Avoiding pitfalls of intraoperative peripheral endovascular surgery with the aid of OsiriX: expanding the use of virtual fluoroscopy

Abstract

We have shown how the analysis of the angiotomography reconstruction through OsiriX program has assisted in endovascular perioperative programming. We presented its application in situations when an unexpected existence of metallic overlapping artifact (orthopedic osteosynthesis) compromised the adequate visualization of the arterial lesion during the procedure. Through manipulation upon OsiriX software, with assistance of preview under virtual fluoroscopy, it was possible to obtain the angles that would avoid this juxtaposition. These angles were reproduced in the C-arm, allowing visualization of the occluded segment, reducing the need for repeated image acquisitions and contrast overload, allowing the continuation of the procedure.

Figure 1

A) Intraoperatory image of digital subtraction angiography, which displays an overlapping caused by the orthopedic metallic rod over the arterial thrombosed segment. B) Study of the tomographic axial view, where marks with the OsiriX’s point tool were performed, over the estimated trajectory of the left subclavian artery. C) Three-dimensional-by-volume reconstruction under virtual fluoroscopy, after marking with points. It was possible to identify, in fact, the overlapping of the structures and the need of the C-arm angular repositioning intraoperatively.

Fig. 2

A) Three-dimensional-by-volume image rotation avoiding the overlap of the osteosynthesis upon the tomographic point marks. The angles used for C-arm repositioning were automatically yielded by the software (right inferior corner). B) Digital subtraction angiography after the angular correction of the radioscopic device, with minimum effect of image superposition, allowing the preview of the thrombosed arterial segment. C) Final outcome after arterial recanalization and the covered-stent implant.