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. 2012 Dec 1;80(7):1090-8.
doi: 10.1002/ccd.24391. Epub 2012 Oct 24.

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

Andrew J Klein  1 , Michael T Tomkowiak, Karl K Vigen, Timothy A Hacker, Michael A Speidel, Michael S Vanlysel, Nehal Shah, Amish N Raval
Affiliations

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

Andrew J Klein et al. Catheter Cardiovasc Interv. .

Abstract

Objectives: 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.

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

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Figures

Figure 1
Figure 1. Imaging Flowchart
Axial T1 weighted fast spin-echo MR images are acquired, contoured and segmented to create 3-dimensional carotid artery surface models. These models are then registered to biplane DSA images in the cath-lab using common anatomic features. The registration is displayed onto live XRF, allowing for multi-modality image fusion guided interventions. MR=magnetic resonance, DSA= digital subtraction angiography, XRF=X-ray fluoroscopy
Figure 2
Figure 2. Imaging and Model Registration
(A) Pre-procedure MRA indicates an occlusion in the LCA. (B) The patent RCA (red) and occluded LCA (blue) arteries are both visible in T1 weighted MR axial images, and contours are used to segment the carotid arteries. (C–D) Intra-procedural biplane DSA from orthogonal views (45° RAO / 45° LAO) reveals the patent RCA and proximal stump of the LCA. (E–F) 3-dimensional models of the carotid arteries are registered to the DSA by aligning the luminal edges of the RCA with its model. MRA=magnetic resonance angiography, LCA=left carotid artery, RCA=right carotid artery, RAO=right anterior oblique, LAO=left anterior oblique, DSA=digital subtraction angiography.
Figure 3
Figure 3. MRI to XRF image fusion guided chronic total occlusion recanalization
(A) Digital substraction angiography shows the guide wire near the distal stump of the LCA. (B) The overlay of the registered MRI model onto the XRF image indicates the guidewire has assumed a sub-intimal course. (C) Necropsy was performed with the wire in place, showing a similar trajectory around the vessel lumen (dashed line). MRI=magnetic resonance imaging, LCA=left carotid artery, XRF=X-ray fluoroscopy
See this image and copyright information in PMC

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