Live 3D Guidance in Endovascular Procedures

T oday’s endovascular interventionists must be skilled with the latest device and imaging technology to best treat their patients. An accurate morphological assessment of blood vessels and their relationship with interventional devices is essential to the management of vascular lesions, and digital subtraction angiography (DSA) has had a central role in the deployment of interventional procedures. High resolution, the ability to selectively evaluate individual vessels, and the access to direct physiological information make DSA a cornerstone technology in endovascular procedures. The addition of three-dimensional rotational angiography (3D RA) and flat panel detector technology have further contributed to greater diagnostic accuracy, faster procedures, and improved outcomes.1-4 In particular, 3D reconstructions from rotational angiograms have overcome limitations of two-dimensional (2D) imaging such as false vascular foreshortening due to projection angle and vessel obscuration due to overlying vessel or bone. These 3D reconstructions are now routinely used to reveal complex vascular relationships. Major developments in hardware and software of x-ray angiographic systems have significantly increased the usability of this technique, and 3D reconstructions are now performed and available for analysis and manipulation in real-time. The availability of 3D reconstructions also carries along a wealth of 3D tools that can improve current procedural workflows starting from disease assessment to treatment evaluation through navigation and treatment planning. The use of 3D RA and associated tools in endovascular procedures is, however, not yet common practice. Although evidence of the clinical benefit and reduction in radiation exposure to patients and staff following the use of 3D RA has been extensively reported for vascular lesions of the neck and brain,5-10 there is not enough information in the literature on how the use of 3D tools can improve the (peripheral) vascular procedural workflow with potentially no changes (or reduction) to radiation and contrast administration. This article provides a showcase of minimally invasive endovascular applications in which the availability of 3D tools was distinctively beneficial to achieve effective disease management in a busy day-to-day clinical practice.