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A new technology is set to change the endovascular game by offering 3D, full-colour guidance to replace the 2D, greyscale standard-of-care. The result? Increased visualisation without the use of fluoroscopy. This is one of the key messages to have emerged from a roundtable discussion at the recent Charing Cross (CX) International Symposium (23–25 April, London, UK) on complex aortic procedures, Fiber Optic RealShape (FORS) technology, and the latest from Philips—FORS-powered LumiGuide.
The CX discussion saw aortic experts Bijan Modarai (King’s College London and Guy’s and St Thomas’ NHS Foundation Trust, London, UK), Isabelle Van Herzeele (Ghent University Hospital, Ghent, Belgium) and Laurent Chiche (Pitié- Salpêtrière Hospital, Paris, France) all share their experience with—and expert opinions on—Philips’ imaging offering.
Modarai began by outlining one of the central challenges of complex endovascular aortic interventions. These lengthy, multi-step procedures involve the prolonged irradiation of both the abdomen and pelvis, he explained.
“We know that this radiation is not without consequences,” Modarai said, detailing that he and his team have found evidence of DNA damage in both operators and patients as a consequence of endovascular aortic procedures.
Van Herzeele pointed out that X-ray offers only 2D visualisation of wires in a grey and white colour scheme, which make it hard to identify guidewires, catheters, and markers. The result is that operators are pressing the fluoroscopy peddle more frequently, increasing the radiation dose for both patients and healthcare staff.
Moreover, endovascular procedures are becoming increasingly common—a trend that has resulted in a parallel rise in the need for hands-on training. This is something Van Herzeele has seen in her practice at an academic institution. “Our nurses are getting worried,” she stated, adding that they are asking about ways in which radiation can be reduced in line with the ALARA (As Low As Reasonably Achievable) principle.
FORS-powered LumiGuide is designed to offer a solution here: 3D device guidance using light instead of X-ray, aiming to offer better visualisation in full colour and without the need for fluoroscopy.
Van Herzeele recalled that she and her team started using FORS technology in January 2024, with Nathalie Moreels (Ghent University Hospital, Ghent, Belgium) being “the main driver” of the whole programme.
The Ghent University team’s first FORS-guided procedure was an endovascular aneurysm repair (EVAR) with an iliac branched device (IBD), using a FORS guidewire and the centre’s own catheters—an option made possible by Philips’ 3D Hub— to cannulate a contralateral limb and hypogastric artery. “That went fantastic,” Van Herzeele remembered. “We were very excited.”
Since then, the team has used FORS mainly in complex aortic pathology for fenestrated cases electively.
One of the main improvements for Van Herzeele has been full 3D visualisation of wires and catheters. “You can visualise the guidewire very easily; it’s now in yellow, and you can also choose different colours for the catheters that you normally use,” she explained. Continuing, Van Herzeele noted that with the LumiGuide and the 3D Hub, there is the added possibility to visualise any catheter of your choice and it “shows you exactly where you are in the patient’s anatomy, without having to step on the fluoroscopy pedal”.
Van Herzeele also gave thought to what FORS has meant for workflow and for the healthcare staff at her centre. “I think the main thing is you don’t have to move your C-arm all the time, you can see what you’re actually doing,” she said. Van Herzeele added that the behaviour of the wire gives the operator some feedback that would not normally be available. “I think the team really embraces the technology from that perspective.”
Chiche shared that until recently the focus at his centre in Paris was predominantly open complex aortic surgery. In November 2020, there was a shift towards offering more endovascular procedures, facilitated by the opening of a hybrid operating room and the addition of Frédéric Cochennec to the Pitié-Salpêtrière Hospital team.
With all the potential benefits of an endovascular practice, however, came the associated radiation risks. “We tried to imagine how we could reduce the radiation dose and how we could reduce the time of exposure, for the patient, for the nurses, for the doctors, and then it appeared that the LumiGuide could help with this,” he recalled.
In November 2023, the centre adopted the LumiGuide technology, with Chiche remarking that it appears to be “a really helpful tool” so far.
“A step forward” in 3D navigation
At CX 2024, Cochennec took the audience though an edited case that demonstrated how LumiGuide can “reduce radiation and help you during the navigation phase in the aorta.”
The case involved a patient with a history of aortic root replacement who presented with a large dissecting thoracic aneurysm extending to the arch. He explained that these cases require a radiation-heavy twostep procedure, first involving the deployment of a branched aortic arch stent graft and secondly either a branched EVAR (BEVAR) or a thoracic endovascular aortic repair (TEVAR). The latter was performed in this specific example.
“I think the FORS technology is a step forward in 3D navigation,” the presenter commented, who went on to report a satisfactory final result with no clinical events after the procedure.
Reflecting on what FORS has brought to his London-based practice, Modarai first identified a “wow factor”—specifically, being able to visualise a procedure in 3D. “I think that’s very powerful.”
According to Modarai, the ability to view the anatomy in a multiplanar way is another “conceptual advance,” using the example of being able to cannulate a superior mesenteric artery in the anterior/posterior position and not having to angulate the C-arm, which saves on radiation.
The discussion then turned to learning curves. Chiche underscored the importance of patient selection with the FORS-powered technology and noted that the procedures are not particularly quick at first but recognised that they are still “probably safer”.
Modarai remembered being surprised by how “intuitive” the workflow was when FORS was introduced at his centre. He also highlighted the importance of patient selection. “I think as time goes by, you learn how FORS performs best, in which anatomies it performs best at this stage, and you can see how the iterations that will come will apply to much more advanced anatomies as time goes by.”
A “revolutionary” technique
Finally, the aortic experts looked to the future of FORS technology and endovascular surgery.
Van Herzeele shared her opinion that FORS is a “revolutionary” technique already and anticipated that the technology could become the “gold standard” not only for complex aortic disease, but also in other areas such as renal and visceral artery disease.
In terms of what could be improved, Van Herzeele commented that a slightly longer guidewire would be beneficial. “I think that’s something we’re sometimes struggling with, but I know that’s on the way,” she said, looking to future iterations of the technology.
In closing, Van Herzeele pointed to the wider, more global impact that FORS and FORS-powered LumiGuide might have. “I hope that the whole revolution will continue,” she said, “and that Philips will continue investing in this technology, and that together with the clinicians who are using it, we can improve the system and make it available worldwide so we can really treat every patient safely and also protect the healthcare of our staff.”
