Navigating
the change

The Sanador Clinic is in the center of Bucharest. The streets are con­gested with traffic, and it is hard to find a park­ing space close to the clinic. The city attracts many stu­dents to its uni­ver­si­ties and is the eighth largest city in the Euro­pean Union with a popu­la­tion of 1.7 mil­lion. As in other Euro­pean coun­tries, the health­care sys­tem is fac­ing the chal­lenges of demo­graphic change and an aging soci­ety. In 2020, 19% of the popu­la­tion was over 65. More than half of all deaths are due to cardio­vascular disease. At 30,000 square meters, Sanador Clinic is the largest private hospi­tal in Romania, and the number one cardio­vascular center in the country. People from all over Romania come to the clinic for treat­ment. “We want our doc­tors to work in the best condi­tions and have access to the latest techno­logy,” says clinic direc­tor Florin Andronescu. “This means we can offer our patients the best options, so they don’t have to travel abroad for treat­ment.”

Andronescu was also the driv­ing force behind the acquisi­tion of the mobile hybrid room. This is the first of its kind that is fully equipped with endo­vascular navi­gation in Romania. The flexi­ble use of the mobile C‑arm played an impor­tant role in the pur­chase deci­sion. “We can con­vert any oper­at­ing room into a hybrid room. In retro­spect, it was exactly the right invest­ment for us,” says Andronescu. The hospi­tal can per­form cardio­vascular inter­ventions in its two fixed hybrid rooms, or in the mobile hybrid room from Ziehm Imaging. One of Romania’s pio­neering cardio­vascular teams prac­tices on the tenth floor of the modern hospi­tal.

Prof. Dr. Victor Costache, his wife Dr. Andreea Costache, and Dr. Anca Chitic have been colleagues for more than six years. The team joined the Sanador Clinic after work­ing together in Sibiu and Brasov. Prof. Costache, head of the depart­ment of Cardio­vascular Sur­gery, had experi­ence with Ziehm Imaging C-arms prior to his posi­tion at the Sanador Clinic. He still remem­bers the first time he used a Ziehm Imaging C-arm during a live-surgery broad­cast at a con­gress. “My initial con­cerns about not being familiar with the sys­tem quickly gave way to enthu­si­asm. I was imme­di­ately con­vinced by the quality of the images and the flexi­bi­lity of the tech­nol­ogy,” says Prof. Costache. “I was very pleased when the hospi­tal direc­tor told me in 2022 that he had pur­chased the Ziehm solu­tion for our new hybrid room. We were able to easily con­nect the sys­tem to our exist­ing equip­ment, like our screens. Since then, the team has been rely­ing on the Ziehm Vision RFD Hybrid Edition¹ in the pre­mium CMOSline² confi­gu­ra­tion. In addition, the team uses a Therenva EndoNaut³ work­station for 3D vascular image fusion, along with the corre­spon­ding EndoSize⁴ plan­ning soft­ware. “For us, the EndoNaut work­station is the best naviga­tion solu­tion avail­able in the mar­ket for vascu­lar proce­dures.”

Today’s pro­ce­dure is an endo­vascular aortic repair (EVAR). The team reviewed the case plan­ning in detail the night before, and now, the plan­ning data from EndoSize is dis­played on the EndoNaut, the intra­oper­ative navi­ga­tion system. This appears to be a stan­dard inter­vention. Dr. Chitic and Dr. Costache pre­pare the approach to the femoral artery with their team. Inser­tion of the guide wire is more diffi­cult than expected, but the atmo­sphere in the oper­at­ing the­atre remains focused and coor­di­nated. Jazz music plays in the back­ground as the first angio­gram is acquired. Sev­eral new par­tial occlu­sions of the iliac artery are visi­ble. These were not as clearly visi­ble on the CT image used for plan­ning. “The patient’s dis­ease appears to be very aggres­sive, and the lesions have pro­gressed much fur­ther than expected in just a few weeks. The C-arm images clearly show us why we are having prob­lems insert­ing the guide­wire,” says Dr. Costache. “We wouldn’t have been able to get the planned stent through the arterio­sclerosis,” adds Dr. Chitic. It’s easy to see that the team, which has been work­ing together for years, under­stands each other almost intu­i­tively. At the oper­at­ing table, they quietly discuss the next steps and change their strategy. Both the well-coor­di­nated team and the excellent setup of the mobile hybrid room give them con­fi­dence in their deci­sions, explains Dr. Costache.

The team navigates through the block­ages in the iliac arteries with the help of the EndoNaut work­station. The team agrees that the sys­tem is very help­ful. It reduces the radi­a­tion dose and the use of con­trast agents, and, impor­tantly, “It helps us save time,” says Dr. Chitic. “What’s more, the work­sta­tion is easy to use. Our stu­dents in resi­dency train­ing also learn how to use the sys­tem very quickly.” The EndoNaut and Ziehm C-arm are used for stan­dard oper­a­tions as well as for emer­gen­cies and com­plex pro­ce­dures. While flexi­bi­lity is the main advan­tage for stan­dard oper­a­tions, the intra­oper­a­tive fusion of the live image with plan­ning data has pro­ven to be a valu­able tool for com­plex pro­ce­dures. 

Prof. Costache is sat­is­fied with the out­come of today’s sur­gery. “We had to change our plan after the first angio­graphy. Instead of a planned EVAR, we per­formed a com­plex dila­tion of the com­mon and exter­nal iliac arteries. The supe­rior intra­oper­a­tive images and image fusion were excel­lent sup­port for us in making the deci­sion.” For Prof. Costache, the ben­e­fits of the mobile hybrid room extend beyond the Sanador Clinic; as the former Romanian Minister of Health, he sees poten­tial for many hospi­tals in Europe. “Healthcare costs are sky­rocket­ing, and many older hospi­tals need to be reno­vated. European hospi­tals can no longer afford the cost of fixed hybrid rooms. The smart com­bi­nation of mobile devices and endo­vascular navi­ga­tion offers a cost-effec­tive alter­native with­out sac­ri­ficing com­fort and image quality.”

The Team: Prof. Costache, his wife Dr. Costache, and Dr. Chitic have been work­ing together for many years. The team's ded­i­ca­tion to work­ing tire­lessly for their patients is matched by their com­mit­ment to train­ing the next gen­er­a­tion of cardio­vascular sur­geons.