Download First Experiences with the Ziehm Vision FD Mobile C

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White Paper No. 02/2009
First Experiences with the Ziehm Vision
FD Mobile C-Arm with Flat-Panel Detector
Leiden University Medical Center (LUMC)
in the Netherlands is the first hospital in
the world using the Ziehm Vision FD in
clinical practice. Since the beginning of
2006, Dr. van der Linden and Dr. Willemssen from the Department of Radiology
have been working with this leadingedge C-arm system in a clinical environment. This technologically groundbreaking new product was awarded the
“Product Innovation Award 2006” by
Frost & Sullivan on September 18, 2006.
Fig.1: Ziehm Vision FD
Ziehm Imaging has taken mobile C-arm imaging
to a new level by introducing the Ziehm Vision FD,
the first mobile C-arm in the world that
uses flat-panel detector technology. The Ziehm
Vision FD‘s cutting edge technology paves the
way for mobile C-arms to advance from purely
fulfilling applications in the operating theater to
undertaking the most advanced interventional
radiological procedures. The Ziehm Vision FD
features a flat-panel detector based on amorphous silicon (a-Si) photodiode technology with
a field size of 20 cm x 20 cm. The flat-panel
detector provides an unmatched dynamic range
with an image quality suitable for a wide
variety of different interventional radiology
procedures.
The compact design enables better patient
access and increased mobility, so that the unit
can easily be brought to the patient instead of the
patient to the unit. The system runs with a pulsing
generator featuring Vision Pulse technology running at a frame rate of up to 30 frames/sec in
fluoroscopy mode as well as in DSA or cine loop
modes. The user interface offers an intuitive
workflow and logical guidance using two synchronized TFT touchscreen control panels, one conveniently mounted on a swivel arm of the C-arm,
the other one mounted on the monitor cart.
Why use a mobile C-arm with digital flat-panel
detector? We asked Dr. van der Linden and
Dr. Willemssen at LUMC in the Netherlands. “We
wanted to have a compact, high-quality C-arm
for OR procedures such as EVARs and simultaneously a mobile high-quality angiography system as a backup here in our Radiology Department. We also intended to use the unit for
CT-guided interventions in combination with X-ray
fluoroscopy instead of CT fluoroscopy for biopsies, catheter placements and vertebroplasty in
order to lower the dose levels. Besides, we were
also very curious to explore further practical applications opened up by this groundbreaking
technology. It was our intention to do some
research in this area”, says Dr. van der Linden.
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White Paper No. 02/2009
Initial Experiences
Case 1: Skeletal Intervention
Dr. Willemssen explains further about the clinical experiences with the Ziehm Vision FD in daily
practice. “The C-arm has been in our department since January 2006, and we have used it for
many vascular and non-vascular examinations
with excellent results. The unit provides highquality images with outstanding contrast resolution. We used the C-arm for abdominal EVARs,
iliac stent placements, biliary PTAs, catheter
placements, biopsies and different skeletal interventions such as arthrographies and vertebroplasties. Normally, we run the unit at a pulse
rate of 15 pulses/sec, and at 5-10 pulses/sec
during catheter placements for further dose
savings.”
A 10-year-old boy presented with pain in the
right foot, especially when standing on his right
heel. Clinical examination revealed a normal
flexion and extension. Pronation and supination,
however, were decreased compared to the other
foot. An X-ray (Fig. 2) of the foot revealed a large
osteolytic lesion in the calcaneus, with sclerotic
margins. During the CT examination blood-fluid
levels were present. The diagnosis of aneurysmal bone cyst was confirmed. Due to pain
and diminished function, treatment was required. Earlier arterial embolization was unsuccessful. Hence direct puncture into the bone
tumor was performed under CT guidance (Fig. 3)
using Ethibloc ® for the embolization.
“The unit is very easy to use and to manoeuvre
thanks to its compact detector dimensions and
smart touchscreen user interface – features that
are highly appreciated by our radiographers. The
C-arm opening is larger than on a conventional
C-arm, thus providing substantially improved patient access. The C-arm movements are not motorized though. This functionality might be taken
into consideration for future improvements, although it is not a must, as the C is very easy to
position anyhow,” adds Dr. Willemssen.
“From our experiences, there is no disadvantage
compared to an X-ray C-arm with image intensifier. On the contrary: the image quality having
such excellent contrast resolution particularly
in DSA is a great improvement. The field size of
20 cm x 20 cm, however, entails some limitations
in the coverage of the lower extremities.”
Fig. 2: X-ray of the left foot showing large lytic
lesion the calcaneus.
Case Highlights from LUMC
“We would like to highlight some cases where
the Ziehm Vision FD performed especially well
compared to conventional C-arm systems”, says
Dr. Willemssen.
Fig. 3: Axial CT image of the embolization
shows the needle placed into the tumor as
well as the embolization material.
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White Paper No. 02/2009
Since one compartment was not embolized, a
second needle was placed into the tumor. The
injection of the embolization material was monitored using the Ziehm Vision FD (Fig. 4). The
system‘s pulsed fluoroscopy mode ensured lowdose radiation.
Case 2: Skeletal Intervention
Fig. 4: Ziehm Vision FD image: the tumor is
clearly visible with good detail, as is the needle
and the embolization material.
Fig. 5: Lateral fluoroscopic image shows the
collapsed third lumbar vertebra with 2 needles
placed in it. The small needle is the RFA needle
and placed in the center of the tumor.
A 61-year-old woman presented with pain in the
lumbar spine. The medical history revealed invasive bladder carcinoma. X-ray of the lumbar spine
showed a collapsed third lumbar vertebra with a
fracture, highly suspicious of a pathologic fracture. Histological biopsy confirmed the diagnosis
of vertebral metastasis. Since the patient experienced a great deal of pain, she was referred to
the Radiology Department for radio frequency ablation and vertebroplasty of the collapsed metastasis vertebra.
We use the Ziehm Vision FD in our single-plane
angiography room to create a biplane system with
simultaneous antero-posterior and lateral projections. Such a combination is very convenient
and time-saving for this type of procedures, eliminating the need for rotating the X-ray tube assembly constantly from the A.P. to lateral position
and vice versa. The Ziehm Vision FD is
ideally suited for this task. Due to its compact
dimensions and wide C-arm opening, the surgeon
benefits from ample space to perform the procedure. The Ziehm Vision FD is used for obtaining
the lateral fluoroscopic images.
We also use this system for CT-guided vertebroplasty. The images obtained using lateral fluoroscopy are the most crucial, and are perfectly
visualized with the Ziehm Vision FD (Fig. 5, 6, 7).
Fig. 6: Lateral fluoroscopic image shows the
distribution of cement into the fracture of the
vertebra.
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White Paper No. 02/2009
Case 3. Vascular Intervention
Fig. 7: Lateral fluoroscopic image shows the
cement placed into the vertebra at the end of
the procedure, located in the center of the
vertebra. No leakage is noted.
A 68-year-old male with diabetes (type II) had
presented with an aneurysm of the infrarenal abdominal aorta and right iliac artery for more than
10 years. The dilation of the aneurysm had been
only slightly progressive in those years. However,
an operation or intervention became necessary
this year. The patient underwent an endovascular
aortic aneurysm repair in the OR under radiological control using the Ziehm Vision FD. A compact and powerful mobile X-ray C-arm is of vital
importance when procedures like these are performed in the OR, where no stationary angiography equipment is available.
The stent-graft is placed just below the renal
arteries, in this case with suprarenal fixation
(Fig. 8).
Excellent image quality is essential for precise
placement of the stent-graft, and the proximal
placement is most critical. With adipose patients,
however, it may become difficult to obtain the required image quality level. Even then the Ziehm
Vision FD produced images of fine quality, thus
avoiding possible complications caused by lack
of visibility.
Fig. 8: Angiogram during placement of the stentgraft. Highlighted the marker indicating the beginning of the covered part of the stent-graft. This
marker must be placed below the renal arteries.
Fig. 9: Coronal contrast-enhanced CT MIP image
2 days after placement of the stent-graft: the covered
part of the stent-graft is placed below the renal
arteries, with normal enhancement of the kidneys.
Conclusion
“Based on the various clinical experiences
we have had in the past few months, we find the
Ziehm Vision FD to be a powerful mobile C-arm
with high performance and superior image quality. It is a valuable tool as a mobile C-arm and can
be used beneficially for a wide range of
both vascular and non-vascular applications,”
summarizes Dr. Willemssen.
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White Paper No. 02/2009
Product Innovation Award 2006
Frost & Sullivan, a renowned European analyst
and consulting house, honoured Ziehm Imaging`s
pioneering mobile C-arm “Ziehm Vision FD” with
the “Frost & Sullivan Product Innovation Award
2006” on September 18, 2006.
The system features a groundbreaking digital
flat-panel detector that replaces the image intensifier traditionally found on this type of X-ray
equipment. The high-dynamic detector enables
distortion-free digital capture of the finest bone
and soft tissue structures required, for instance,
in the area of neurosurgery or tumor localization
for radiation therapy. Entirely new fields of application for mobile C-arms will open up when
combining the unit with navigation or Computer
Aided Surgery (CAS) systems.
With the introduction of the Vision FD, Ziehm
Imaging has taken a major leap forward in setting the direction for the future of mobile
C-arms,” says Frost & Sullivan Medical Imaging
Team Leader, Karthik Arun B. “The Vision FD is
expected to set new standards for image quality
and patient safety as well as to expand the number of applications where mobile C-arms can be
used.” In presenting this award to Ziehm, the renowned market research organization has recognized the trend setting technology which,
within a few more years, will be standard equipment in every high-tech OR.