Augmented Reality-based Feedback for Technician-in-the-loop C-arm Repositioning

Interventional C-arm imaging is crucial to percutaneous orthopedic procedures as it enables the surgeon to monitor the progress of surgery on the anatomy level. Minimally invasive interventions require repeated acquisition of X-ray images from different anatomical views to verify tool placement. Achieving and reproducing these views often comes at the cost of increased surgical time and radiation dose to both patient and staff. This work proposes a marker-free "technician-in-the-loop" Augmented Reality (AR) solution for C-arm repositioning. The X-ray technician operating the C-arm interventionally is equipped with a head-mounted display capable of recording desired C-arm poses in 3D via an integrated infrared sensor. For C-arm repositioning to a particular target view, the recorded C-arm pose is restored as a virtual object and visualized in an AR environment, serving as a perceptual reference for the technician. We conduct experiments in a setting simulating orthopedic trauma surgery. Our proof-of-principle findings indicate that the proposed system can decrease the 2.76 X-ray images required per desired view down to zero, suggesting substantial reductions of radiation dose during C-arm repositioning. The proposed AR solution is a first step towards facilitating communication between the surgeon and the surgical staff, improving the quality of surgical image acquisition, and enabling context-aware guidance for surgery rooms of the future. The concept of technician-in-the-loop design will become relevant to various interventions considering the expected advancements of sensing and wearable computing in the near future

Fusion of 3D QCA and IVUS/OCT

The combination/fusion of quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS)/optical coherence tomography (OCT) depends to a great extend on the co-registration of X-ray angiography (XA) and IVUS/OCT. In this work a new and robust three-dimensional (3D) segmentation and registration approach is presented and validated. The approach starts with standard QCA of the vessel of interest in the two angiographic views (either biplane or two monoplane views). Next, the vessel of interest is reconstructed in 3D and registered with the corresponding IVUS/OCT pullback series by a distance mapping algorithm. The accuracy of the registration was retrospectively evaluated on 12 silicone phantoms with coronary stents implanted, and on 24 patients who underwent both coronary angiography and IVUS examinations of the left anterior descending artery. Stent borders or sidebranches were used as markers for the validation. While the most proximal marker was set as the baseline position for the distance mapping algorithm, the subsequent markers were used to evaluate the registration error. The correlation between the registration error and the distance from the evaluated marker to the baseline position was analyzed. The XA-IVUS registration error for the 12 phantoms was 0.03 ± 0.32 mm (P = 0.75). One OCT pullback series was excluded from the phantom study, since it did not cover the distal stent border. The XA-OCT registration error for the remaining 11 phantoms was 0.05 ± 0.25 mm (P = 0.49). For the in vivo validation, two patients were excluded due to insufficient image quality for the analysis. In total 78 sidebranches were identified from the remaining 22 patients and the registration error was evaluated on 56 markers. The registration error was 0.03 ± 0.45 mm (P = 0.67). The error was not correlated to the distance between the evaluated marker and the baseline position (P = 0.73). In conclusion, the new XA-IVUS/OCT co-registration approach is a straightforward and reliable solution to combine X-ray angiography and IVUS/OCT imaging for the assessment of the extent of coronary artery disease. It provides the interventional cardiologist with detailed information about vessel size and plaque size at every position along the vessel of interest, making this a suitable tool during the actual intervention

Continuous roadmapping in liver TACE procedures using 2D–3D catheter-based registration

PURPOSE: Fusion of pre/perioperative images and intra-operative images may add relevant information during image-guided procedures. In abdominal procedures, respiratory motion changes the position of organs, and thus accurate image guidance requires a continuous update of the spatial alignment of the (pre/perioperative) information with the organ position during the intervention. METHODS: In this paper, we propose a method to register in real time perioperative 3D rotational angiography images (3DRA) to intra-operative single-plane 2D fluoroscopic images for improved guidance in TACE interventions. The method uses the shape of 3D vessels extracted from the 3DRA and the 2D catheter shape extracted from fluoroscopy. First, the appropriate 3D vessel is selected from the complete vascular tree using a shape similarity metric. Subsequently, the catheter is registered to this vessel, and the 3DRA is visualized based on the registration results. The method is evaluated on simulated data and clinical data. RESULTS: The first selected vessel, ranked with the shape similarity metric, is used more than 39 % in the final registration and the second more than 21 %. The median of the closest corresponding points distance between 2D angiography vessels and projected 3D vessels is 4.7–5.4 mm when using the brute force optimizer and 5.2–6.6 mm when using the Powell optimizer. CONCLUSION: We present a catheter-based registration method to continuously fuse a 3DRA roadmap arterial tree onto 2D fluoroscopic images with an efficient shape similarity

Automatic Estimation of Coronary Blood Flow Velocity Step 1 for Developing a Tool to Diagnose Patients With Micro-Vascular Angina Pectoris

Aim: Our aim was to automatically estimate the blood velocity in coronary arteries using cine X-ray angiographic sequence. Estimating the coronary blood velocity is a key approach in investigating patients with angina pectoris and no significant coronary artery disease. Blood velocity estimation is central in assessing coronary flow reserve. Methods and Results: A multi-step automatic method for blood flow velocity estimation based on the information extracted solely from the cine X-ray coronary angiography sequence obtained by invasive selective coronary catheterization was developed. The method includes (1) an iterative process of segmenting coronary arteries modeling and removing the heart motion using a non-rigid registration, (2) measuring the area of the segmented arteries in each frame, (3) fitting the measured sequence of areas with a 7◦ polynomial to find start and stop time of dye propagation, and (4) estimating the blood flow velocity based on the time of the dye propagation and the length of the artery-tree. To evaluate the method, coronary angiography recordings from 21 patients with no obstructive coronary artery disease were used. In addition, coronary flow velocity was measured in the same patients using a modified transthoracic Doppler assessment of the left anterior descending artery. We found a moderate but statistically significant correlation between flow velocity assessed by trans thoracic Doppler and the proposed method applying both Spearman and Pearson tests. Conclusion: Measures of coronary flow velocity using a novel fully automatic method that utilizes the information from the X-ray coronary angiographic sequence were statistically significantly correlated to measurements obtained with transthoracic Doppler recordings.publishedVersio

Development of a Surgical Assistance System for Guiding Transcatheter Aortic Valve Implantation

Development of image-guided interventional systems is growing up rapidly in the recent years. These new systems become an essential part of the modern minimally invasive surgical procedures, especially for the cardiac surgery. Transcatheter aortic valve implantation (TAVI) is a recently developed surgical technique to treat severe aortic valve stenosis in elderly and high-risk patients. The placement of stented aortic valve prosthesis is crucial and typically performed under live 2D fluoroscopy guidance. To assist the placement of the prosthesis during the surgical procedure, a new fluoroscopy-based TAVI assistance system has been developed. The developed assistance system integrates a 3D geometrical aortic mesh model and anatomical valve landmarks with live 2D fluoroscopic images. The 3D aortic mesh model and landmarks are reconstructed from interventional angiographic and fluoroscopic C-arm CT system, and a target area of valve implantation is automatically estimated using these aortic mesh models. Based on template-based tracking approach, the overlay of visualized 3D aortic mesh model, landmarks and target area of implantation onto fluoroscopic images is updated by approximating the aortic root motion from a pigtail catheter motion without contrast agent. A rigid intensity-based registration method is also used to track continuously the aortic root motion in the presence of contrast agent. Moreover, the aortic valve prosthesis is tracked in fluoroscopic images to guide the surgeon to perform the appropriate placement of prosthesis into the estimated target area of implantation. An interactive graphical user interface for the surgeon is developed to initialize the system algorithms, control the visualization view of the guidance results, and correct manually overlay errors if needed. Retrospective experiments were carried out on several patient datasets from the clinical routine of the TAVI in a hybrid operating room. The maximum displacement errors were small for both the dynamic overlay of aortic mesh models and tracking the prosthesis, and within the clinically accepted ranges. High success rates of the developed assistance system were obtained for all tested patient datasets. The results show that the developed surgical assistance system provides a helpful tool for the surgeon by automatically defining the desired placement position of the prosthesis during the surgical procedure of the TAVI.Die Entwicklung bildgeführter interventioneller Systeme wächst rasant in den letzten Jahren. Diese neuen Systeme werden zunehmend ein wesentlicher Bestandteil der technischen Ausstattung bei modernen minimal-invasiven chirurgischen Eingriffen. Diese Entwicklung gilt besonders für die Herzchirurgie. Transkatheter Aortenklappen-Implantation (TAKI) ist eine neue entwickelte Operationstechnik zur Behandlung der schweren Aortenklappen-Stenose bei alten und Hochrisiko-Patienten. Die Platzierung der Aortenklappenprothese ist entscheidend und wird in der Regel unter live-2D-fluoroskopischen Bildgebung durchgeführt. Zur Unterstützung der Platzierung der Prothese während des chirurgischen Eingriffs wurde in dieser Arbeit ein neues Fluoroskopie-basiertes TAKI Assistenzsystem entwickelt. Das entwickelte Assistenzsystem überlagert eine 3D-Geometrie des Aorten-Netzmodells und anatomischen Landmarken auf live-2D-fluoroskopische Bilder. Das 3D-Aorten-Netzmodell und die Landmarken werden auf Basis der interventionellen Angiographie und Fluoroskopie mittels eines C-Arm-CT-Systems rekonstruiert. Unter Verwendung dieser Aorten-Netzmodelle wird das Zielgebiet der Klappen-Implantation automatisch geschätzt. Mit Hilfe eines auf Template Matching basierenden Tracking-Ansatzes wird die Überlagerung des visualisierten 3D-Aorten-Netzmodells, der berechneten Landmarken und der Zielbereich der Implantation auf fluoroskopischen Bildern korrekt überlagert. Eine kompensation der Aortenwurzelbewegung erfolgt durch Bewegungsverfolgung eines Pigtail-Katheters in Bildsequenzen ohne Kontrastmittel. Eine starrere Intensitätsbasierte Registrierungsmethode wurde verwendet, um kontinuierlich die Aortenwurzelbewegung in Bildsequenzen mit Kontrastmittelgabe zu detektieren. Die Aortenklappenprothese wird in die fluoroskopischen Bilder eingeblendet und dient dem Chirurg als Leitfaden für die richtige Platzierung der realen Prothese. Eine interaktive Benutzerschnittstelle für den Chirurg wurde zur Initialisierung der Systemsalgorithmen, zur Steuerung der Visualisierung und für manuelle Korrektur eventueller Überlagerungsfehler entwickelt. Retrospektive Experimente wurden an mehreren Patienten-Datensätze aus der klinischen Routine der TAKI in einem Hybrid-OP durchgeführt. Hohe Erfolgsraten des entwickelten Assistenzsystems wurden für alle getesteten Patienten-Datensätze erzielt. Die Ergebnisse zeigen, dass das entwickelte chirurgische Assistenzsystem ein hilfreiches Werkzeug für den Chirurg bei der Platzierung Position der Prothese während des chirurgischen Eingriffs der TAKI bietet

Comparison of the accuracy of voxel based registration and surface based registration for 3D assessment of surgical change following orthognathic surgery

Purpose: Superimposition of two dimensional preoperative and postoperative facial images, including radiographs and photographs, are used to evaluate the surgical changes after orthognathic surgery. Recently, three dimensional (3D) imaging has been introduced allowing more accurate analysis of surgical changes. Surface based registration and voxel based registration are commonly used methods for 3D superimposition. The aim of this study was to evaluate and compare the accuracy of the two methods.<p></p> Materials and methods: Pre-operative and 6 months post-operative cone beam CT scan (CBCT) images of 31 patients were randomly selected from the orthognathic patient database at the Dental Hospital and School, University of Glasgow, UK. Voxel based registration was performed on the DICOM images (Digital Imaging Communication in Medicine) using Maxilim software (Medicim-Medical Image Computing, Belgium). Surface based registration was performed on the soft and hard tissue 3D models using VRMesh (VirtualGrid, Bellevue City, WA). The accuracy of the superimposition was evaluated by measuring the mean value of the absolute distance between the two 3D image surfaces. The results were statistically analysed using a paired Student t-test, ANOVA with post-hoc Duncan test, a one sample t-test and Pearson correlation coefficient test.<p></p> Results: The results showed no significant statistical difference between the two superimposition methods (p<0.05). However surface based registration showed a high variability in the mean distances between the corresponding surfaces compared to voxel based registration, especially for soft tissue. Within each method there was a significant difference between superimposition of the soft and hard tissue models.<p></p> Conclusions: There were no significant statistical differences between the two registration methods and it was unlikely to have any clinical significance. Voxel based registration was associated with less variability. Registering on the soft tissue in isolation from the hard tissue may not be a true reflection of the surgical change