The future is
mobile

While Seifert’s demeanor com­muni­cates “com­mander-in-chief”, he’s still approach­able. The surgeon started work­ing with Ziehm Imag­ing mobile C‑arms in 1996 and has stayed loyal to the manufac­turer ever since. Today, three proce­dures are slated here in Chemnitz, all of which will take place in hybrid oper­at­ing rooms. Seifert and his team’s first proce­dure of the day will be an endo­vascular abdo­mi­nal aor­tic aneu­rysm repair (EVAR). The opera­tion is one of the stan­dard proce­dures per­formed in the two vascu­lar sur­gery hybrid oper­at­ing rooms in Chemnitz.

Seifert per­formed his first surgi­cal proce­dure in a hybrid OR in 2007 and is con­sidered to be one of the pio­neers of the “hybrid move­ment”. Hybrid sur­gery was designed to com­bine the con­ventional sur­gical setting with medi­cal imag­ing in the same room. This com­bi­na­tion reduces risks and stress for the patient and also stream­lines the surgi­cal work­flow. Hybrid oper­ations are now the stan­dard proce­dure for com­plex proce­dures with high intra­oper­ative imag­ing require­ments. They are most com­monly used for cardiac and vascular surgery, as well as for neuro­sur­gery. Proce­dures involv­ing the aorta are risky, time-consum­ing and radia­tion-inten­sive. The hybrid OR offers enor­mous advan­tages for this type of sur­gery, Seifert explains. The hybrid OR is the only set­ting that ensures the com­bi­na­tion of hygiene class 1A and imag­ing, which is other­wise found only in radio­log­ical units. The big­gest advan­tage of the special OR is that the patient needs to under­go only one surgi­cal proce­dure, Seifert says.

“Since 2014, we have had a hybrid OR with a fixed angi­og­ra­phy unit here in Chemnitz. The hybrid OR with a mobile C‑arm is directly adjacent,” Seifert adds. For a long time, the intra­oper­ative image quality of the mobile C‑arm was con­sidered to be inade­quate for hybrid applica­tions in vascular sur­gery, where it is crucial to precisely visu­alize even the tiniest anatom­ical struc­tures. This has changed in recent years, Seifert says. “The image quality of mobile C‑arms is now out­standing.”

Seifert especially appreci­ates the fact “that with a mobile C‑arm, we are able to com­pletely change the surgi­cal set-up during the proce­dure and also change sides if need be.” In addi­tion, the mobile C‑arm can also be used in another room as needed. Seifert explains that this has made imag­ing more efficient and in turn, more cost-effective. In addi­tion to flexible room sched­uling, the surgeon sees the substan­tially lower invest­ment costs as a par­tic­ular advan­tage. Setting up and equipping a standard hybrid oper­ating room takes time and requires considerable construc­tion efforts. In contrast, the mobile C‑arm’s lower instal­lation and operating costs open up pos­si­bilities for smaller hospitals or those on tight budgets to perform hybrid pro­ce­dures as well, Seifert says. In terms of tech­nology, the mobile C‑arm also offers a number of advantages for vascular sur­gery, Seifert explains. “For me, the effortless way the colli­mators work and the rotation of the clinical image in the oper­ation setting are both real advantages.”

Seifert’s mobile hybrid OR features a Ziehm Vision RFD Hybrid Edition¹, a mobile C‑arm that has been specifi­cally tailored for use in a hybrid OR. “The C‑arm has a very special shape and our pet name for it is ‘The Turtle’.” Seifert is referring to the modern design of the flat-panel detec­tor, whose semi-circular shape in fact does resemble a turtle, to some extent. The Ziehm Vision RFD Hybrid Edition com­bines a number of high­lights that Seifert con­siders to be particu­larly impor­tant for a mobile C‑arm, especially its full motor­ization in four axes that can be con­trolled directly from the sterile field via two joysticks. “This feature makes using it effort­less for surgeons and their teams.”

During the proce­dure, Seifert uses the wire­less foot­switch to pin­point the posi­tion at the patient that is best suited for his work. When he changes his operat­ing position, he simply takes the footswitch with him. Safety and efficiency are particularly important in an operat­ing room, Seifert says. That’s why he likes to use the Anatomical Marking Tool when he performs EVAR. The “ingenious drawing tool”, as Seifert describes it, allows him to pre­cisely trace the course of the inter­nal iliac artery in the live dis­play of the digital subtrac­tion angi­og­ra­phy (DSA). Seifert simply uses his forceps as a stylus to input the neces­sary infor­mation onto the clinical image of the C‑arm on the ster­ilely wrapped touch­pad. In so doing, Seifert marks a sort of “canal” that can be viewed live on all his moni­tors and which shows him pre­cisely where the aortic stent must be released in the super­imposed fluoro­scopy. “This makes us more certain that we have posi­tioned the pros­thesis properly and it offers the advan­tage of consid­er­ably less radiation,” Seifert adds.

During EVAR, Seifert applies CO₂ to visu­al­ize the con­trast. Pressure is used to guide the CO₂ into the artery, where it forms a gas bubble and pushes the blood flow of the vessels ahead of it. Con­trary to con­ven­tional contrast media con­taining iodine, CO₂ does not pose the risk of an allergic reaction. Seifert was one of the first surgeons to incorporate CO₂ in clinical routine due to its better tolera­bility: “CO₂ can be used as a contrast agent in any patient. It does not burden the thyroid and is not expelled through the kidneys.” Seifert plans to elimi­nate the use of conven­tional contrast media in as many surgi­cal proce­dures as pos­sible to reduce the risk to the patients. The increase in common con­ditions such as obesity and diabetes has boosted the demand for CO₂ angi­og­ra­phy. For many patients with these con­ditions, iodin­ated con­trast media are not an option.

In Seifert’s view, the Ziehm Vision RFD Hybrid Edition offers the ideal imaging system for CO₂ angi­og­ra­phy. “We are working with one of the few systems that performs immediate inver­sion of the subtrac­tion image, which allows us to ideally visual­ize the contrast.” The rapid inver­sion of the negative contrast – in other words, the possi­bility to make the CO₂ within the vessels appear black – enables the angi­og­ra­phy images to be dis­played in the manner in which the sur­geon is accus­tomed. As he looks at the final image of the surgery, Seifert is pleased with the high quality of CO₂ angi­og­ra­phy with the Ziehm Vision RFD Hybrid Edition. “We have suc­ceeded in placing the stent graft in an ideal position, without using conven­tional con­trast media.”

Seifert is satis­fied as he wraps up the pro­ce­dure. Despite the heavily calci­fied arteries and the diffi­cult morphol­o­gy of the surgi­cal site, the pro­ce­dure has been success­ful. The patient has been spared a post­opera­tive follow-up scan and a pos­si­ble ad­di­tion­al oper­a­tion. As Seifert puts it, his “Turtle” has done an out­stand­ing job. “The future belongs to the mobile hybrid OR. The mobile C‑arm with the image quality we have expe­ri­enced today offers a space-saving and cost-efficient alter­na­tive to a fixed installed unit.”