fusion
• 31 after CT fusion
• Less• Fluoro, procedure time
• Radiation, Contrast dose
• Less blood loss (p<0.0001)
• Trend for lower hospital stay (p=0.07)
Mc Nally et al. J Vasc Surg 2015
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102 pts intra-operative fusionStandard (44)/Fenestrated (18)/Branched (26)/Thoracic (14)
Hartault-A-Eur-J-Vasc-Endovasc-Surg-2015
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Comprehensive biomechanical modeling of EVAR
• Developing a comprehensive patient-specific biomechanical model of the aorto-iliac vascular structure and surrounding organs
• Intra-luminal thrombus
• Abdominal fat
• Spine
• Simulating EVAR to perform advanced procedural planning
• Assessing arterial deformations during EVAR
• Improving 2D/3D roadmap guidance (elastic registration using the simulation outputs
• Performing procedural rehearsal for physicians training
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EVAR simulation
• Use the mesh to create a biomechanical model
• Aorta• Stent-graft
• Use Finite element analysis to estimate the interaction between SG and aorta
• Simulate SG deploiement to optimize SG planning
• Simulate vessel deformation to optimize image guidance
• Procedure reharsal for training
Roy D et al. IMA Journal of Applied Mathematics 2014;79:1011-1026
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Displacement = 80mm
Lumen only
Finite element mesh
Points defining the spine curve
Done in 10 min. from segmentation files.
Simulation: aorta
Roy D et al. Numerical analysis 2014
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Overall Workflow
StartPatients AAA, Thrombus, Spine, Pelvic
Bone and Fat Reconstruction
Deformation and configuration
Plug in for translating patient data to LSDYNA
Select stent-graft
Deployment Simulation
Zero Pressure GeometrySimu
lation
Translating simulation result to prioperative softwareR
oad
map
Tools identification
Proper simulation selection
Tools detection
3D roadmap
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Patient geometry reconstruction
Thrombus
Patient from LCTI database
Spine
Lumen
ORS software
Numerical Model
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Device Characterization (Cook Medical)
1
23
Equivalent mean properties for typical sections of body and leg catheters.
123
Eaxial = 402 MPaEcirc. = 165 MPa
Stent(Steel/nitinol)
Graft(Dacron)
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Abdominal fat characterization
• The hyper-Viscoelastic material is considered for the surrounding organ
• The experimental data on human adipose
tissue is taken from Gerhard Sommer et al.
Stress strain data
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Vessel Wall characterization
• AAA exhibits significant anisotropic behavior
Stress strain data
39
•Hyperelastic Matrix •Collagen fibers reinforcement•Layered structure of AAA
Matrix Fibers
I=IntimaM=MediaA=Adventitia
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Results: Arterial deformation by guidewires
Dugas A et al. CVIR 2012;35:779-87
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Results: Stent-Graft Deployment
(1) (2) (3)
(4) (5)
(6)
41
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Results: Stent-Graft Deployment
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Multimodal image fusion and simulation for EVAR
• 3D roadmap will minimize procedure time, contrast, irradiation and complication in complex EVAR procedures
• Improved visualization and correction if overlay done after AAA segmentation and mesh creation
• Automated device detection useful to perform geometric correction during the procedure
• Biomechanical simulation of AAA, SG and their mutual interaction will play a major role in the future