So the overall intention of using 3D. So you can either a spin or an outside CT or MR, etc.
To reduce radiation and contrast media. More information than just standard, static 2D imaging. Not necessarily static but, just 2D imaging where you'd have to rotate the angles. And with that image information you can actually rotate it around and actually use it in real time.
So it's for improved clinical success. The tools are obviously a 3D data set. Overlay and then in addition to the overlay you can use 3D advanced applications.
So in a nutshell 3D overlay is superimposition over live fluoro, right?
You can either use a DynaCT or a conebeam CT in the room. Segment out that information and then overlay it. Or you can use an actual outside 3D data set. Any Dicom image data set will do. Regardless of the vendor. So you would import it and then merge
it with the current exam study. Here again this is kinda one of our 3D graphics of merging an MRI and a CT. So they kinda correlate. It uses less contrast. You can save up to 99% of the dose.
These are all variables but we have had studies where we have had that low of dose reduction.
So here are some quick examples. So this was taken from one of my customers. It's just a simple DynaCT or conebeam CT. You do a hand injection with a syringe
because there's obviously no automated CO2 injectors out there that I'm aware of, right now. And these are the safest. And what they would do is over the cross sectional anatomy right there they would just put dots, right. And the line, the computer would connect the dots.
Right here, and that would be it. And it looks like a little stick man. So I was watching and they were doing this very efficiently at the site. And I kinda was looking at it and I was like, why don't we take this one step further.
You already have the information, the CO2 information right here, right. That lack of contrast is the CO2 gas, so by using an algorithm in our system you can actually derive that. So you can, both work.
You're still just trying to connect your needle to either the line or the 3D graphics. But this is just a simple window and level. You cut out somethings with the computer just so that it's not obstructing any view. And you hit overlay, and that's it.
And what this does is as you rotate the C arm. Left, right, obliques, cranial caudal, zoom, this all tracks, this all stays with you. I can pull the patient, slide the patient out of the field of view, bring them back in. It's all still there.
This is one of the other methods and this is actually using the outside CT previously. A late contrast, or a late phase CT. You have to do a little more post processing on these CTs. So it's more of the planning stage. Probably about five, 10 minutes before the study
is often times how it's done. Where the imaging staff will go in with a tool and kinda carve out the portal vein. And so this is what we got. And with this there's often times just slight manipulation of the 3D because of patient positioning.
And we'll kinda cover that later. This was actually a very successful study that we did.
Here again you're gonna see a theme running here. It really doesn't matter what the anatomy is. In this situation obviously it's a cerebral aneurysm. You do a 3D DSA spin, the vessel automatically segments out.
So you can actually look at it. This is what a lot of neurologists will do. They'll just look at it, spin it around, that's great. Go in and treat the aneurysm. When the next step, all you have to do is hit overlay and it projects itself over the live fluoro.
You can fade that in and out just like a roadmap. It's exactly what this is. This is just a 3D roadmap where I don't have to continually inject over and over. If I change my working angle I don't have to inject this. Okay so we're reducing dose
and we're reducing contrast load. So you can obviously see the, I'm getting confused here. You can actually see the wire into aneurysm.
This is from our EVAR, fusion overlay. You can obviously segment out the osteo regions. Renal, SMA, you can actually just have
a wire frame around here. Just an outline segment out the renal arteries. You would just take a pre-procedural CT. Import it into the live study or you can do a CT, a DynaCT in the room with the five second protocol.
So I think the advantages over importing a CT, you are not having to inject a load of contrast for five seconds. When the CT already has the data. But sometimes the physicians will want a realtime study. So if something has changed.
It's just yet another, this is our fusion package. 3D 3D fusion, 2D 3D fusion which I really haven't covered yet but in a sense 3D fusion is taking a 3D CT or an MR and a spin in the room, lining up the information. Make sure they matchup and then they become one in a sense.
Don't really go into depth on that but it's just overlapping and then they know where each other belong, they know how they're associated with each other so. 2D fusion is I take a 3D data set and I take an AP and a lateral fluoroscopy image and then I line it up.
That is actually sometimes quicker. It seems to be a little less confusing sometimes but it kinda depends on the study. But it's really a great advancement where I don't have to do another spin, I don't have to radiate somebody a little bit more.
You just take an AP fluoro and a lateral fluoro. Line it up, good to go. And this is just superimposing blood volumes and I mean it's really not isolated to particular studies. It obviously can be overlaid into live fluoro. Tumor size, blood capacity, so you can get multiple areas
of information all in one.
This is obviously a carotid. Using 3D registration. So this is, the orange would be the spin we did in the room. The gray would be the outside CT that had all the information on it.
You line up the information in multiple planes. You segment out, you click overlay, and there you go. So you have a roadmap exactly like you would be thinking of, just take an AP and a lateral as opposed to injecting contrast, there you go. It is superimposed over your live fluoro.
This is one of our studies we kinda hold up. Using about 10 Ccs of contrast we were able to angioplasty stent a renal artery. An angiogram, obviously the stats are down here. We fused and superimposed the aorta, which include the renal.
You can mag up, no additional injections, nothing. And from there the wire was guided over. That was actually the wire there. Angioplastied a post dilatation angio and they were done. I mean imagine only taking two angiograms to stent a renal artery.
So there are, this is not a one size fits all type of situation. It's a kind of, I kind of use the language with some of my clients, it's a choose your own adventure. There are pros and cons to each. It's current if you do a DyanaCT
or a conebeam CT in the room. It's current information, it's real time. It's right there, it's what's happening. It's not a week ago or two weeks ago. There's no fusion necessary. So you just do the spin.
You manipulate the image and you click overlay and there it is. The cons are, sometimes there's setups right. You have sterile drapes. You have lines, you have wires, you have anesthesia who's upset that you're even encroaching on their space.
You have physicians tapping their feet. So if done smoothly it's fine but there are those times where you actually need to do some adjustments and additional contrast injection if it's an arterial study. With the DynaCT you also don't get as detailed information
as you do with a CT. So the pros for using an outside study. It's already acquired. You have everything needed. There's no additional radiation needed to the patient. You don't have to do another spin.
No additional contrast. Any data set. The cons, mismatching. In the CT or the MR maybe they were done with their arms up. In our exam room, arms are down. You always see slight shift in anatomy internally.
That can be taken care of during the procedure just with a slight adjustment but you have to do an injection, confirm that it's adjusted or confirm any adjustment and then slide it down. Definitely not out of the realm of possibility but that can be a con if somebody's trying
to trust the information. And the outside information could be months and weeks old. I've talked with a couple physicians and a month ago patient's tumor was this, now all of sudden it's this. I wish I would've known.
So it's a choose your own adventure.
The 3D tools I've already talked about. The graphic overlay, automated. The next step is gonna be the automated advanced applications that we have. And this is the list, I'm not gonna go into all of 'em.
I've just kind of selected out a couple of 'em. But there's perfusion, there's needle guidance, there's embo guidance, those kind of things so. Needle guidance, you do an in room spin or an outside CT. Plot A to B and the system will actually move to those trajectories for you.
So it actually moves to the needle right down the barrel. And it moves to the needle lateral. So in theory, spot fluoros, that's all that's necessary to actually get to where you're going. You just go back and forth, a spot fluoro, back and forth. And you can measure depth, you can measure
anything you need. You can actually free hand and move to any angle that the physician feels comfortable with. And you can see down here, do do do. There's the cross hairs of laser. They're just posistioning the laser
or they're positioning the needle with the crosshairs without fluoroing that. So they're hand's not in field of view, they're not getting radiated. This obviously more information on the endoleak. Posterior approach.
So you have the 3D data set. This is actually a picture of the live. So you can see the dots marking the depth to go in. And then here's the 3D image. It's kinda hard to tell on this but it is overlaid over the live fluoro so.
Just additional information so.
EVAR procedures, the prep. Guidance, automated. This is just kind of in a nutshell what the 2D fusion is. So the 3D CT will be read and then your X-ray will be as expected, black and white.
You kind of match that up, accept it, and there you go. That information can be fused over and overlaid. So, and then in this situation they just did a post-procedural spin, check the embolization. And this slide's probably not gonna work but it's more of the EVAR guidance.
It's automated, it would show a mesh or you could have a vessel. It's interesting.
So with our embo guidance you draw a line on the tumor, there you go. You can kinda see that up here.
And you got a circle, a dot, what it does is then connects from the tumor to the catheter and any feeders that possibly come in. So we've actually advanced on that. It's a one click and it has the potential of plotting multiple vessels as opposed to just A to B.
It can actually go here and there you go. You can turn those on, turn those off, rotate them. There you go. Here's an actual 2D overlay. And this, it's kind of hard to get a representation but this isn't just static.
This, if I rotated this to 45 degrees REO that would all track. You can fade that out, just slightly blend it so it's like a roadmap and you can watch your catheter go left or to the right. Depending on the bifurcation.
You can see the contrast and check to make sure that the contrast is going with the lines.
Here's another one we have, the PBV, blood parenchymal volume. This is for the neuro, this is for the liver. We're looking for different things.
We're looking, we want perfusion over here where we don't want it over here. The brain, it's a bleed. There's the angio and here's blood volume. The liver, you have the perfusion over here. You have the angio.
You can actually merge the two together. You can see the blood volumes here. You have the angio, they're actually merged together. So we're looking for perfusion and then we wanna stop it. So they would do a pre-procedural with the perfusion and do a post, see when a great ending point is.
So the actual study is customized for them.
You know this is kind of wrapping up. It's just a tool. It's a tool to help supplement. It's like roadmaps, it's like DSAs. It's a tool to supplement your imaging.
You have the ability to reduce contrast, contrast media, dose. You can get more information because the CT and the DynaCTs are more, are richer with information. So you have the potential of getting more outta the study by bringing the two together.
And of course, confidence and improved success for the patient. I mean in a nutshell that's it. Like I said, this is just an overview but--
Are there any questions, I appreciate your attention. Yes?
- [Speaker] For your CO2 cycle when you're actually doing your tips could you do that one more time? Is it a live acquisition that you're taking that you overlay for referral by the image? - Is it a line acquisition, live, yes. It's real time, yeah so they would, we would
have a 50 CC syringe the second that they stepped on the pedal for the spin in real time in the room, bolus inject as hard as possible. And then it comes out on the other end, the computer reads it. You look at the study, quick cut, overlay, that's it.
You know, like anything else with CO2 it can be spotty sometimes. You can obviously see some drop off and sometimes it doesn't work but that's where you can fall back to original technique that the team was using was, draw it lines.
You can go through the cross sectional anatomy. Dot, dot, dot. So if the 3D reconstruction doesn't come up efficiently or if there are gaps and that's exactly what I needed. Which we see, it's choose your own adventure. It's hey I've got this, now I've got this.
I think the biggest key here is to be interactive with it. You know that is the biggest hurdle that I think we have is, I just wanna hand the catheters do this, get the patient in, get the patient out. And some of the things that I've seen
is when these studies have been used and used efficiently we've actually cut the time of the cases down, you know as opposed to a three hour tips you've got a one hour tips. And I think some of the staff can attest to that, that I've worked with so, great question so.
Anything else? Yes, oh, yeah. - [Audience Member] What's the spin on that CO2? - It depends on the system but that was a five second or six second depending on your system. So a DynaCT.
Yes. - [Questioner] Do you have a perfusion imaging application ready to use to skip perfusion CT? I'm just curious. - It is accurate to give a representation. It's not a true CT perfusion that's approved
but it gives you the same visual information. It doesn't have the same calculated information. It's kind of a gray area on that. But we do have teams that when they know it is a stroke I have and they go straight in and you know, time is of the essence.
So let's get 'em in the room and if we can get the information in the room as opposed to in the room, transferred out, now in the exam room, absolutely. That is the physician's, that's dealer's choice on that. I have seen that happen and I have seen
it been very effective.
Yes ma'am. - [Woman] Do you have any suggestions for engaging the staff--(unintelligible murmur) - That is a fantastic question. Because this is kind of a chicken or the egg
and I wanna make sure I'm not going over time here but it's a chicken or the egg, right? The physicians wanna use it, the staff wanna try. Maybe they don't use it very often so it falls off and then the next time they ask, I don't remember how to do it, right.
I mean you can see where this goes, right? And you guys have probably all run into this. What I did with one of my customers, clients, however you wanna call it. I went to the staff and I said hey let's do this stuff in the background, okay.
Because it's like going out into the middle of a race and you haven't trained, okay. I think the biggest misconception is hey I need to do this in real time in a real case to do it to get an understanding of it. But that's one of the toughest times to do it.
If I haven't trained for the race I can't do the race efficiently. And then you get the toe tapping of the doctor and you're like, forget it. And move on and we scrap it. So what I did is I suggested we do it in the background
on minimally invasive case, something they don't even need. They did spins all the time so we could just take that spin in the background without them expecting it. Do this, okay, and then you do it again. And then you do it again, and then you do it again. And then you introduce this to the doctor
or maybe he's looking in the corner of the screen which happens sometimes. What's that, hey that's-- That opened up the door, right? And it's self discovery in manner of speaking. And then the doctor's all of a sudden like,
hey that could potentially be helpful. And I've done that in my training. All of a sudden it's over there. They look down, hey can, and I notice the physicians looking at that screen as opposed the live fluoro. They didn't expect it, they weren't demanding it.
It was supplemental and then it became crucial to the success of the case. Great, great question. That is the biggest hurdle to get over on this. Anyone else?
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