Multimodal Image Fusion in Endovascular Complex Aortic Aneurysm Repair

125 Pages·2016·2.39 MB·English

Multimodal image fusion in endovascular complex
aortic aneurysm repair
Citation for published version (APA):
Karmann-Sailer, A-M. H. (2016). Multimodal image fusion in endovascular complex aortic aneurysm
repair. [Doctoral Thesis, Maastricht University]. Datawyse / Universitaire Pers Maastricht.
https://doi.org/10.26481/dis.20161214ak
Document status and date:
Published: 01/01/2016
DOI:
10.26481/dis.20161214ak
Document Version:
Publisher's PDF, also known as Version of record
Please check the document version of this publication:
• A submitted manuscript is the version of the article upon submission and before peer-review. There can
be important differences between the submitted version and the official published version of record.
People interested in the research are advised to contact the author for the final version of the publication,
or visit the DOI to the publisher's website.
• The final author version and the galley proof are versions of the publication after peer review.
• The final published version features the final layout of the paper including the volume, issue and page
numbers.
Link to publication
General rights
Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright
owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these
rights.
• Users may download and print one copy of any publication from the public portal for the purpose of private study or research.
• You may not further distribute the material or use it for any profit-making activity or commercial gain
• You may freely distribute the URL identifying the publication in the public portal.
If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license above,
please follow below link for the End User Agreement:
www.umlib.nl/taverne-license
Take down policy
If you believe that this document breaches copyright please contact us at:
[email protected]
providing details and we will investigate your claim.
Download date: 12 Feb. 2023
Multimodal Image Fusion in
Endovascular Complex Aortic Aneurysm Repair
Anna-Margaretha Sailer
U

P
ISBN 978 94 6159 634 5 M
Cover A.M. Karmann
Printed by Datawyse | Universitaire Pers Maastricht UNIVERSITAIRE
PERSMAASTRICHT
© Anna-Margaretha Hedwig Karmann (geboren Sailer), Maastricht 2016

Copyright of the individual chapters lies with the publisher of the journal listed at the beginning of each
respective chapter. No part of this thesis may be reproduced in any form, by print, photocopy, digital file,
internet, or any other means without written permission from the author.
Multimodal Image Fusion in
Endovascular Complex Aortic Aneurysm Repair

PROEFSCHRIFT

ter verkrijging van de graad van doctor aan
de Universiteit Maastricht,
op gezag van de Rector Magnificus,
Prof. dr. Rianne M. Letschert
volgens het besluit van het College van Decanen,
in het openbaar te verdedigen
op woensdag 14 december 2016 om 12.00 uur

door

Anna-Margaretha Hedwig Karmann (geboren Sailer)
Promotores
Prof. Dr. G.W.H. Schurink
Prof. Dr. M.W. de Haan

Copromotor
Dr. C.R.L.P.N. Jeukens

Beoordelingscommissie
Prof. Dr. R.J. van Oostenbrugge (voorzitter)
Prof. Dr. W.F. Buhre
Dr. J.A. van Herwaarden (Universitair Medisch Centrum, Utrecht)
Prof. Dr. P.A.M. Hofman
Prof. Dr. L.J. Schultze Kool (Radboud Universitair Medisch Centrum, Nijmegen)
CONTENTS
Chapter 1 General Introduction 7
Chapter 2 CTA with fluoroscopy image fusion guidance in endovascular
complex aortic aneurysm repair 15
Chapter 3 Quantification of respiratory movement of the aorta and side
branches 29
Chapter 4 Radiation exposure of abdominal cone beam computed
tomography 41
Chapter 5 Occupational radiation exposure during endovascular aortic repair 57
Chapter 6 Endovascular treatment of complex aortic aneurysms: Prevalence
of acute kidney injury and effect on long-term renal function 69
Chapter 7 Fusion image guidance in endovascular peripheral artery
interventions – a feasibility study 83
Chapter 8 General Discussion 97
Chapter 9 Valorization 105
Summary 109
Samenvatting 111
Acknowledgement 115
Curriculum Vitae 119
List of Publications 121

5

1
CHAPTER
General Introduction

7
CHAPTER 1
ENDOVASCULAR AORTIC ANEURYSM REPAIR
Aortic aneurysms are defined as aortic segments with a 50% increase in diameter
compared to the normal aorta.1 Aortic aneurysms affect between 2 and 8 percent of the
western population with a generally higher prevalence in males, patients of advanced age
and a localization in the abdominal aorta.2-4 Although pathogenesis of aneurysm
formation and growth are not fully understood, aortic aneurysms have the habit to grow
over time, significantly increasing the risk of rupture and eventual mortality.5-7 Surgical
repair with open exposure of the aneurysm has successfully been performed since the
1950s by suturing a prosthetic graft proximally and distally into the adjacent aorta or iliac
arteries. The high mortality rate of more than 4 % associated with open aneurysm repair
and a general trend towards minimally invasive surgery techniques led to the concept of
delivering a covered stent graft endoluminally to the location of the aneurysm, effectively
sealing off the aneurysm wall from systemic pressures and thereby preventing further
aneurysm growth and rupture.8
In 1991, the first published report of stent graft implantation for abdominal aortic
aneurysm in humans delivered scientific proof for the feasibility of endovascular
aneurysm exclusion by delivering an endograft through small incisions in peripheral
arteries. Since then three prospective randomized controlled trials on elective aortic
repair have shown a manifest benefit of 30-day postoperative mortality in favor of
endovascular treatment compared to open surgery.10-12 These results have been
supported by data from large registries and one metaanalysis.13-15 For low risk patients,
operative mortality rates between open surgery and endovascular repair were found
similar.16 In 1994, Dake et al first reported the use of thoracic endovascular aortic repair
(TEVAR) by introducing stent-grafts for the treatment of descending thoracic aortic
aneurysms in a series of patients who were at high risk for open surgery.17 In the following
20 years, endovascular aortic repair has evolved at a rapid pace, targeting the treatment
of more and more complex vascular pathology.
Aortic aneurysms are considered complex when the arterial anatomy does not provide a
sufficient infrarenal or thoracic sealing zone. In consequence, the aortic stent graft needs
to be extended above the level of relevant side branches such as the renal arteries,
visceral arteries and supraaortic branches. In order to provide adequate graft sealing and,
at the same time, preserve aortic side branch patency and blood supply to the depending
organs, the main aortic branches arising from the affected part of the aorta are peri-
operatively catheterized and stented through customized fenestrations or branches in
the aortic stent graft (FEVAR/BEVAR).18 Fenestrated and branched endovascular aortic
repair (FEVAR/BEVAR) nowadays allows the treatment of complex aortic aneurysms such
as juxta-and suprarenal aneurysms, thoraco-abdominal aneurysms and aortic arch
aneurysms.
8
General Introduction
CHALLENGES OF ENDOVASCULAR REPAIR OF COMPLEX AORTIC
ANEURYSMS
Although standard endovascular repair proved favorable in perioperative survival, blood
loss and shorter hospital stay compared to open surgery, EVAR relies on exposure to
ionizing radiation and iodinated contrast medium. In addition, endovascular approaches
face several challenges in complex aortic pathology. The endovascular repair of complex
vascular anatomy is highly personalized and crucially depends on the quality and co-
operation of different imaging modalities, with pre-operative computed tomography (CT)
and intraoperative fluoroscopy being the most commonly used radiologic techniques.
With increasing complexity of the treated pathology and the introduction of customized
fenestrated and branched endovascular technology, the ability to precisely assess the
three-dimensional (3D) architecture of the patient’s aorta and its side branches before
and during the procedure becomes crucial for a safe and effective endovascular repair.
Multidetector computed tomography (MDCT) provides detailed 3D morphologic
information of the aorta and arterial structure which allows for adequate preoperative
patient selection, detailed procedure planning and patient-specific prosthesis sizing.
Intraoperative arterial imaging has historically been limited to two-dimensional (2D)
angiography and fluoroscopy. The technical success of fenestrated and branched
aneurysm repair relies substantially on the secure access to the side aortic branches. This
requires correct positioning and deployment of the aortic stent graft at the right level and
degree of rotation, atraumatic navigation into the target vessels through the
fenestrations and branches as well as adequate stenting of the vessels.
A safe and effective execution of these complex procedures would ideally require
intraoperative access to the entire 3D vascular architecture information of the MDCT in
order to have constant knowledge about the position of the origins of the target vessel
and aortic anatomy which would facilitate optimal viewing projections and 3D image
guided navigation. With the current, conventional 2D fluoroscopy and angiography,
guidewires and catheters are maneuvered “blindly” without visualization of the arterial
anatomy or by road mapping based on vascular architecture visualization obtained from
administration of iodinated contrast media. Different projections are usually mandatory
for different target vessels which typically requires repeated contrast administration for
new roadmaps in different working projections.
The technical complexity of fenestrated and branched procedures on one hand and the
limited intraoperative vascular information on the other contribute to a substantial
increase in procedure time, radiation exposure and iodinated contrast media in
endovascular complex aneurysm repair.19,20 Higher radiation exposure increases the risk
of deterministic injuries and induction of stochastic carcinogenic effects in patients,
endovascular surgeons, interventional radiologists and other staff members involved in
9