David H Deaton
Over the last two decades, vascular reconstruction has witnessed a revolution (or perhaps evolution) to catheter-based therapies in most peripheral circulatory beds. While almost every surgeon involved in the development of modern endovascular techniques initially used mobile C-arms in their traditional operating room environments, they now have state-of-the-art fixed imaging in their “hybrid” operating rooms. Should this be the new standard for all endovascular procedures, operating rooms and facilities? And are there any downsides to these advanced systems?
While few can argue against the fact that advanced fixed imaging systems offer the highest image quality, they are expensive (in both initial cost and maintenance), and diminish the options for performing endovascular procedures in different operating room environments and in the conduct of certain combined open and endovascular (ie. “hybrid”) procedures. In a world where the cost and efficiency of care is under ever-increasing scrutiny, there is a strong case to be made for using mobile imaging in a significant majority of endovascular cases.
While the C-arms of the mid 1990s offered essentially no specific technologies for vascular imaging (such as subtraction angiography and road-mapping), the current generation of mobile imaging systems can perform the vast majority of imaging modalities and features found on fixed systems without costing 10 times as much. The most recent generation of mobile systems allows the operator table-side control of both imaging modality and C-arm position. Combined with mobile “floating” operating room table technology, the traditional operating room can easily be converted into a high-end endovascular environment without expensive renovation of existing infrastructure and has the capabilities to be used essentially in any room available. Mobile systems also preserve the creativity of the modern vascular surgeon to combine advanced open and endovascular techniques in a manner not possible in a room with a fixed fluoroscopic table and imaging system.
At our centre at Georgetown University, Washington, USA, we employ a hybrid approach to our imaging needs. For most non-aortic outpatient intervention we utilise a “cath lab” environment refitted with a fixed-imaging system optimised for peripheral procedures (ie. large image intensifier and no traditional cardiac modalities). Outside of our conventional operating room our productivity is maximised with quick turnover and without any formal anaesthesia support. For aortic and more complex and hybrid procedures in the lower extremity or elsewhere we use the latest generation of mobile imaging in the operating room. We also use the operating room environment for physiologically or psychologically less stable patients. This diverse portfolio of imaging and operating environments allows us to tailor care to the specific needs of the patient and are not limited to a simple consideration of imaging equipment.
Essentially, one must ask the question: “Do we need the most expensive and advanced system to do every case?” Of course, the answer is “no”. Advanced imaging systems are best utilised for complex anatomy where fine detail and extreme imaging flexibility are critical elements for optimal outcomes (such as intracranial cerebrovascular procedures, complex distal lower extremity intervention and complex aortic intervention). Many of the more routine endovascular procedures performed can be easily accomplished with mobile systems that offer the economic flexibility to purchase multiple systems that allow higher procedural volume and technical redundancy in the case of imaging system failure.
David H Deaton is chief, Vascular and Endovascular Surgery, MedStar Georgetown University Hospital, Washington, DC, USA