The next leap in simplifying and advancing 3D imaging by BIBA Publishing

June 2021 | Educational Supplement

interventionalnews.com

This educational supplement has been sponsored by Phillips

SmartCT

Introducing the next-generation Azurion: Simplifying 3D imaging with SmartCT Studies have shown that three-dimensional (3D) computed tomography (CT)like imaging can enhance diagnostic accuracy,1–3 and support improved patient outcomes.4 Despite these advantages, it can still be considered difficult to perform by many users. The Philips Image Guided Therapy clinical application software SmartCT, working with the Azurion image guided therapy platform, simplifies 3D acquisition for clinical users, by providing step-by-step guidance and visual aids. In addition, once acquired, 3D images are automatically displayed on the touch screen module in the appropriate rendering mode, and the user can easily control and interact with advanced 3D visualisation and measurement tools. In this educational supplement to Interventional News, readers can find a step-bystep guide to the streamlined workflow enabled by Philips SmartCT (page 3). as well as testimonials from physicians familiar with SmartCT (pages 4–7).

Azurion SmartCT guided acquisition

WITH THE COVID-19 PANDEMIC increasing the demand for CT scans, access to 3D imaging has never been more important. 3D images are “CT-like” in nature, and provide high-resolution renderings that significantly aid in performing complex interventional procedures. SmartCT has a variety of advanced 3D acquisition, visualisation, and measurement tools, all of which can be controlled at tableside on the intuitive touch screen.

SmartCT Angio

SmartCT Angio is an X-ray acquisition technique that generates a high-resolution 3D visualisation of either cerebral, abdominal, cardiac, or peripheral vasculature from a single rotational angiography run—all controlled via the touch screen at the table. This can improve visibility of tortuous and complex anatomy. After acquisition, clinicians can quickly render volumes, segment lesions and vessels, perform measurements, and mark vessel paths to assess the size and location of pathology and thereby plan the optimal treatment.

SmartCT Soft Tissue

SmartCT Soft Tissue is an X-ray acquisition technique that generates a CT-like visualisation of soft tissue in relation to other structures during procedures—all controlled via the touch screen at the table. The CT-like images can be used to assess soft tissue, bone structure, and stent deployment before, during, and after interventional procedures. This technique is particularly useful for oncology and neurology procedures because it aids in better assessing the soft tissue of structures affected by the vasculature of interest.

SmartCT Vaso

This technique provides high-resolution 3D imaging that reveals key information about cerebral vascular structures to support the highest possible spatial assessment of vessels in the soft tissue cohort.

SmartCT Roadmap

SmartCT Roadmap provides a live 3D image overlay that can be segmented to emphasise the targeted vessel and lesions, supporting fast catheter navigation. The SmartCT

Hicham Kobeiter interacting with the 3D visualisation tools on the touch screen module

3D images in the angio lab are 'CT-like' in nature.” Roadmap overlays a 3D reconstruction of the vessel tree, vessel segments, or lesions with live fluoro images. The transparency and contrast of the 3D image can be adapted to enhance visibility of details.

References 1. Loffroy R et al, Comparing the detectability of hepatocellular carcinoma by C-arm dual-phase cone-beam computed tomography during hepatic arteriography with conventional contrast-enhanced magnetic resonance imaging, Cardiovasc Intervent Radiol. 2012, 3. 2. Berman et al, The use of three-dimensional rotational angiography to assess the pulmonary circulation following cavo-pulmonary connection in patients with single ventricle. Catheter Cardiovasc Interv. 2012 Nov 15;80(6):922–30. 3. Schernthaner et al, Delayed-phase cone-beam CT improves detectability of intrahepatic cholangiocarcinoma during conventional transarterial chemoembolization, Cardiovasc Intervent Radiol, 38 (4), 929–36, 2015. 4. Miyayama et al, Comparison of local control in transcatheter arterial chemoembolization of hepatocellular carcinoma ≤6cm with or without intraprocedural monitoring of the embolized area using cone-beam computed tomography, Cardiovasc Intervent Radiol, 2014, 37 (2), 388–95.

June 2021

SmartCT

Advancing 3D imaging

SmartCT streamlines IR workflow SmartCT—the Philips Image Guided Therapy clinical application software that works on the Azurion image guided therapy platform—streamlines workflow in the interventional radiology (IR) suite. From the easy room set-up and intuitive, comprehendible protocol selection, to the ability to acquire and interact with 3D images at the table-side, the solution is designed with the modern interventionalist in mind.

Table-side control

One way the system achieves this slick workflow is to make all acquisition, visualisation, and measurement tools accessible on the touch screen. This offers total control of 3D imaging within the sterile field, which can save time during procedures; this is especially useful when treating patients within the context of the COVID-19 pandemic, when demands on hospital resources and time are high. Many tasks (such as 3D lesion segmentation and centre line with vessel contour detection) are semiautomated and made available at table-side to speed up 3D image analysis. With SmartCT, the user can perform two-point Marc Sapoval setting up a CBCT acquisition following SmartCT's step-by-step guidance measurements on 3D images on the touch screen. This can help to quickly Injection protocol suggestioni check the length to a target vessel, measure To help have a consistent image quality of distances for stent deployment, measure the the contrast-enhanced 3D images, SmartCT size of anatomy, or identify a discrepancy to displays a suggestion of injection protocol speed up planning of the optimal treatment that is customisable. angle and aid navigation. In addition, clinicians can choose and Easy isocentering store the projection angles they want for their Zero dose isocentering can be performed by treatment. SmartCT, providing visual feedback of the With SmartCT, it is possible to rotate field of view position in both AP and lateral, the 3D image and store the corresponding using previously acquired projections. projection angle that will be used during treatment. With Azurion’s full system Easy 3D acquisition automatic position control (APC), the user In order to prevent the user from releasing the acquisition button too early, SmartCT can recall any of the stored positions. guides the clinician or technician: once they Furthermore, the cut anatomy tool in the have pressed the acquisition button, the SmartCT software allows interventionalists system starts a countdown visual feedback on using the platform to quickly and easily the time, which remains for X-ray delay and cut away structures that obstruct the 3D actual 3D acquisition. It will prompt the user visualisation of the anatomy of interest. to release the button once the rotational scan Several other features of the SmartCT is completed. system underpin its success at simplifying workflow in the IR suite.

Easy room preparation

Room preparation tasks can be shown on the FlexVision to help the physician position equipment and the Azurion system so that 3D images can be acquired any time they are needed during the procedure. June 2021

Easy protocol selection

To help easily select the required protocol, SmartCT’s acquisition guidance displays pictorials showing the type of 3D image that can be selected, without the need to memorise the name of the protocol.

Easy 3D interaction on the TSM

Once acquired, the 3D image appears within a few seconds on the TSM and the FlexVision, prompting the interventionalist with the corresponding rendering mode, ready for them to review and analyse on the TSM.

The injector protocols shown by SmartCT are suggestions that the user can tailor as desired. Philips does not endorse the use of injector protocols.

SmartCT

Tableside control of imaging settings facilitates high standard of care With more than a decade’s experience of using Philips Healthcare systems, Hicham Kobeiter enthuses to Interventional News about the new SmartCT system, which he has had in his department since the summer of 2020. He emphasises the intraprocedural display of a step-by-step guide to the intervention, the interface’s user-friendly nature, and, most importantly to him, tableside control of imaging settings as especially useful features.

clinical answers and meet physicians' needs. SmartCT is the latest evolution of the interface developed by Philips to help interventional radiologists and their team members in the Hicham Kobeiter angiosuite master image guidance, whatever their level of expertise with 3D imaging.ii All steps of the intervention are displayed on monitors intraprocedurally, which measurably aids workflow.

What is the learning curve like for the SmartCT system? Hicham Kobeiter interacting with the 3D image at table-side

Can you give us a brief description of your department?

Our interventional radiology (IR) unit is a part of the imaging department at the Henri Mondor University Hospital in Créteil, France. Our IR unit includes two angiography labs: one with the Philips AlluraClarity monoplane, and one with the Philips Azurion biplane. The team’s expertise covers all types of image-guided therapy within IR, including endovascular aneurysm repair (EVAR), thoracic endovascular aortic repair (TEVAR), peripheral arterial disease (PAD) management, embolization, chemoembolization, Y-90 treatment, stenting, ablation, and venous access.

How important is 3D imaging in your procedures?

We started working with Philips in 2009, using their software to overlay 3D images onto the patient`s live images during aortic endovascular treatment. We have since published work evidencing the feasibility of this technology, and demonstrating the impact of these techniques on reducing the volume of contrast media used. Based on our positive experience, we extended this use to almost all other fields of IR, including in visceral aneurysm embolization, transarterial chemoembolization (TACE), Y-90 HCC treatment, transjugular intrahepatic portosystemic shunt (TIPS) and prostate artery embolization (PAE).

SmartCT gives interventional radiologists more autonomy.” The goal of this 3D imaging and overlay software is to obtain better detection and precision, and to reduce complications.

How do you divide the tasks between interventional radiologists and technologists?

The involvement of technologists in radiology is crucial to the successful use of 3D imaging during interventions. Before starting any procedure, the room set-up and C-arm and table positioning should be checked by the technologist. During the intervention, the technologist is in charge of ensuring that protocol is followed, and that the system set-up is verified. For our team of technologists and physicians, 3D imaging is a routine acquisition.

What does the SmartCT add to your Philips systems?

We have been collaborating with Philips for more than a decade to develop different types of image guidance software. Over time, this software has become increasingly user-friendly and better adapted to provide

The user level of expertise required is described in the SmartCT Instructions for Use as the Intended Operator Profile. The views expressed reflect personal experiences. Results may vary.

iii

SmartCT is really user-friendly! There is a learning curve, but it is relatively short: two to seven days, depending on if you are used to another system, or if you are starting with SmartCT. If you are used to another system, the learning curve is longer than first starting with this very intuitive software.

What changes did you implement in your department during COVID-19?

All COVID-positive patients were isolated from non-COVID patients. Physicians working with infected patients had to follow a set pathway to get to the IR suite. Once the patient was in the room, all staff who were inside had to stay within the operating room and could not go back to the control room. SmartCT really came into its element in this scenario; it allows the user to have control over almost all of the imaging settings— including fluoroscopy, 2D and 3D imaging, reviewing diagnostics, and reconstructions— directly from the control-pad at the tableside. By having this autonomy we could reduce the risk of spreading the virus between the operating and control rooms in the IR angiosuite.

What are the top two features of SmartCT? Tableside control of image settings, and the ability to control the 3D workstation and reconstruction at the tableside. Hicham Kobeiter is an interventional radiologist at the Henri Mondor University Hospital in Créteil, France.iii June 2021

SmartCT

Advancing 3D imaging

3D image acquisition and visualisation with SmartCT helps reduce PAE procedural time Marc Sapoval explains how the Azurion with SmartCT system (Philips) aids prostate artery embolization (PAE); by enabling the easy 3D visualisation of the complicated prostate anatomy, the system helps interventionalists locate the prostate artery and calculate the appropriate angulation for approach.

Can you give us a brief description of your department?

We have two angiography labs with cone beam CT, and one interventional CT unit. We cover all aspects of interventional radiology (IR) in our department, with the exception of neurointerventional procedures. We have had the Philips Azurion system for one year.

Do you think the use of 3D imaging is only for less experienced interventional radiologists?

Not at all! I actually believe the more expertise you acquire, the more interest you develop in cone beam CT. I think everybody needs it, from the resident to the senior physician. Specifically in PAE, cone beam CT is useful for finding the target vessel and the appropriate approach projection, for confirming that the prostate is covered by the artery, and for ensuring the absence of any non-target vessels

reduce the number of angiography acquisitions and reduce the duration of the intervention. In addition, now we can interact with the 3D images in Marc Sapoval the room, we do not need to unscrub and re-scrub several times to access the 3D imaging console anymore.

PAE is a complex and challenging procedure. Does SmartCT help overcome some of the challenges? It does in the sense that it brings 3D imaging into the lab and makes it a real clinical reality, thus allowing us to perform a much safer intervention. The 3D visualisation also really helps with identifying the prostate artery; this is very challenging in PAE, as the vessels are so small. Finding the appropriate angulation of approach and the correct

The workflow is faster with SmartCT.” SmartCT. In terms of room set-up, it gives you more independence—if there are no technicians in the room, you can do the job on your own, which is real progress from having to have a technician in the control room to manipulate the 3D volume for you.

How do you typically divide the tasks between interventional radiologists and technologists during your PAE interventions?

Radiologists are now empowered to perform the 3D processing themselves at tableside if required—though they should not take over the role of technologists. Advanced 3D processing can still be performed by the technologists in the control room using the broader capabilities of the SmartCT workstation. This co-operation is of real added value for the team.

How user-friendly is SmartCT?

Marc Sapoval using SmartCT in a PAE procedure

What has changed since the upgrade of your system to SmartCT?

Having SmartCT allows the interventional radiologist to do all the mapping and processing themselves at the table-side, meaning they do not have to rely on a technician—who is sometimes super welltrained, but is also sometimes unable to help due to high staff turnover. Before SmartCT, we would initially do a diagnostic angiogram to find the target vessel. Now, we can June 2021

vessel are the most demanding aspects of the procedure, and SmartCT helps make these easier. It is also useful in confirming that you are in the right vessel once the procedure has started, limiting non-target embolization (the most common complication with PAE). What is good about what we have now is that we can do SmartCT with lateral positioning of the C-arm because we have a ceiling-mounted room, as opposed to a floormounted room, which has some limitations. In addition, the workflow is faster with

The views expressed reflect personal experiences. Results may vary.

There is a learning curve, but a fast one. While it is relatively short, this is always a hard question to answer: it depends on your case numbers, and the time you take to really master the technology. I would say that after maybe 10 cases, you begin to have a good understanding of the basic functions, which will allow you to do maybe 60–70% of the job. The next level will probably take more time, but, overall, I think it is a reasonable learning curve. It is adapted to our clinical practice, so does not require tremendous effort to master at least the basics of the technology, and to become almost independent.

What are the top two features of SmartCT? The system’s ease of use, and its reliability.

Marc Sapoval is an interventional radiologist at Georges Pompidou European Hospital, Paris, France, and co-founder of the Global Embolization and Cancer Symposium Technologies (GEST).iv

SmartCT

The Azurion system in complex EVAR: “Spacious, comfortable, and extremely intuitive” Wouter Van Den Eynde talks to Interventional News about his experience with the latest Azurion system (Philips), enthusing about its intuitive nature and flexible C-arm positioning. While he chooses to use Azurion for all his endovascular procedures, he specifically talks through his set-up for a complex endovascular aneurysm repair (EVAR), highlighting how the system helps at all stages: pre-, intra-, and post-procedurally.

When would you use Azurion with FlexArm?

We use the FlexArm for all our endovascular procedures, from aortic interventions to carotid stenting and embolization procedures. Hybrid procedures, such as aortic arch and ascending aortic repairs, are also performed in our hybrid room in cooperation with our cardiac surgeon colleagues.

What do you like about the Azurion with FlexArm?

The control and positioning of the C-arm is extremely intuitive compared with the previous version. With only one button you can move the C-arm into the desired position. Creating fusion images is possible by using a two-dimensional (2D) or threedimensional (3D) registration. Both are easily performed and controlled with the touch screen on the table. We preferentially use the 3D registration because of its greater accuracy. Once the fusion image is created, you can simply change it with the touchscreen. Another advantage is the FlexArm. The FlexArm offers maximal flexibility and is not as bulky as a floor-mounted system. With the FlexArm, the operator or nurse no longer has to adjust their position in relation to the C-arm; now, the C-arm can be completely adjusted to the position of the surgeon and the nurse, offering improved ergonomics. The FlexArm also gives us the option to make off-centre images, as the C-arm can function in all possible angulations and positions. Furthermore, the on-table touchscreen allows us to control the complete system while standing in a sterile environment next to the patient.

Which Azurion tools support you the most during your 6

procedure? How do these tools benefit your procedures? The latest Azurion version offers several new tools, such as the full-system automatic position control (APC). Another very useful feature is the marker tool, where you can mark a target vessel or lesion by using the touch screen or the mouse. Even accurately measuring the diameter of a vessel or lesion length is easy with the touchscreen. The touchscreen allows you to use the optical zoom and to locate the point of interest in your image. With the FlexSpot workstation, we are able to plan and to prepare all our cases simultaneously while the hybrid room is being used by a colleague. Each aortic intervention is finished by doing a cone beam computed tomography

Having the fullsystem APC makes it possible to exactly recall any C-arm and table position from any previously performed Digital Substraction Angiography or stored Fluoroscopy run.” (CBCT) at the end of the procedure to detect stent abnormalities. The Philips Azurion offers us the possibility of doing dual-phase CBCT, which can be useful in detecting and classifying endoleaks. The dual-phase

CBCT is also used to detect acute bleeding sites whereby the second and late phase can be helpful in the detection of lowflow bleeding.

Why would you use cone beam CT during complex EVAR procedures? What extra information does a cone beam CT provide you compared to DSA? Wouter Van Den Eynde

We start almost every EVAR procedure with a CBCT with a 3D registration for the fusion imaging. Furthermore, each procedure is finished by doing a CBCT with or without contrast, depending on the renal function of the patient. A CBCT without contrast is useful to detect any stent compression or insufficient overlap at the level of the fenestrations or branches in cases of complex EVAR. It is also useful in EVAR cases with tortuous iliacs or small aortic bifurcations to detect stent compression or stenosis which can be missed with a DSA. A CBCT with contrast can be helpful to detect and to classify endoleaks and to make immediate treatment of type 1 and 3 endoleaks possible with a reduction of the reintervention rate. With a DSA, classifying an endoleak is not always straightforward.

What are the challenges in setting up the operating room for using cone beam CT during an EVAR procedure?

When performing a CBCT with the Philips Azurion, the path of the C-arm is obvious. No changes are required in our set-up or installation of the patient, because the CBCT programme of the Philips Azurion offers two different ways to do a CBCT with 3D registration. The first is a propeller-like movement with the centre of rotation at the proximal end of the table. This requires several changes in your set-up. However, when making a 3D registration with a roll movement with the C-arm perpendicularly positioned over the patient, no adaptations are necessary.

For what other type of vascular procedures would you use SmartCT?

During embolization procedures, SmartCT is also very valuable. The fusion imaging helps us in defining and understanding the anatomy to the target lesion. EmboGuide calculates and indicates the path to follow to get to your target lesion. In cases of low-flow bleeding, June 2021

Advancing 3D imaging

FlexArm with VesselNavigator

SmartCT Soft Tissue after FEVAR

FEVAR with VesselNavigator

SmartCT Soft Tissue after EVAR

it is not always possible to visualise the focus during the arterial phase. In those cases, a dual-phase CBCT can be very helpful.

SmartCT is a user-friendly and intuitive platform to do a CBCT and 3D-rotational angiography imaging. The system guides you through the procedure with stepby-step instructions.”

What was your experience of the learning curve for SmartCT? SmartCT is a user-friendly and intuitive platform to do a CBCT and 3D-rotational angiography (RA) imaging. For each different modality, the system guides you through the procedure with step-by-step instructions on your screen. The touchscreen also makes the learning curve very short.

Can you describe your workflow using SmartCT during a typical complex EVAR case? Each aortic intervention is prepared by selecting and marking our target vessels on the preoperative CT scan in VesselNavigator, which will be used to create an overlay for the fusion imaging. The procedure is started

by taking a 3D registration when the patient is installed in the operating room, but before they are prepped and draped. When no calcifications are present in the aortic wall,

a 2D registration is made instead of a 3D registration, where bony landmarks are being used as a reference. Both registrations are performed bedside with the touchscreen and take two to five minutes. During the procedure, when the endograft is at the intended deployment site, the first angiography is made. These images are used to correct our fusion imaging with the touchscreen. Once corrected, the fused images continuously follow the movement of the C-arm and table during the whole procedure, thereby reducing the radiation exposure. When the endografts are successfully deployed and all target vessels are connected, a DSA and CBCT/3D-RA is made. This enables us to detect endoleaks and compression or stenosis of the stents. Wouter Van Den Eynde is a vascular and endovascular surgeon at the Imelda Hospital, Bonheiden, Belgium.v

All rights reserved. Published by BIBA Publishing, London T:+44 (0)20 7736 8788, publishing@bibamedical.com. The opinions expressed in this supplement are solely those of Philips and the featured physicians and may not reflect the views of Interventional News.

June 2021

The views expressed reflect personal experiences. Results may vary.