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PubMed1997

Vaginal topography does not correlate well with visceral position in women with pelvic organ prolapse.

The objective was to determine whether vaginal topography accurately predicts the location of the pelvic viscera on fluoroscopy in women with pelvic organ prolapse. Eighty-nine women undergoing preoperative evaluation for reconstructive pelvic surgery at a tertiary care referral practice formed the study population. Each woman completed a comprehensive urogynecologic history and physical examination, which included a quantified (POP-Q) assessment of her vaginal topography, as described by Bump et al. In addition each woman underwent pelvic floor fluoroscopy (PFF). Visceral sites were selected which corresponded clinically to the vaginal sites measured by the POP-Q. The most dependent portion of the bladder, small intestine, rectum and urethrovesical junction was measured. Twenty-five (28%) women had stage II prolapse, 34 (38%) had stage III prolapse, and 28 (32%) had stage IV prolapse. The remaining 2 women were symptomatic, with stage I prolapse. For the entire study population there was no correlation between the fluoroscopic position of the small bowel and/or rectum and any apical or posterior wall POP-Q site (C, Ap or Bp). There was no correlation with the fluoroscopic position of the UVJ at rest or with straining and the corresponding POP-Q site (Aa). The fluoroscopic position of the most dependent portion of the bladder correlated only modestly with the upper (Ba, rho = 0.51) and lower Aa, rho = 0.68) anterior vaginal wall POP-Q sites. In women without prior surgery (n = 33) there was only modest correlation between the fluoroscopic position of the bladder and the corresponding POP-Q site (Aa, rho = 0.71). In this unoperated subpopulation there was no correlation with PFF and any other POP-Q site. In women who had undergone prior hysterectomy (n = 25) or hysterectomy with anterior and/or posterior colporrhaphy (n = 17), there was only a modest correlation of the most dependent portion of the bladder and the upper anterior vaginal wall site (Bb, rho = 0.67 and rho = 0.55, respectively). It was concluded that vaginal topography does not reliably predict the position of the associated viscera on PFF in women with primary or recurrent pelvic organ prolapse.

Female↗

PubMed1999

Catheter entrapment by atrial suture during minimally invasive port-access cardiac surgery.

PURPOSE: The port-access approach allows surgeons to perform heart operations through small intercostal openings, or "ports". This technique requires new skills for anesthesiologists. A pulmonary artery venting (PAV) catheter and, in some cases, a coronary sinus catheter (for administration of retrograde cardioplegia) are positioned with the aid of fluoroscopy and transesophageal echography (TEE). Both catheters have a wider diameter than the more commonly used conventional PA catheter and present distinctive features. We report a case in which a pulmonary artery venting catheter was entrapped by a suture during a port-access procedure. CLINICAL FEATURES: A 35-yr-old man with severe mitral valve insufficiency was scheduled for valve repair. After a successful bypass procedure, resistance was felt while attempting to withdraw the PAV catheter. On fluoroscopy, fixation of the catheter at the heart level was established and perforation by suture was confirmed after injection of a contrast agent. Because of the risk of cardiac wall rupture and tamponade, the thorax was reopened. After release of some atrial sutures, the catheter could be withdrawn easily. Transfixion by a suture was confirmed by visual examination. CONCLUSION: The more frequent use of a PAV catheter in minimally invasive cardiac surgery with the port-access technique should remind the anesthesiologist of the higher risk of entrapment by surgical sutures. Surgeons should be aware of the risk of accidentally transfixing this catheter during closure of the atriotomy via the port.

Adult↗

PubMed2004

A new guidance device facilitates percutaneous puncture of the foramen ovale in human cadavers.

PURPOSE: Trigeminal neuralgia is the most common neurological cause for facial pain. Contemporary interventional treatment relies on surgical microvascular decompression or, alternatively, percutaneous interventions targeting the semilunar ganglion via the foramen ovale. For the latter approach, only free-hand punctures using fluoroscopy devices have been reported. Therefore, the present study aimed to evaluate a new fluoroscopy-based guidance device for transforaminal puncture. METHODS: Two experienced examiners punctured the foramen ovale bilaterally free-hand, and using a guidance device in human cadavers (n = 9). The number of attempts for puncture was recorded. A new attempt was counted each time the needle had to be retracted for redirection. RESULTS: As compared to the free-hand puncture of the foramen ovale (4.44 +/- 2.79), the new guidance device significantly reduced the number of trials needed (1.37 +/- 0.69). CONCLUSION: The employment of a guidance device facilitated percutaneous transforaminal puncture and resulted in a significantly decreased number of puncture attempts as compared to free-hand techniques in human cadavers.

Cadaver↗

PubMed1999

The anatomic and functional variability of rectoceles in women.

Fluoroscopic parameters of the rectum in women with pelvic organ prolapse were studied. Ninety-eight consecutive women undergoing reconstructive pelvic surgery completed a urogynecologic history with physical examination and pelvic floor fluoroscopy. The presence of rectocele and contrast trapping was determined on each fluoroscopic study. Each frame of the study was measured to determine the rectal width. Seventy-eight per cent of the women had fluoroscopically demonstrated rectoceles. Their maximum and minimum rectal widths were larger than those of women without rectoceles. Contrast-retaining rectoceles were larger than non-contrast retaining rectoceles. Fluoroscopic evidence of contrast retention did not relate to patient symptoms. There was no difference in the grade of posterior wall prolapse in women with and without rectoceles. Rectoceles have anatomic and functional variability. Fluoroscopy may be a valuable adjunct to the physical examination in assisting gynecologic surgeons to refine their surgical approach for rectocele repair.

Adult↗

PubMed2006

Transperineal permanent seed implantation of "low-risk" prostate cancer: 5-year-experiences in 118 patients.

PURPOSE: To evaluate 5-year prostate-specific antigen (PSA) relapse-free survival of transperineal permanent seed implantation (TPSI) in 118 patients with "low-risk" prostate cancer, that means stage cT1c-T2a, Gleason Score < 7, and initial PSA value < 10 ng/ml. PATIENTS AND METHODS: From 04/1999 to 06/2002, a total of 118 patients underwent a mono-TPSI, using ultrasound-based preplanning and intraoperative verification by both ultrasound and conventional fluoroscopy as well as postoperative CT planning. Patients were monitored during the 1st year in 3-month intervals, and in 6-monthly intervals from then onward. Biochemical failure was defined according to ASTRO criteria with three consecutive PSA rises observed from a posttreatment nadir PSA value. The median follow-up was 48.9 months (range: 37.0-80.2 months). 114 patients were eligible, four patients were lost to follow-up. RESULTS: For the entire group, PSA relapse-free survival at 5 years was 94.7%, with six patients (5.3%) having a PSA relapse between 8 and 20 months after implantation. In the bNED patients (no biochemical evidence of disease), PSA values were < 0.2 ng/ml in 82.5% (94/114 patients), < 0.5 ng/ml in 13.2% (15/114 patients), < 1.0 ng/ml in 2.6% (3/114 patients), and < 1.5 ng/ml in 1.7% (2/114 patients). In summary, PSA values < 0.2 ng/ml, < 0.5 ng/ml and < 1.0 ng/ml occurred in 82.5%, 95.7% and 98.3%, respectively. Out of the six patients with recurrent disease, three had a local tumor recurrence only, and three developed distant metastases. CONCLUSION: In low-risk prostate cancer patients, TPSI with intraoperative ultrasound-based treatment planning and fluoroscopy leads to excellent local tumor control and PSA relapse-free survival.

Adenocarcinoma↗

PubMed2004

[Computer-assisted surgery for pelvic injuries].

For pelvic fractures, pre- and postoperative imaging includes spiral computed tomography, providing high resolution and accuracy. In conventional pelvic operations, these image data cannot be used directly. Intraoperative imaging is limited with fluoroscopy and visualization by the approaches. One solution in terms of precision and reduction of radiation exposure could be computer-assisted surgery (CAS). This method can be divided into navigation, which requires active registration, CT based navigation and registration-free fluoroscopy-based or Iso-C-3D-based navigation. Applications for CAS in the pelvis include sacroiliac screw osteosynthesis in pelvic ring fractures, navigated periacetabular screw fixation, and correction operations for malhealed pelvic ring fractures. Nowadays, CAS is still costly and frequently requires additional staff. However, it helps to reduce complications caused by implant placement. With the introduction of new health care requirements in Germany, this may be an economic argument as well. Current developments focusing on accurate navigated reduction will provide new indications for CAS, further decrease complication rates, and help to reduce the invasiveness of pelvis operations.

Acetabulum↗

PubMed2003

[Navigated Iso-C(3D)-based drilling of a osteochondral lesion of the talus].

Retrograde drilling of osteochondral lesions has obtained acceptable results in the initial stage. Intraoperatively not all lesions are accessible with the arthroscopic technique, despite being readily identifiable with modern imaging preoperatively. As an alternative, open surgical treatment is recommended to achieve good results. The use of computer-assisted navigated retrograde drilling of osteochondral lesions has been described with promising results as a new technique. Computed tomography (CT)- and fluoroscopy-based navigation systems in current use are limited in their flexibility. The drawbacks of fluoroscopy are lack of three-dimensional imaging intraoperatively. CT-based navigation still requires intraoperative cumbersome registration, extra preoperative planning, and imaging with further technical resources. In the current case report, we describe a patient with an osteochondral lesion of the posteromedial talus. In addition to the current method of arthroscopic evaluation and treatment, we also introduce an alternative technique of using Iso-C(3D)-based navigation-assisted retrograde drilling of the lesion. The advantages of this technique are an actual intraoperative three-dimensional imaging for the use of navigation without the need for anatomical registration and an immediate postoperative control of surgical treatment. The results of this case report demonstrate accurately navigated drilling with the described system. The accuracy was confirmed with immediate intraoperative Iso-C(3D) and postoperative CT scans. Our results indicate that the use of an Iso-C(3D) navigation system is a possible alternative to arthroscopic or open drilling for osteochondral lesions of the talus. To provide further evidence for the use of Iso-C (3D)-based drilling, current studies will start at our institution.

Adult↗

PubMed2006

[The clinical use of the ISO-C(3D) imaging system in calcaneus fracture surgery].

We compared in a prospective study including 82 patients treated with ORIF of an intraarticular calcaneus fracture the quality of fluoroscopy, intraoperatively Iso-C(3D) and postoperative CT-scans. Therefore the posterior facet of the calcaneus (PFOC) was divided into three sectors. Joint steps and fracture gaps were detected by two independent investigators and statistically analysed. Another focus was to evaluate if the findings due to intraoperatively Iso-C(3D) assessment performed by the surgeon were correct and subsequently influenced the surgical procedure. There were no statistically differences between the Iso-C(3D)- and CT findings concerning joint steps or fracture gaps in PFOC sectors I-III. With fluoroscopy an assessment of the PFOC sectors I and II was not possible. In six cases (7.3%), intraoperative reduction was redone after performing an Iso-C(3D) scan. In ten cases, 12 malpositioned screws were replaced (12.2%/14.6%). These results suggest that intraoperative 3D Iso-C(3D) imaging provides a high diagnostic reliability. By careful assessment of the images the surgeons receive information which could lead to a change of the operative strategy.

Algorithms↗

PubMed2003

[Flat-panel detectors in X-ray systems].

For all application segments X-ray systems with flat-panel detectors increasingly enter the market. In digital radiography,mammography and cardiologic angiography flat-panel detectors are already well established while they are made ready for market introduction in general angiography and fluoroscopy. Two flat-panel detector technologies are available. One technology is based on an indirect conversion process of X-rays while the other one uses a direct conversion method. For radiography and dynamic applications the indirect method provides substantial advantages, while the direct method has some benefits for mammography. In radiography and mammography flat-panel detectors lead to clear improvements with respect to workflow, image quality and dose reduction potentials. These improvements are fostered by the immediate availability of the image, the large dynamic range and the high sensitivity to X-rays. New applications and the use of complex image processing algorithms have the potential to enlarge the present diagnostic range of applications. Up to now, image intensifiers are still the well-established technology for angiography and fluoroscopy. Nevertheless flat-panel detectors begin to enter this field, especially in cardiologic angiography. Characteristics of flat-panel detectors such as the availability of distortion-free images, the excellent contrast resolution, the large dynamic range, the high sensitivity to X-rays and the usability in magnetic fields provide the basis for improved and new diagnostic and interventional methods.

Angiography↗

PubMed2002

[Placement of pedicle screws using different navigation systems. A laboratory trial with 12 spinal preparations].

A well-known problem occurring with thoracolumbar spondylodesis is the perforation of pedicle screws through the pedicle wall. It occurs in up to 40% of the implanted screws. To reduce this problem, computed tomography (CT)-based navigation systems have been introduced, which allow the surgeon multidimensional control of the screw position in virtual reality and real time during insertion. In the recent past, fluoroscopy-based navigation systems have also been built. We inserted 77 pedicle screws in human lumbar cadaveric spine specimens either without navigation, with CT-based navigation, or with fluoroscopy-based navigation. In the critical sizes of pedicles between 6.5 and 9 mm, we found the best results with CT-based navigation, but there was no significant difference between the three methods. The minimal pedicle and the screw diameters should be reported in every study on pedicle screw misplacement and spine navigation since they represent the most important factor in pedicle wall perforations.

Bone Screws↗

PubMed2002

Weight-bearing knee kinematics in subjects with two types of anterior cruciate ligament reconstructions.

Weight-bearing knee kinematics in patients who received two types of anterior cruciate ligament reconstruction were studied using a fluoroscopy-based three-dimensional measurement technique. Eleven patients with more than 1-year follow-up and good or excellent results participated in this study. Six subjects received anterior cruciate ligament reconstruction using a multiply folded semitendinosus and gracilis tendon graft, and five received combined intra- and extra-articular anterior cruciate ligament reconstruction using the iliotibial tract. The step up/down activity of normal and operated knees was recorded using lateral fluoroscopy. A customized three-dimensional contour model was created from two orthogonal views of each knee and all six degrees of freedom of knee movement were determined using a model matching technique. Both the normal and the reconstructed knees exhibited posterior condylar translation and internal tibial rotation with knee flexion, consistent with previous reports of normal kinematics. There were no statistically significant differences in the axial rotations or lateral or medial condylar anterior/posterior translations between operated and normal knees or between the two groups of operated knees.

Adolescent↗

PubMed2002

Patient and occupational dose in neurointerventional procedures.

Neurointerventional procedures can involve very high doses of radiation to the patient. Our purpose was to quantify the exposure of patients and workers during such procedures, and to use the data for optimisation. We monitored the coiling of 27 aneurysms, and embolisation of four arteriovenous malformations. We measured entrance doses at the skull of the patient using thermoluminescent dosemeters. An observer logged the dose-area product (DAP), fluoroscopy time and characteristics of the digital angiographic and fluoroscopic projections. We also measured entrance doses to the workers at the glabella, neck, arms, hands and legs. The highest patient entrance dose was 2.3 Gy, the average maximum entrance dose 0.9+/-0.5 Gy. The effective dose to the patient was estimated as 14.0+/-8.1 mSv. Other average values were: DAP 228+/-131 Gy cm(2), fluoroscopy time 34.8+/-12.6 min, number of angiographic series 19.3+/-9.4 and number of frames 267+/-143. The highest operator entrance dose was observed on the left leg (235+/-174 microGy). The effective dose to the operator, wearing a 0.35 mm lead equivalent apron, was 6.7+/-4.6 microSv. Thus, even the highest patient entrance dose was in the lower part of the range in which nonstochastic effects might arise. Nevertheless, we are trying to reduce patient exposure by optimising machine settings and clinical protocols, and by informing the operator when the total DAP reaches a defined threshold. The contribution of neurointerventional procedures to occupational dose was very small.

Adolescent↗

PubMedDate not supplied

Quantifying and minimizing radiation exposure during pediatric cardiac catheterization.

This study reports findings from evaluations of new technologies to measure radiation exposure during pediatric cardiac catheterization procedures. A strategy of pulsed fluoroscopy and low power settings resulted in significantly lower patient radiation exposure compared to conventional 60 frames/sec, high-power settings during fluoroscopy. During radiofrequency ablation procedures, thyroid and thoracic skin sites outside the direct fluoroscopic field received minimal radiation exposure. Intrathoracic radiation exposure was measured with the use of an esophageal dosimeter. In conclusion, strategies to reduce total radiation exposure should be employed, radiation dose should be measured, and assessment of radiation skin injury should be included in post-catheterization assessment.

Adolescent↗

PubMed2006

Retrograde approach for device closure of muscular ventricular septal defects in children and adolescents, using the Amplatzer muscular ventricular septal defect occluder.

This study presents technique and initial experience of retrograde deployment of the Amplatzer muscular ventricular septal defect occluder (AmVSDo) for closure of muscular ventricular septal defects (VSDs). The conventional technique for closing muscular VSDs involves the creation of an arteriovenous guidewire circuit and use of a transvenous approach for device deployment. Seven patients aged 2.2-15 years underwent transcatheter closure of a muscular VSD using the retrograde approach without making the arteriovenous wire circuit. Mean fluoroscopy and procedural times were compared to those previously reported in publications describing the use of the antegrade approach. Unpaired Student's t-test was used to compare the two parameters in two groups. Our technique was successful in all patients reported. The mean fluoroscopy time in the retrograde versus the antegrade group was 33.8 +/- 20.9 and 41.9 +/- 6.2 minutes, respectively (not significant), and the mean procedural time in the two groups was 91.1 +/- 22.1 and 114 +/- 33.9 minutes respectively (p = 0.025). No complications were noted. We suggest that some muscular VSDs can be safely closed retrogradely without the use of an arteriovenous loop, thus reducing the radiation exposure and also the cost of the procedure. Further studies are needed to confirm this initial experience.

Adolescent↗

PubMedDate not supplied

Neonatal cardiac catheterization: A 10-year transition from diagnosis to therapy.

To assess the changing role of cardiac catheterization in the care of the neonate, a retrospective review of all catheterizations between January 1984 to December 1985 (group I) and January 1994 to December 1995 (group II) at C.S. Mott Children's Hospital was performed. Neonatal cardiac catheterization was performed more frequently (p = 0.02) in group I, comprising 14% (110 of 772) of all catheterizations versus 11% (93 of 880) in group II. Access was performed by cutdown in 15 patients (13 venous and 2 arterial), all in group I. In group I, 20 of 110 patients (18%) had balloon atrial septostomies; no other catheter interventions were performed. Interventions were more frequent (p = 0.003) and varied in group II, including 15 septostomies, 17 balloon valvuloplasties (13 pulmonary and 4 aortic), 2 coil embolizations of collaterals, and 1 cardiac biopsy. Despite the higher prevalence and complexity of interventions in group II, fluoroscopy times (median; range: 16 min; 2-55 vs 16 min; 1-107) were similar in both groups (p = not significant) as well as the prevalence of complications. Neonatal cardiac catheterizations are performed less frequently than they were a decade ago at our institution, and therapeutic interventions have become more common. Despite these changes, fluoroscopy time and the rate of complications have not increased.

Cardiac Catheterization↗

PubMed1998

A comparison between digital fluoroscopic hard copies and 105-mm spot films in evaluating vesicoureteric reflux in children.

OBJECTIVE: To compare fluoroscopic freeze-frame digital images with conventional 105-mm spot films during voiding cystourethrography (VCUG) with regard to diagnostic quality and radiation dose. MATERIALS AND METHODS: VCUG was performed on 57 consecutive children by a commercially available fluoroscopic digital system. Both freeze-frame digital images and conventional 105-mm spot films were obtained during 90 s of fluoroscopy. Skin radiation dose was assessed separately for spot films and for both fluoroscopy and spot films, employing thermoluminescent crystals on the anterior surface of the body. Patients were classified into three age groups: group A younger than 12 months, group B 1-5 years old and group C 5-12 years of age. RESULTS: Digital and conventional images provided diagnostically identical results in 108 out of 114 ureters examined (94.7%). Percentage reductions in skin radiation dose due to the fluoroscopic hard copies compared with the four 105-mm radiographs were 53.8%, 50.5% and 57.1% for groups A, B and C, respectively. CONCLUSION: Substitution of conventional 105-mm spot films during VCUG with digital fluoroscopic hard copies resulted in a substantial reduction in radiation dose. Digital images were as accurate as the conventional films in excluding vesicoureteric reflux (VUR). The two methods correlated well in diagnosing and grading VUR.

Child↗

PubMed2000

Sonographic guidance of air enema for intussusception reduction in children.

BACKGROUND: Fluoroscopically guided air reduction of intussusception is a well-accepted technique. There are only two previous reports in which US has been used to monitor pneumatic reduction. OBJECTIVE: To assess the ability of US to monitor the success of air reduction of intussusception. MATERIALS AND METHODS: Sonographically guided air-enema reduction of intussusception in 199 children. In phase I (11 children), the success or failure of reduction was confirmed by fluoroscopy. In phase II (188 children), complete reduction was confirmed by clinical improvement of the child and repeat sonography 1 h later showing no persistent intussusception. RESULTS: In phase I, fluoroscopy confirmed the accuracy of US in all 11 children. In phase II, the success rate of initial reduction was 95%. Following successful reduction, US repeated 1 h later showed no recurrence of intussusception in 92%. In ten (5%) of 188, initial reduction was unsuccessful; fluoroscopically guided air reduction successfully reduced only three of these ten failures. CONCLUSIONS: Air enema guided by US is a practical and reliable technique for the reduction of intussusception.

Air↗

PubMed2000

MR arthrography of the shoulder and hip after fluoroscopic landmarking.

PURPOSE: To describe a technique for intra-articular injection in the MR suite after conventional fluoroscopic landmarking in order to streamline MR arthrography. DESIGN AND PATIENTS: This technique was performed on 33 consecutive patients referred for MR arthrography of the shoulder to evaluate the glenoid labrum and on 15 consecutive patients referred for MR arthrography of the hip to evaluate the acetabular labrum. The patients were landmarked in the fluoroscopy suite, followed by a conventional MR examination. The intra-articular injection was then performed on the MR table and the MR arthrographic sequences obtained. RESULTS: One of the 48 injections was extra-articular, requiring a second injection. The other injections were performed without incident, and the average total procedure time for all injections was 10 min. CONCLUSIONS: This technique is a reliable method of streamlining intra-articular injections when performing conventional MR imaging prior to the MR arthrographic portion of the examination. It shortens the total MR examination time by eliminating a visit to the fluoroscopy suite in the middle of the MR study, and its use of a straight anterior approach for both the shoulder and hip joints should be familiar to most people who perform conventional arthrography.

Adolescent↗