Deep Learning-Based Intraoperative Stent Graft Segmentation on Completion Digital Subtraction Angiography During Endovascular Aneurysm Repair

PURPOSE : Modern endovascular hybrid operating rooms generate large amounts of medical images during a procedure, which are currently mostly assessed by eye. In this paper, we present fully automatic segmentation of the stent graft on the completion digital subtraction angiography during endovascular aneurysm repair, utilizing a deep learning network. TECHNIQUE : Completion digital subtraction angiographies (cDSAs) of 47 patients treated for an infrarenal aortic aneurysm using EVAR were collected retrospectively. A two-dimensional convolutional neural network (CNN) with a U-Net architecture was trained for segmentation of the stent graft from the completion angiographies. The cross-validation resulted in an average Dice similarity score of 0.957 ± 0.041 and median of 0.968 (IQR: 0.950 - 0.976). The mean and median of the average surface distance are 1.266 ± 1.506 mm and 0.870 mm (IQR: 0.490 - 1.430), respectively. CONCLUSION : We developed a fully automatic stent graft segmentation method based on the completion digital subtraction angiography during EVAR, utilizing a deep learning network. This can provide the platform for the development of intraoperative analytical applications in the endovascular hybrid operating room such as stent graft deployment accuracy, endoleak visualization, and image fusion correction

Automated image fusion during endovascular aneurysm repair: a feasibility and accuracy study

Purpose: Image fusion merges preoperative computed tomography angiography (CTA) with live fluoroscopy during endovascular procedures to function as an overlay 3D roadmap. However, in most current systems, the registration between imaging modalities is performed manually by vertebral column matching which can be subjective, inaccurate and time consuming depending on experience. Our objective was to evaluate feasibility and accuracy of image-based automated 2D-3D image fusion between preoperative CTA and intraoperative fluoroscopy based on vertebral column matching. Methods: A single-center study with offline procedure data was conducted in 10 consecutive patients which had endovascular aortic repair in which we evaluated unreleased automated fusion software provided by Philips (Best, the Netherlands). Fluoroscopy and digital subtraction angiography images were collected after the procedures and the vertebral column was fused fully automatically. Primary endpoints were feasibility and accuracy of bone alignment (mm). Secondary endpoint was vascular alignment (mm) between the lowest renal artery orifices. Clinical non-inferiority was defined at a mismatch of < 1 mm. Results: In total, 87 automated measurements and 40 manual measurements were performed on vertebrae T12–L5 in all 10 patients. Manual correction was needed in 3 of the 10 patients due to incomplete visibility of the vertebral edges in the fluoroscopy image. Median difference between automated fusion and manual fusion was 0.1 mm for bone alignment (p = 0.94). The vascular alignment was 4.9 mm (0.7–17.5 mm) for manual and 5.5 mm (1.0–14.0 mm) for automated fusion. This did not improve, due to the presence of stiff wires and stent graft. Conclusion: Automated image fusion was feasible when all vertebral edges were visible. Accuracy was non-inferior to manual image fusion regarding bone alignment. Future developments should focus on intraoperative image-based correction of vascular alignment

Anatomic Suitability for Branched Thoracic Endovascular Repair in Patients with Aortic Arch Pathological Features

Background Endovascular repair has become a viable alternative for aortic pathological features, including those located within the aortic arch. We investigated the anatomic suitability for branched thoracic endovascular repair in patients previously treated with conventional open surgery for aortic arch pathological features. Methods and Results Patients who underwent open surgery for aortic arch pathological features at our institution between 2000 and 2018 were included. Anatomic suitability was determined by strict compliance with the anatomic criteria within manufacturers' instructions for use for each of the following branched thoracic stent grafts: Relay Plus Double-Branched (Terumo-Aortic), TAG Thoracic Branch Endoprosthesis (W.L. Gore & Associates), Zenith Arch Branched Device (Cook-Medical), and Nexus Stent Graft System (Endospan Ltd/Jotec GmbH). Computed tomography angiography images were analyzed with outer luminal line measurements. A total of 377 patients (mean age, 64±14 years; 64% men) were identified, 153 of whom had suitable computed tomography angiography images for measurements. In total, 59 patients (15.6% of the total cohort and 38.6% of the measured cohort) were eligible for endovascular repair using at least one of the devices. Device suitability was 30.9% for thoracic aneurysms, 4.6% for type A dissections, 62.5% for type B dissections, and 28.6% for other pathological features. Conclusions The anatomic suitability for endovascular repair of all aortic arch pathological features was modest. The highest suitability rates were observed for thoracic aneurysms and for type B dissections, of which repair included part of the aortic arch. We suggest endovascular repair of arch pathological features should be reserved for high-volume centers with experience in endovascular arch repair

Image Fusion During Standard and Complex Endovascular Aortic Repair, to Fuse or Not to Fuse?: A Meta-analysis and Additional Data From a Single-Center Retrospective Cohort

Purpose: To determine if image fusion will reduce contrast volume, radiation dose, and fluoroscopy and procedure times in standard and complex (fenestrated/branched) endovascular aneurysm repair (EVAR). Materials and Methods: A search of the PubMed, Embase, and Cochrane databases was performed in December 2019 to identify articles describing results of standard and complex EVAR procedures using image fusion compared with a control group. Study selection, data extraction, and assessment of the methodological quality of the included publications were performed by 2 reviewers working independently. Primary outcomes of the pooled analysis were contrast volume, fluoroscopy time, radiation dose, and procedure time. Eleven articles were identified comprising 1547 patients. Data on 140 patients satisfying the study inclusion criteria were added from the authors’ center. Mean differences (MDs) are presented with the 95% confidence interval (CI). Results: For standard EVAR, contrast volume and procedure time showed a significant reduction with an MD of −29 mL (95% CI −40.5 to −18.5, p<0.001) and −11 minutes (95% CI −21.0 to −1.8, p<0.01), respectively. For complex EVAR, significant reductions in favor of image fusion were found for contrast volume (MD −79 mL, 95% CI −105.7 to −52.4, p<0.001), fluoroscopy time (MD −14 minutes, 95% CI −24.2 to −3.5, p<0.001), and procedure time (MD −52 minutes, 95% CI −75.7 to −27.9, p<0.001). Conclusion: The results of this meta-analysis confirm that image fusion significantly reduces contrast volume, fluoroscopy time, and procedure time in complex EVAR but only contrast volume and procedure time for standard EVAR. Though a reduction was suggested, the radiation dose was not significantly affected by the use of fusion imaging in either standard or complex EVAR

sj-docx-3-jet-10.1177_15266028231165731 – Supplemental material for Initial Clinical Experience With AneuFix Injectable Biocompatible Elastomer for Translumbar Embolization of Type 2 Endoleaks

Supplemental material, sj-docx-3-jet-10.1177_15266028231165731 for Initial Clinical Experience With AneuFix Injectable Biocompatible Elastomer for Translumbar Embolization of Type 2 Endoleaks by Stefan P. M. Smorenburg, Rutger J. Lely, Bas-Jeroen van Kelckhoven, Erik G. Vermeulen, Kak Khee Yeung, Rombout R. Kruse, Martin Kraai, Chrit M. Stassen, Michael J. Jacobs and Arjan W. J. Hoksbergen in Journal of Endovascular Therapy</p

sj-docx-2-jet-10.1177_15266028231165731 – Supplemental material for Initial Clinical Experience With AneuFix Injectable Biocompatible Elastomer for Translumbar Embolization of Type 2 Endoleaks

Supplemental material, sj-docx-2-jet-10.1177_15266028231165731 for Initial Clinical Experience With AneuFix Injectable Biocompatible Elastomer for Translumbar Embolization of Type 2 Endoleaks by Stefan P. M. Smorenburg, Rutger J. Lely, Bas-Jeroen van Kelckhoven, Erik G. Vermeulen, Kak Khee Yeung, Rombout R. Kruse, Martin Kraai, Chrit M. Stassen, Michael J. Jacobs and Arjan W. J. Hoksbergen in Journal of Endovascular Therapy</p

sj-docx-1-jet-10.1177_15266028231165731 – Supplemental material for Initial Clinical Experience With AneuFix Injectable Biocompatible Elastomer for Translumbar Embolization of Type 2 Endoleaks

Supplemental material, sj-docx-1-jet-10.1177_15266028231165731 for Initial Clinical Experience With AneuFix Injectable Biocompatible Elastomer for Translumbar Embolization of Type 2 Endoleaks by Stefan P. M. Smorenburg, Rutger J. Lely, Bas-Jeroen van Kelckhoven, Erik G. Vermeulen, Kak Khee Yeung, Rombout R. Kruse, Martin Kraai, Chrit M. Stassen, Michael J. Jacobs and Arjan W. J. Hoksbergen in Journal of Endovascular Therapy</p