Multimodality image fusion to guide peripheral artery chronic total arterial occlusion recanalization in a swine carotid artery occlusion model: Unblinding the interventionalist

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To demonstrate the feasibility of magnetic resonance imaging (MRI) to X-ray fluoroscopy (XRF) image fusion to guide peripheral artery chronic total occlusion (CTO) recanalization. Endovascular peripheral artery CTO revascularization is minimally invasive, but challenging, because the occlusion is poorly visualized under XRF. Devices may steer out of the artery, which can lead to severe perforation. Merging preacquired MRI of the CTO to the live XRF display may permit upfront use of aggressive devices and improve procedural outcomes. Swine carotid artery CTOs were created using a balloon injury model. Up to 8 weeks later, MRI of the carotid arteries was acquired and segmented to create three-dimensional surface models, which were then registered onto live XRF. CTO recanalization was performed using incrementally aggressive CTO devices (group A) or an upfront aggressive directed laser approach (group B). Procedural success was defined as luminal or subintimal device position without severe perforation. In this swine model, MRI to XRF fusion guidance resulted in a procedural success of 57% in group A and 100% in group B, which compared favorably to 33% using XRF alone. Fluoroscopy time was significantly less for group B (8.5 ± 2.6 min) compared to group A (48.7 ± 23.9 min), P < 0.01. Contrast dose used was similar between groups A and B. MRI to XRF fusion-guided peripheral artery CTO recanalization is feasible. Multimodality image fusion may permit upfront use of aggressive CTO devices with improved procedural outcomes compared to XRF-guided procedures.