Image fusion technology is of value because it has the potential to a useful tool, for optimal c-arm positioning and angulation in particreduce intra-operative radiation and contrast dose. It can provide a 3D roadmap to guide intervention limited, by monoplane systems, to a 2D view in real time. The ideal scenario is as follows: A Cone Beam CT (CBCT) is performed at the beginning of the aortic intervention. This 3D data set is then fused with a higher resolution 3D data set from a conventional thin-slice CTscan (TSCT) and a high quality 3D road map (the fusion image) is produced which obviates or greatly reduces the need for any further contrast use throughout the procedure until completion. Vessel cannulation and device delivery takes place solely based on the Fusion Image (FI), used as a 3D roadmap. Enthusiasm for this technology has been borne out by several publications indicating that, compared with conventional techniques, the application of fusion imaging to both complex and noncomplex aortic interventions is associated with shorter procedure times, less contrast use, and lower radiation dose. Clearly such benefits can be achieved, and not necessarily require precise alignment between the FI and the real time target on fluoroscopy. Koutouzi et al. present an important paper, quantifying the accuracy of 3D CT image fusion for EVAR and indicating the shortfall that exists with current techniques. Firstly examining how the CBCT compares with TSCT in producing the FI and secondly how the FI compares with the DSA image prior to device deployment. Acceptable accuracy was defined as <3 mm misalignment between renal arteries when fusing the TSCTwith theCBCT.Thiswas achieved inonly 37%ofpatients when registration was performed manually using L1 and L2 vertebral alignment, and in none when using an automated process. This suggests that the position of the aorta and the renal arteries relative to the vertebral columnvaries from the TSCT to the intraoperatively CBCT.We also see variation between the CBCT and the pre-deployment DSA image (using renal arteries or fiducial markers as reference points). Only 58% of patients had misalignment of 3 mm or less. Part of this is shownby the authors tobedue topatientmovement intra-operatively, and part of it, is likely to be related to change in the shape of the aorta caused by stiff wires. We can surmise that the position of the renal arteries relative to bony landmarks varies (albeit by millimetres) from one CT to the next and from a CBCT at the start of an EVAR to the pre-deployment angiogram, with stiff wires or an aortic device in place. Current fusion technology cannot yet compensate for this. The authors’ findings are consistent with other recent publications and also emphasise the importance of ongoing manual re-registration. This labour intensive process, required intra-operatively, is an inconvenience as is the potential for the fusion image to impair visualisation of wires or other markers on fluoroscopy. For now, image fusion remains
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