Certainty
in real-time

Between the first sur­gical repair of an abdom­inal aortic aneur­ysm (AAA) and today lie almost 70 years. For a long time, the only solu­tion for the often-life-threat­en­ing mal­for­ma­tions of the aorta was a com­pli­cat­ed open sur­gical proce­dure. Cur­rently, more and more doc­tors are advo­cating mini­mally inva­sive treat­ment of aortic aneu­rysms. For patients, the new method is much gentler: less blood loss, improved wound heal­ing, and reduced cardio­vascular insuf­fi­cien­cies shorten hospi­tal stays in most cases.

Professor Dr. Gian Franco Veraldi is an expert in this modern method of vascu­lar sur­gery. With more than 8,000 sur­gical proce­dures and a professor­ship for vascu­lar and cardiac sur­gery at the Univer­sity of Verona, he is in high demand, and he radiates profes­sion­al­ism in his daily work: relaxed but con­cen­trated. Today, together with his assis­tant Dr. Marco Macrì, he is pre­par­ing for a mini­mally inva­sive treat­ment of AAA. The patient is in his late 60s and is a high-risk patient. He had a stent implanted sev­eral years ago that now has to be extended with a stent con­nec­tion to treat another aneu­rysm. For Prof. Dr. Veraldi, the mini­mally inva­sive pro­ce­dure is a sound and impor­tant alter­native to an open opera­tion. “More than 60 per­cent of our opera­tions are mini­mally inva­sive, i.e., endovascular aortic repair (EVAR). This is the more reli­able alter­native for us, espe­cially for older patients, as it is gen­tler and, more impor­tantly, faster than open sur­gery,” says Prof. Dr. Veraldi.

He and his team have been using the Ziehm Vision RFD 3D CMOSline¹ since early 2019. Although the 3D C‑arm was origi­nally designed for com­pli­cated pro­ce­dures in ortho­pedics, trauma­tol­ogy, and spinal surgery, with its high-resolution 2D imaging capa­bil­ities it is equally suit­able for multi­disci­plinary use in vascu­lar sur­gery and angi­og­raphy. Prof. Dr. Veraldi there­fore oper­ates on the aneu­rysm with the new C‑arm in the usual way for the time being; he does not have to change his routine proce­dure. The stent graft is intro­duced via the pelvic arteries into the aorta using a cath­eter sys­tem while under con­stant 2D X‑ray con­trol. Prof. Dr. Veraldi places the stent in the affec­ted vascu­lar sec­tion – pre­cise to the milli­meter. For opti­mum adap­ta­tion and seal­ing of the pros­the­sis in the vessel, the stent is pressed against the aortic wall using a dilatable balloon. It is partic­ularly impor­tant that the renal arteries are not covered by the stent in order to main­tain supply to the organ, and that a piece of the new implant over­laps the existing stent.

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“The com­bi­na­tion of high-end 2D imaging and innova­tive intra­opera­tive 3D stent control in one sys­tem allows us to optimize proven sur­gical tech­niques in the field of vascu­lar sur­gery.”

In the past, the usual method of intra­opera­tive control angio­graphy often did not give Prof. Dr. Veraldi the assur­ance he needed, and he had to rely on his experi­ence. Normally, he would have been able to close the patient follow­ing a final con­trast agent angio­gram. After a few days a post­oper­ative CT would have been per­formed to check the loca­tion, the cor­rect open­ing of the stent, and whether there was suffi­cient blood supply to the aorta and adja­cent vessels. If the post­opera­tive exam had shown that some­thing was not 100 per­cent correct, the patient would have had to undergo a cor­rective inter­vention. “This was always unsat­is­fac­tory for me,” says Professor Dr. Veraldi. “The post­opera­tive CT scan to verify the result of the opera­tion is still con­sid­ered the gold stan­dard today. How­ever, it does not give us any certainty during the pro­ce­dure that our work has been successful.”

“In the past, after stent place­ment and the final con­trast angio­gram, we had to wait days for the post­operative CT. This was always unsatis­factory for me. Today we proceed differently. After the place­ment of the stent, we perform an intra­operative 3D scan, which gives us the oppor­tu­nity to check. If neces­sary we can imme­di­ately make improve­ments.”

“Today, in three out of four cases, thanks to intra­operative 3D moni­tor­ing, we adjust our treat­ment strategy during the oper­a­tion. This will reduce the number of revi­sion oper­a­tions and shorten hospi­tal stays.”

With the mobile 3D C‑arm, Prof. Dr. Veraldi now has a new oppor­tu­nity: “3D imag­ing allows us to con­duct an intra­opera­tive check on the stent place­ment. This enables us to con­firm whether the stent has unfolded optimally after the vascu­lar proce­dure has been com­pleted – even while the patient is still under anes­thesia. There is no need to wait for the post­operative CT. And we can imme­diately be sure that we have worked pre­cisely,” says Prof. Dr. Veraldi. This innova­tive additional step in the EVAR proce­dure not only enables better sur­gical results, but is also safer. “If the 3D scan shows that we have to inflate the balloon a little more to achieve per­fect results, for example, we can decide this imme­di­ately and adapt our sur­gical proce­dure accord­ingly.” A final 3D scan then shows whether the stent is perfectly placed, and the opera­tion can be success­fully com­pleted. Thanks to this new treat­ment method, patients can be discharged from the hospi­tal after just a few days.

“Currently, the post­operative CT scan is regarded as the gold stan­dard for veri­fy­ing sur­gical results after an EVAR proce­dure. The com­par­i­son of the intra­operative 3D scan and the post­operative con­trol image from the CT shows us, how­ever, that we now have the same options intra­operatively as post­operatively. This not only makes us more efficient, but also saves lives in extreme cases.”

For Prof. Dr. Veraldi, the 3D scan has become the stan­dard proce­dure for the treat­ment of com­pli­cated aneu­rysms. The head of vascu­lar sur­gery is convinced by the pos­si­bil­ity of immedi­ately recog­nizing whether all measures have been success­ful, even during chal­leng­ing opera­tions. “We now have the same options intra­operatively as we otherwise only had in a post­operative CT.”

“Now we can finally see in real time what we used to have to wait several days for.” For Prof. Dr. Veraldi, this is not only an impor­tant addi­tional bene­fit. He thinks that the 3D con­trol scan will help spread and more widely estab­lish the EVAR pro­ce­dure. The number of open opera­tions, but above all the num­ber of revi­sions, would decrease signifi­cantly as a result. “We can hardly expect more from today’s tech­nol­ogy. It offers us an excellent advance in mini­mally inva­sive AAA treat­ment and helps us not only increase our effi­ciency, but also improve the lives of our patients.”