Joachim Kettenbach

Endovascular Management of Lost or Misplaced Intravascular Objects: Experiences of 12 Years

This paper reports our experience with endovascular techniques for the retrieval of lost or misplaced intravascular objects. Over 12 years, 78 patients were referred for interventional retrieval of intravascular foreign objects. In this retrospective study, radiological procedure records and patients’ medical records were reviewed to determine the exact removal procedure in every case, to report success rates, and to identify significant procedure-related complications. Written, informed consent was obtained from all patients prior to the intervention; this retrospective analysis was performed according to the guidelines of the Institutional Review Board. Thirty-six of seventy-eight foreign objects (46%) were located in the venous system, 27 of 78 (35%) in the right heart, and 15 of 78 (19%) in the pulmonary arteries. For foreign object removal, in 71 of 78 (91%) cases a snare loop was used, in 6 of 78 (8%) cases a sidewinder catheter combined with a snare loop was used, and in 1 case (1%) a sidewinder catheter alone was used for foreign object removal. In 68 of 78 (87%) cases, primary success was achieved. In 3 of 78 cases (4%), foreign objects were successfully mobilized to the femoral vessels and surgically removed. In 7 of 78 cases (9%), complete removal of the foreign object was not possible. In 5 of 78 cases (6%), minor complications occurred during the removal procedure. In conclusion, endovascular retrieval of lost or misplaced intravascular objects is highly effective, with relatively few minor complications. On the basis of our findings, these techniques should be considered as the therapy of choice.

Antibiotic Abscess Penetration: Fosfomycin Levels Measured in Pus and Simulated Concentration-Time Profiles

ABSTRACT The present study was performed to evaluate the ability of fosfomycin, a broad-spectrum antibiotic, to penetrate into abscess fluid. Twelve patients scheduled for surgical or computer tomography-guided abscess drainage received a single intravenous dose of 8 g of fosfomycin. The fosfomycin concentrations in plasma over time and in pus upon drainage were determined. A pharmacokinetic model was developed to estimate the concentration-time profile of fosfomycin in pus. Individual fosfomycin concentrations in abscess fluid at drainage varied substantially, ranging from below the limit of detection up to 168 mg/liter. The fosfomycin concentrations in pus of the study population correlated neither with plasma levels nor with the individual ratios of abscess surface area to volume. This finding was attributed to highly variable abscess permeability. The average concentration in pus was calculated to be 182 ± 64 mg/liter at steady state, exceeding the MIC50/90s of several bacterial species which are commonly involved in abscess formation, such as streptococci, staphylococci, and Escherichia coli. Hereby, the exceptionally long mean half-life of fosfomycin of 32 ± 39 h in abscess fluid may favor its antimicrobial effect because fosfomycin exerts time-dependent killing. After an initial loading dose of 10 to 12 g, fosfomycin should be administered at doses of 8 g three times per day to reach sufficient concentrations in abscess fluid and plasma. Applying this dosing regimen, fosfomycin levels in abscess fluid are expected to be effective after multiple doses in most patients.

Rigid 2D/3D slice‐to‐volume registration and its application on fluoroscopic CT images

Registration of single slices from FluoroCT, CineMR, or interventional magnetic resonance imaging to three dimensional (3D) volumes is a special aspect of the two-dimensional (2D)/3D registration problem. Rather than digitally rendered radiographs (DRR), single 2D slice images obtained during interventional procedures are compared to oblique reformatted slices from a high resolution 3D scan. Due to the lack of perspective information and the different imaging geometry, convergence behavior differs significantly from 2D/3D registration applications comparing DRR images with conventional x-ray images. We have implemented a number of merit functions and local and global optimization algorithms for slice-to-volume registration of computed tomography (CT) and FluoroCT images. These methods were tested on phantom images derived from clinical scans for liver biopsies. Our results indicate that good registration accuracy in the range of 0.50 and 1.0 mm is achievable using simple cross correlation and repeated application of local optimization algorithms. Typically, a registration took approximately 1 min on a standard personal computer. Other merit functions such as pattern intensity or normalized mutual information did not perform as well as cross correlation in this initial evaluation. Furthermore, it appears as if the use of global optimization algorithms such as simulated annealing does not improve reliability or accuracy of the registration process. These findings were also confirmed in a preliminary registration study on five clinical scans. These experiments have, however, shown that a strict breath-hold protocol is inevitable when using rigid registration techniques for lesion localization in image-guided biopsy retrieval. Finally, further possible applications of slice-to-volume registration are discussed.

Robot-assisted biopsy using computed tomography-guidance: initial results from in vitro tests.

Purpose:We sought to develop a robotic system for computed tomography (CT)-guided biopsy to validate the feasibility, accuracy, and efficacy of the system using phantom tests. Materials and Methods:Ten peas (mean diameter 9.9 ± 0.4 mm) embedded within a gel phantom were selected for biopsy. Once the best access was defined on CT images, the position of the phantom was recorded by an optical tracking system. Positional data about the phantom and the corresponding CT image was transferred to the robot planning system (Linux-based industrial PC equipped with video capture card). Once the appropriate position, angulation, and pitch were calculated, the robotic arm moved automatically with 7 degrees-of-freedom to the planned insertion path, aiming the needle-trajectory at the center of the target. Then, the biopsy was performed manually using a coaxial technique. The length of all harvested specimens was measured and short cut pieces of a guidewire were pushed into the target to evaluate the deviation of the actual needle track from the target. Results:In all targets, biopsy specimens (mean length 5.6 ± 1.4 mm) were harvested with only 1 needle pass required. The mean deviation of the needle tip from the center of the target in the x and z axes was 1.2 ± 0.9 mm and 0.6 ± 0.4 mm, respectively. Conclusions:Robotic-assisted biopsies in vitro, using CT guidance, were feasible and provided high accuracy.

Intraoperative and interventional MRI: Recommendations for a safe environment

In this paper we report on current experience and review magnetic resonance safety protocols and literature in order to define practices surrounding MRI‐guided interventional and surgical procedures. Direct experience, the American College of Radiology White paper on MR Safety, and various other sources are summarized. Additional recommendations for interventional and surgical MRI‐guided procedures cover suite location/layout, accessibility, safety policy, personnel training, and MRI compatibility issues. Further information is freely available for sites to establish practices to minimize risk and ensure safety. Interventional and intraoperative MRI is emerging from its infancy, with twelve years since the advent of the field and well over 10,000 cases collectively performed. Thus, users of interventional and intraoperative MRI should adapt guidelines utilizing universal standards and terminology and establish a site‐specific policy. With policy enforcement and proper training, the interventional and intraoperative MR imaging suite can be a safe and effective environment.

Stochastic rank correlation: A robust merit function for 2D/3D registration of image data obtained at different energies

In this article, the authors evaluate a merit function for 2D/3D registration called stochastic rank correlation (SRC). SRC is characterized by the fact that differences in image intensity do not influence the registration result; it therefore combines the numerical advantages of cross correlation (CC)-type merit functions with the flexibility of mutual-information-type merit functions. The basic idea is that registration is achieved on a random subset of the image, which allows for an efficient computation of Spearmans rank correlation coefficient. This measure is, by nature, invariant to monotonic intensity transforms in the images under comparison, which renders it an ideal solution for intramodal images acquired at different energy levels as encountered in intrafractional kV imaging in image-guided radiotherapy. Initial evaluation was undertaken using a 2D/3D registration reference image dataset of a cadaver spine. Even with no radiometric calibration, SRC shows a significant improvement in robustness and stability compared to CC. Pattern intensity, another merit function that was evaluated for comparison, gave rather poor results due to its limited convergence range. The time required for SRC with 5% image content compares well to the other merit functions; increasing the image content does not significantly influence the algorithm accuracy. The authors conclude that SRC is a promising measure for 2D/3D registration in IGRT and image-guided therapy in general.

Computer-based imaging and interventional MRI: applications for neurosurgery.

Advances in computer technology and the development of open MRI systems definitely enhanced intraoperative image-guidance in neurosurgery. Based upon the integration of previously acquired and processed 3D information and the corresponding anatomy of the patient, this requires computerized image-processing methods (segmentation, registration, and display) and fast image integration techniques. Open MR systems equipped with instrument tracking systems, provide an interactive environment in which biopsies and minimally invasive interventions or open surgeries can be performed. Enhanced by the integration of multimodal imaging these techniques significantly improve the available treatment options and can change the prognosis for patients with surgically treatable diseases.

Computer-Assisted Intra-Operative Magnetic Resonance Imaging Monitoring of Interstitial Laser Therapy in the Brain: A Case Report

Hardware and software for a customized system to use magnetic resonance imaging (MRI) to noninvasively monitor laser-induced interstitial thermal therapy of brain tumors are reported. An open-configuration interventional MRI unit was used to guide optical fiber placement and monitor the deposition of laser energy into the targeted lesion. T1-weighted fast spin echo and gradient echo images were used to monitor the laser tissue interaction. The images were transferred from the MRI scanner to a customized research workstation and were processed intraoperatively. Newly developed software enabled rapid (27-221 ms) availability of calculated images. A case report is given showing images which reveal the laser-tissue interaction. The system design is feasible for on-line monitoring of interstitial laser therapy.

A comparison of biventricular and conventional transvenous defibrillation: a computational study using patient derived models.

Conventional transvenous defibrillation is performed with an ICD using a dual current pathway. The defibrillation energy is delivered from the RV electrode to the superior vena cava (SVC) electrode and the metallic case (CAN) of the ICD. Biventricular defibrillation uses an additional electrode placed in the LV free wall with sequential shocks to create an additional current vector. Clinical studies of biventricular defibrillation have reported a 45% reduction in mean defibrillation threshold (DFT) energy. The aim of the study was to use computational methods to examine the biventricular defibrillation fields together with their corresponding DFTs in a variety of patient derived models and to compare them to simulations of conventional defibrillation. A library of thoracic models derived from nine patients was used to solve for electric field distributions. The defibrillation waveform consisted of a LV → SVC + CAN monophasic shock followed by a biphasic shock delivered via the RV → SVC + CAN electrodes. When the initial voltage of the two shocks is the same, the simulations show that the biventricular configuration reduces the mean DFT by 46% (3.5 ± 1.3 vs 5.5 ± 2.7 J, P = 0.005). When the leading edge of the biphasic shock is equal to the trailing edge of the monophasic shock, there is no statistically significant difference in the mean DFT (4.9 ± 1.9 vs 5.5 ± 2.7 J, P > 0.05) with the DFT decreasing in some patients and increasing in others. These results suggest that patient‐specific computational models may be able to identify those patients who would most benefit from a biventricular configuration. (PACE 2004; 27:586–593)

Laser-induced thermotherapy of cerebral neoplasia under MR tomographic control

SummaryThe purpose of this study was to monitor interstitial laser therapy (LITT) in palliative treatment of brain tumours by using temperature-sensitive MRI sequences and image-processing techniques in realtime. Three consenting patients with recurrent gliomas were treated with LITT (3–4.5 W, 3–6 min). Temperature sensitive monitoring was performed either by T1 weighted fast spin echo (FSE) sequences, combined with pixel subtraction, optical flow (OF) computation, or by spoiled gradient recalled (SPGR) sequences used for chemical shift-based imaging. Both sequences were applied at 0.5 T (Signa SRGE Medical System, Milwaukee, Wl, USA). Pixel subtraction identified thermal changes in brain tumours, but could not evaluate the temperature values as chemical-shift based imaging. OF computation displayed the predicted course of thermal changes and revealed that the rate of heat deposition can be anisotropic, which may be related to heterogeneous tumour structure and/or vascularisation.Local tumour control was ...