Introduction: Successful application of endovascular neurosurgery depends on high quality imaging to define the pathology and devices as they are being deployed, especially in proximity to the skull base or in patients who have undergone prior endovascular treatment. We sought to optimize real-time image guidance using a simple algorithm that can be applied to any existing fluoroscopy system. We worked with Siemens to develop the Stent Deployment protocol designed to improve visualization during complex endovascular device deployment. Our experience in several cases demonstrates the utility of the protocol for improving device deployment.
Methods: Exposure management and image post processing parameters were modified compared to traditional fluoroscopy to improve visualization of device position and material density during deployment. We used this optimized protocol during critical stages of aneurysm coiling, carotid stenting, Woven EndoBridge (WEB) device deployment, and flow diverter device deployment, in addition to traditional fluoroscopy. Demonstrative examples of the application of the Stent Deployment protocol were reviewed retrospectively.
Results: The Stent Deployment protocol improved real-time visualization of device position and deployment characteristics during key steps of endovascular procedures compared to traditional fluoroscopy. It was particularly useful for applications near the skull base or with overlying devices obscuring the field of view. This protocol aided assessment of coil packing density during aneurysm coiling and optimized deployment and positioning of flow diverters, carotid stents, and the intrasaccular WEB device.
Conclusions: The Stent Deployment protocol is a simple image capture and post-processing algorithm that can be applied to existing fluoroscopy systems to improve real-time visualization of device deployment without hardware modifications. Improved image guidance facilitates aneurysm coil packing and proper deployment of carotid stents, flow diverters, and the WEB device.
Patient Care: While many clinicians are engaged in trials of advancing device technology, imaging quality is an area ripe with potential for increased neuro-interventionalist involvement. Stent Deployment, a simple image-capture and processing algorithm that can be applied to any fluoroscopy system, improves image guidance for aneurysm coiling, endosaccular device deployment, flow diverter deployment, and carotid stent deployment. Improved image guidance can help mitigate stent misplacement, incomplete coil packing, and aneurysm recanalization that can result from suboptimal visualization during endovascular device deployment.
Learning Objectives: By the conclusion of the session, participants should be able to: 1) Describe the importance of high quality image guidance for proper deployment of endovascular devices, 2) Identify the most useful applications of the Stent Deployment protocol, such as in proximity to the skull base and in patients who have undergone previous endovascular treatment, and 3) Discuss the utility of improving image guidance with a simple image capture and post-processing algorithm that can be applied to any existing fluoroscopy system without hardware modification.