A New World Opening Up
EVAR Technology Offers Advantages for Both Advanced and Standard Procedures
Prof. Eric Verhoeven is Head of the University Department of Vascular Surgery at Nuremberg Hospital, Professor of Vascular Surgery at the University in Leuven, and Guest Professor of Surgery at the University of Lisbon. He was recently honored for a very special record: He is probably the first surgeon in the world to have performed more than 1,000 fenestrated and branched endovascular aneurysm repair (EVAR) interventions with his team.
How many EVAR cases have you performed here in Nuremberg so far?
E. VERHOEVEN: Nuremberg Hospital is a very large municipal hospital with about 2,500 beds, and it has a very big endovascular center. Upon my arrival in 2009, I instituted advanced endovascular techniques: fenestrated and branched grafting. We witnessed a compound annual growth rate of 20 percent. And today we do about 250 cases a year, including up to 130 complex cases. If you compare us with other hospitals, we have a much larger number of advanced cases because a lot of patients are referred to us.
You just performed your 1,000th EVAR case, right?
E. VERHOEVEN: Yes, we’ve now achieved that number. I started doing this procedure in 2000 in Groningen. The technology was slowly emerging, and I was allowed to be part of the research team. We were able to move forward slowly. We did four cases in 2000, 10 cases in 2001, and we now do 130 a year.
How many people are in the “club” of those who’ve performed 1,000 EVAR cases?
E. VERHOEVEN: Over the last few years, the technology has really boomed. Today there are a number of bigger centers – but at the moment, we are probably one of the largest centers in the world. According to Cook, having performed 1,000 EVAR cases may be a world record, if you relate it to just one person. But I like to see it as a team effort.
What is the main benefit of a hybrid room for these EVAR cases?
E. VERHOEVEN: In Nuremberg, we’re lucky to have two hybrid rooms featuring Artis zeego systems1, which is a very advanced technology. Not everyone needs an Artis zeego, but the zeego is certainly the Rolls-Royce of fixed imaging systems. It gives you the ideal setup for each case. We are using the robots for all our cases, and I realize that the Hybrid OR environment takes care of both the patient and the personnel in the room. It’s certainly safer and quicker, and we can also achieve higher quality.
You had the opportunity to test the new syngo EVAR guidance. What is your experience?
E. VERHOEVEN: In the beginning, I was a bit skeptical because it took a few more steps, and I had the impression that we didn’t need it. But in using the technique, we see a number of advantages that we didn’t expect. Now I’m completely convinced that fusion technology is the way to go for every EVAR procedure!
How frequently do you use EVAR guidance today?
E. VERHOEVEN: We’re moving quickly to 100 percent. And the reason for that is training. I’m conservative, and I still think, “I can do without.” But it’s not about me: It’s about the team! It’s about taking the next step for the patients and the staff working in the room.
Is EVAR guidance a technology for advanced procedures only?
E. VERHOEVEN: We thought of doing fusion for only the most advanced cases, but we quickly started to use fusion imaging for standard EVAR procedures as well, because it’s so quick and now also automated. So now we use fusion imaging for every case. At this point it’s probably more valuable for advanced procedures, but it also offers advantages for standard procedures. It’s a fantastic tool, and it’s moving forward so quickly that it will soon help a lot of surgeons who don’t have the chance to do many cases, or those who are at the beginning of their career, or who have somewhat less experience.
Can you highlight the main advantages of fusion imaging?
E. VERHOEVEN: The greatest advantage is that you have a 3D image all the time without having to strain your brain. The second is that it allows you to do a number of steps without having to do additional angios. It’s showing that you can reduce OR time, you can reduce radiation, and you can reduce contrast dose. Considering that we’re only at the beginning of fusion technology, it’s a new world that’s opening
What has to be done to prepare for fusion imaging?
E. VERHOEVEN: We can register the preoperational CT dataset with two simple fluoroscopic images to the zeego. To increase the precision of the overlay, we now do the registration images with the stiff wire in the aorta to avoid reregistration later. This is really only a 10- to 15-second job.
What is your experience with the automated preparation of the CT dataset?
E. VERHOEVEN: It’s moving so quickly and becoming so easy that I don’t have to look at it anymore, because our radiology technicians have been well trained by Siemens Healthineers. In one to five minutes the preoperational CT dataset is prepared for fusion imaging and we can get going. The only thing that’s needed during the procedure is the “fine-tuning,” to get the perfect adjustment.
Low-dose acquisition protocols for endovascular treatment
Before, during, and after EVAR procedures, patients undergo extended exposure to X-ray and iodinated contrast, and the clinical staff is also exposed to scattered radiation on a daily basis. Special attention must be given to the relevant regulations for radiation dose reduction and to monitoring patients and personnel. To ensure safe and efficient EVAR procedures, engineers from Siemens Healthineers and experienced customers like Eric Verhoeven worked together to optimize the Artis systems imaging protocols, especially for image guidance during fenestrated EVAR. The result: the EVAR xCARE protocols, which allow the surgeon to perform procedures in strict accordance with the ALARA principle, using the lowest achievable dose. Compared with the standard Artis systems’ settings for diagnostic imaging, which require optimal image quality, image guidance can be performed with a 95 percent lower dose.1
1 33 mGy/min high-quality Fluoro versus 1.8 mGy/min with EVAR xCARE
How does fusion imaging support you during stent deployment?
E. VERHOEVEN: In many ways! During deployment it’s all about orientation. In fenestrated procedures, you deploy the graft in orientation to one or two of the target vessels. With fusion we can look at all vessels. If you have a branched graft, it’s very important that all four branches land above the target vessels. Without fusion technology, we chose the most critical vessel and planned to land the branch above it and hoped for the other branches to be fine. With fusion during the deployment, we can look at all four vessels at the same time. It just takes the touch of a button, you turn your C-arm, and you can see where your branches land in relation to the target vessels. So again, it gives you a safer deployment.
What about contrast use?
E. VERHOEVEN: We certainly use less contrast, because we know where to go. For the deployment we still do one angiogram. This is the reference for the whole procedure. With fusion you don’t need additional angiograms while catheterizing the target vessels: You can reposition your graft according to the fusion. The big advantage is that you can adjust the angle to each target vessel much more easily, and you can rely on the position to be correct. But we always control to be in the correct branch of the correct vessel with a little injection of contrast under fluoroscopy.
What about radiation exposure?
E. VERHOEVEN: If you can prepare everything in a standardized way, if you know that your wires are in the correct position and the position of your C-arm is optimized – you can do all the repositioning without radiation. This is a very big advantage for everyone.
Where is vascular surgery headed? What are the trends?
E. VERHOEVEN: There’s no doubt that vascular surgery is at an important crossroads. From one perspective, we have fantastic endovascular techniques to treat our patients. But these techniques are also becoming more complex, and they need to be used on patients with good indications and by well-trained teams, and also in the perfect environment. The hybrid rooms give us the option to control our work, to adapt our work, and to extend our work. In a few years, every endovascular procedure will be performed in a dedicated hybrid room. But the most important thing is to always have the correct indications, the correct planning, and the correct execution. That makes vascular surgery more suited for centralization, because we need larger teams with more experience to do it.
What about open surgery?
E. VERHOEVEN: Open surgery will always be needed. But open surgery is also becoming more complex. What remains for open surgery are those really “ugly” cases that can’t be treated with endovascular procedures, or cases that go wrong with endovascular surgery. And these cases are probably being seen by a dwindling number of people who still have the vast experience that surgeons had in the past. We will continue to see centralization – but probably even more in open surgery than in endovascular surgery. I think it’s important that everybody knows their limits. We should help the somewhat smaller centers to master the techniques that they want to master. That’s why I regularly go outside my hospital to help people when they’re confronted with more difficult cases.
1This article refers to an installation of Artis zeego. Artis zeego is no longer available and is replaced by ARTIS pheno.
The statements by Siemens’ customers described herein are based on results that were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.