Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter November 1, 2013

Technical concepts for vascular electromagnetic navigated interventions: Aortic in situ fenestration and transjugular intrahepatic porto-systemic shunts

  • Tobias Penzkofer EMAIL logo , Peter Isfort , Hong-Sik Na , Christoph Wilkmann , Sabine Osterhues , Andreas Besting , Christoph Hänisch , Stefan Bisplinghoff , Johannes Jansing , Sylvie von Werder , Jorge Gooding , Mathias de la Fuente , Andreas H. Mahnken , Catherine Disselhorst-Klug , Thomas Schmitz-Rode , Christiane K. Kuhl and Philipp Bruners

Abstract

This work presents concepts for complex endovascular procedures using electromagnetic navigation technology (EMT). Navigation software interfacing a standard commercially available navigation system was developed, featuring registration, electromagnetic field distortion correction, breathing motion detection and gating, and state-of-the-art 3D imaging post processing. Protocols for endovascularly placed, in-situ fenestrated abdominal aortic stent grafts and an EMT guided transjugular intrahepatic portosystemic shunt (TIPSS) creation have been designed. A dedicated set of interventional devices was developed for each of the procedures: For aortic in-situ fenestration a combination of high-porosity stentgrafts, steerable catheters and electromagnetically navigated guidewires was used, for TIPSS a dual-navigated (sheath and stylet) TIPSS-device was designed and manufactured. The developed devices underwent phantom testing, in preparation for animal experiments to prove the feasibility of the approach. Once established, these systems could aid in performing these challenging interventional radiology procedures, exploiting the unique characteristics of electromagnetic navigation and solving multiple of the problems associated with these interventions being performed under X-ray fluoroscopy, such as lacking real-time 3D information or extensive exposure to ionizing radiation.


Corresponding author: Tobias Penzkofer, Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany; Surgical Planning Laboratory, Brigham and Women′s Hospital, Boston, MA, USA; and Applied Medical Engineering, RWTH Aachen University Hospital, Aachen, Germany, E-mail:
aThese authors contributed equally.

Acknowledgments

The projects were carried out within the medtec-in.nrw project, supported by the state North Rhine-Westphalia and the European Union under the Ziel2 and EFRE programs.

References

[1] Abi-Jaoudeh N, Glossop N, Dake M, et al. Electromagnetic navigation for thoracic aortic stent-graft deployment: a pilot study in swine. J Vasc Interv Radiol 2010; 21: 888–895.10.1016/j.jvir.2009.12.402Search in Google Scholar

[2] Barratt DC, Davies AH, Hughes AD, Thom SA, Humphries KN. Accuracy of an electromagnetic three-dimensional ultrasound system for carotid artery imaging. Ultrasound Med Biol 2001; 27: 1421–1425.10.1016/S0301-5629(01)00447-1Search in Google Scholar

[3] Bismuth J, Duran C, Hassoun HT. In situ fenestration for branch vessel preservation during EVAR. Methodist Debakey Cardiovasc J 2012; 8: 33–36.10.14797/mdcvj.370Search in Google Scholar

[4] Bock M, Volz S, Zuhlsdorff S, et al. Automatic slice tracking in interventional magnetic resonance imaging. Z Med Phys 2003; 13: 177–182.10.1078/0939-3889-00165Search in Google Scholar PubMed

[5] Boyer TD, Haskal ZJ. American association for the study of liver diseases practice guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension. J Vasc Interv Radiol 2005; 16: 615–629.10.1097/01.RVI.0000157297.91510.21Search in Google Scholar PubMed

[6] British Society for Endovascular Therapy and The Global Collaborators on Advanced Stent-Graft Techniques for Aneurysm Repair. Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United Kingdom. Circulation 2012; 125: 2707–1215.10.1161/CIRCULATIONAHA.111.070334Search in Google Scholar PubMed

[7] Brost A, Wu W, Koch M, et al. Combined cardiac and respiratory motion compensation for atrial fibrillation ablation procedures. Med Image Comput Comput Assist Interv 2011; 14: 540–547.10.1007/978-3-642-23623-5_68Search in Google Scholar PubMed

[8] Brown LC, Thompson SG, Greenhalgh RM, Powell JT. and Endovascular Aneurysm Repair Trial. Incidence of cardiovascular events and death after open or endovascular repair of abdominal aortic aneurysm in the randomized EVAR trial 1. Br J Surg 2011; 98: 935–942.10.1002/bjs.7485Search in Google Scholar PubMed

[9] Canavati R, Millen A, Brennan J, et al. Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair. J Vasc Surg 2013; 57: 362–367.10.1016/j.jvs.2012.08.040Search in Google Scholar PubMed

[10] Cello JP, Ring EJ, Olcott EW, et al. Endoscopic sclerotherapy compared with percutaneous transjugular intrahepatic portosystemic shunt after initial sclerotherapy in patients with acute variceal hemorrhage. A randomized, controlled trial. Ann Intern Med 1997; 126: 858–865.10.7326/0003-4819-126-11-199706010-00002Search in Google Scholar PubMed

[11] Cross J, Gurusamy K, Gadhvi V, et al. Fenestrated endovascular aneurysm repair. Br J Surg 2012; 99: 152–159.10.1002/bjs.7804Search in Google Scholar PubMed

[12] Cross J, Raine R, Harris P, Richards T, Fevar Consensus Working Group of the British Society of Endovascular Therapy. Indications for fenestrated endovascular aneurysm repair. Br J Surg 2012; 99: 217–224.10.1002/bjs.7811Search in Google Scholar PubMed

[13] Darcy M. Evaluation and management of transjugular intrahepatic portosystemic shunts. Am J Roentgenol 2012; 199: 730–736.10.2214/AJR.12.9060Search in Google Scholar PubMed

[14] de Lambert AS, Esneault A, Lucas P, Haigron P, Cinquin JL Magne. Electromagnetic tracking for registration and navigation in endovascular aneurysm repair: a phantom study. Eur J Vasc Endovasc Surg 2012; 43: 684–689.10.1016/j.ejvs.2012.03.007Search in Google Scholar PubMed

[15] Eesa M, Clark T. Transjugular intrahepatic portosystemic shunt: state of the art. Semin Roentgenol 2011; 46: 125–132.10.1053/j.ro.2010.08.006Search in Google Scholar PubMed

[16] Elkouri S, Martelli E, Gloviczki P, et al. Most patients with abdominal aortic aneurysm are not suitable for endovascular repair using currently approved bifurcated stent-grafts. Vasc Endovascular Surg 2004; 38: 401–412.10.1177/153857440403800502Search in Google Scholar PubMed

[17] Fidelman N, Kwan SW, LaBerge JM, Gordon RL, Ring EJ, Kerlan RK, Jr. The transjugular intrahepatic portosystemic shunt: an update. Am J Roentgenol 2012; 199: 746–755.10.2214/AJR.12.9101Search in Google Scholar PubMed

[18] Garcia-Villarreal L, Martinez-Lagares F, Sierra A, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal rebleeding after recent variceal hemorrhage. Hepatology 1999; 29: 27–32.10.1002/hep.510290125Search in Google Scholar PubMed

[19] Hinchliffe RJ, Braithwaite BD, Hopkinson BR. The endovascular management of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2003; 25: 191–201.10.1053/ejvs.2002.1846Search in Google Scholar PubMed

[20] Holden A, Mertens R, Hill A, Marine L, Clair DG. Initial experience with the Ventana fenestrated system for endovascular repair of juxtarenal and pararenal aortic aneurysms. J Vasc Surg 2013; 57: 1235–1245.10.1016/j.jvs.2012.10.125Search in Google Scholar PubMed

[21] Keefer A, Hislop S, Singh MJ, Gillespie D, Illig KA. The influence of aneurysm size on anatomic suitability for endovascular repair. J Vasc Surg 2010; 52: 873–877.10.1016/j.jvs.2010.04.064Search in Google Scholar PubMed

[22] Levy EB, Zhang H, Lindisch D, Wood BJ, Cleary K. Electromagnetic tracking-guided percutaneous intrahepatic portosystemic shunt creation in a swine model. J Vasc Interv Radiol 2007; 18: 303–307.10.1016/j.jvir.2006.12.716Search in Google Scholar PubMed

[23] Manning BJ, Ivancev K, Harris PL. In situ fenestration in the aortic arch. J Vasc Surg 2010; 52: 491–494.10.1016/j.jvs.2009.07.088Search in Google Scholar PubMed

[24] Manstad-Hulaas F, Tangen GA, Gruionu LG, Aadahl P, Hernes TA. Three-dimensional endovascular navigation with electromagnetic tracking: ex vivo and in vivo accuracy. J Endovasc Ther 2011; 18: 230–240.10.1583/10-3301.1Search in Google Scholar PubMed

[25] Mazer LM, Chiakof EL, Goodney PP, Edwards MS, Corriere MA. Single versus multi-specialty operative teams: association with perioperative mortality after endovascular abdominal aortic aneurysm repair. Am Surg 2012; 78: 207–212.10.1177/000313481207800239Search in Google Scholar

[26] McWilliams, RG, Murphy M, Hartley D, Lawrence-Brown MM, Harris PL. In situ stent-graft fenestration to preserve the left subclavian artery. J Endovasc Ther 2004; 11:170–4.10.1583/03-1180.1Search in Google Scholar PubMed

[27] Murphy EH. Dimaio JM, Dean W, Jessen ME, Arko FR. Endovascular repair of acute traumatic thoracic aortic transection with laser-assisted in-situ fenestration of a stent-graft covering the left subclavian artery. J Endovasc Ther 2009; 16:457–63.10.1583/09-2746.1Search in Google Scholar PubMed

[28] Na HS, Penzkofer T, Isfort P, et al. Hyther: Electromagnetically navigated in situ fenestration of aortic stent grafts. Biomed Tech (Berl) 2012.10.1515/bmt-2012-4544Search in Google Scholar

[29] Penzkofer T, Bruners P, Isfort P, et al. Vascular electromagnetic tracking: experiences in phantom and animal cadaveric models. In World Congress on Medical Physics and Biomedical Engineering 2009, Theme 06 (Surgery, Minimal Invasive Interventions, Endoscopy and Image Guided Therapy). Munich, Germany 2009.10.1007/978-3-642-03906-5_63Search in Google Scholar

[30] Penzkofer T, Bruners P, Isfort P, et al. Aortic stent graft in situ fenestration using electromagnetic navigation and high porosity grafts materials: phantom experiments. Cardiovasc Intervent Radiol 2010; 33: 202.Search in Google Scholar

[31] Penzkofer T, Bruners P, Pfeffer J, Steinseifer U, Schmitz-Rode T, Mahnken A. Electromagnetic tracking for vascular interventions: initial results in a rapid prototyped phantom. In CIRSE 2008. Copenhagen 2008.Search in Google Scholar

[32] Pomier-Layrargues G, Villeneuve JP, Deschenes M, et al. Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: a randomised trial. Gut 2001; 48: 390–396.10.1136/gut.48.3.390Search in Google Scholar PubMed PubMed Central

[33] Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351: 1607–1618.10.1056/NEJMoa042002Search in Google Scholar

[34] Rosch J, Hanafee WN, Snow H. Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology 1969; 92: 1112–1114.10.1148/92.5.1112Search in Google Scholar

[35] Rossle M, Deibert P, Haag K, et al. Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal rebleeding. Lancet 1997; 349: 1043–1049.10.1016/S0140-6736(96)08189-5Search in Google Scholar

[36] Rossle M, Haag K, Ochs A, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med 1994; 330: 165–171.10.1056/NEJM199401203300303Search in Google Scholar PubMed

[37] Sauer P, Theilmann L, StremmelW, Benz C, Richter GM, Stiehl A. Transjugular intrahepatic portosystemic stent shunt versus sclerotherapy plus propranolol for variceal rebleeding. Gastroenterology 1997; 113: 1623–1631.10.1053/gast.1997.v113.pm9352865Search in Google Scholar PubMed

[38] Tse LW. Commentary: first clinical case of antegrade in situ fenestration of an aortic stent-graft. J Endovasc Ther 2012; 19: 721–722.10.1583/JEVT-12-4038C.1Search in Google Scholar PubMed

[39] United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010; 362: 1863–1871.10.1056/NEJMoa0909305Search in Google Scholar PubMed

[40] Wheatley G.H 3rd. In situ fenestration of the internal iliac artery as a bailout technique associated with endovascular repair of an abdominal aortic aneurysm: long-term follow-up. J Endovasc Ther 2012; 19: 716–720.10.1583/JEVT-12-4038R.1Search in Google Scholar PubMed

[41] Wood BJ, Zhang H, Durrani A, et al. Navigation with electromagnetic tracking for interventional radiology procedures: a feasibility study. J Vasc Interv Radiol 2005; 16: 493–505.10.1097/01.RVI.0000148827.62296.B4Search in Google Scholar PubMed PubMed Central

Received: 2013-4-17
Accepted: 2013-10-7
Published Online: 2013-11-1
Published in Print: 2014-4-1

©2014 by Walter de Gruyter Berlin/Boston

Downloaded on 28.3.2024 from https://www.degruyter.com/document/doi/10.1515/bmt-2013-0045/html
Scroll to top button