A Comprehensive Review of In Situ Fenestration of Aortic Endografts.

An Experimental Study of Laser in situ Fenestration of Current Aortic Endografts.

A survey of catheter tracking concepts and methodologies

Assess electromagnetically guided in situ fenestration of juxtarenal aortic stent grafts in an in vivo model. Using a newly developed electromagnetic guidance system together with a modified, electromagnetically guidable catheter with steerable tip, an electromagnetically trackable guidewire and a custom in situ fenestrateable stent graft, a series of seven animal experiments was performed. In a swine model, stent grafts were placed juxtarenally, covering the renal arteries. Subsequently, the perfusion of the renal arteries was restored using electromagnetically guided in situ fenestration of the graft at the renal ostia followed by covered stent placement. Intervention times and technical success were assessed. The individual components were successfully combined for the animal experiments. Thirteen of fourteen fenestration experiments in seven animals were successful in restoring perfusion through in situ fenestration. Fenestration (catheter introduction—guidewire placement in renal artery across graft) could be achieved in on average 10.5 ± 9.2 min, and subsequent covered stent placement (guidewire placement—covered stent placement) took on average 32.7 ± 17.5 min. No significant differences between left and right side reperfusion times could be detected. Reperfusion in <30 min was achieved in 3/14 attempts. Electromagnetically navigated in situ aortic fenestration for juxtarenal aortic stent grafts was feasible in a healthy animal model. Identified remaining challenges were: shortening the procedure to avoid long warm ischemia times, using an aortic aneurysm animal model, and improving the stability of the stent graft material.

Electromagnetically Navigated In Situ Fenestration of Aortic Stent Grafts: Pilot Animal Study of a Novel Fenestrated EVAR Approach

OBJECTIVE
To facilitate precise local ablation of hepatocellular carcinoma (HCC) in a setting of combined ablation and transarterial chemoembolization (TACE), we evaluated accuracy and efficiency of a novel technique for navigated positioning of ablation probes using intrahepatic tumor referencing and electromagnetic (EM) guidance, in a porcine model.

METHODS
An angiographic wire with integrated EM reference sensor at its tip was inserted via a transarterial femoral access and positioned in the vicinity of artificial liver tumors. The resulting offset distance between the tumor center and the intrahepatic endovascular EM reference was calculated. Subsequently, EM tracked ablation probes were inserted percutaneously and navigated toward the tumor center, relying on continuous EM guidance via the intrahepatic reference. Targeting accuracy was assessed as the Euclidean distance between the tip of the ablation probe and the tumor center (Target Positioning Error, TPE). Procedural efficiency was assessed as time efforts for tumor referencing and tumor targeting.

RESULTS
In 6 animals, 124 targeting measurements were performed with an offset distance < 30 mm (clinically most feasible position), resulting in a mean TPE of 2.9 ± 1.6 mm. No significant correlation between the TPE and different intrahepatic offset distances (range 21 to 61 mm, n = 365) was shown as long as the EM reference was placed within the liver. However, the mean TPE increased when placing the EM reference externally on the animal skin (p < 0.01). TPE was similar when targeting under continuous ventilation or in apnea (p = 0.50). Mean time for tumor referencing and navigated targeting was 6.5 ± 3.8 minutes and 14 ± 8 seconds, respectively.

CONCLUSION
The proposed technique allows precise and efficient navigated positioning of ablation probes into liver tumors in the animal model. We introduce a simple approach suitable for combined ablation and TACE of HCC in a single treatment session.

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Multi-Operational Selective Computer-Assisted Targeting of hepatocellular carcinoma-Evaluation of a novel approach for navigated tumor ablation.

This work presents concepts for complex endovascular procedures using electromagnetic navigation technology (EMT). Navigation software interfacing a standard commercially available navigation system was developed, featuring registration, electromagnetic field distortion correction, breathing motion detection and gating, and state-of-the-art 3D imaging post processing. Protocols for endovascularly placed, in-situ fenestrated abdominal aortic stent grafts and an EMT guided transjugular intrahepatic portosystemic shunt (TIPSS) creation have been designed. A dedicated set of interventional devices was developed for each of the procedures: For aortic in-situ fenestration a combination of high-porosity stentgrafts, steerable catheters and electromagnetically navigated guidewires was used, for TIPSS a dual-navigated (sheath and stylet) TIPSS-device was designed and manufactured. The developed devices underwent phantom testing, in preparation for animal experiments to prove the feasibility of the approach. Once established, these systems could aid in performing these challenging interventional radiology procedures, exploiting the unique characteristics of electromagnetic navigation and solving multiple of the problems associated with these interventions being performed under X-ray fluoroscopy, such as lacking real-time 3D information or extensive exposure to ionizing radiation.

Technical concepts for vascular electromagnetic navigated interventions: aortic in situ fenestration and transjugular intrahepatic porto-systemic shunts.

The endovascular repair of aortic aneurysms overlapping regions with side branches (e.g. renal arteries) is a remaining challenge, as sufficient fixation of the stent graft with preservation of the blood flow to abdominal organs is hindered considerably, frequently necessitating open surgery or complex debranching operations followed by graft implantation. In this abstract we present a concept and phantom study for in-situ fenestration of aortic stent grafts using an electromagnetically guided catheter/guidewire system to allow for endovascular repair of large AAA.

In.nrw Hyther: Electromagnetically navigated in situ fenestration of aortic stent grafts

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Electromagnetically Navigated In Situ Fenestration of Aortic Stent Grafts: Pilot Animal Study of a Novel Fenestrated EVAR Approach

Technical concepts for vascular electromagnetic navigated interventions: aortic in situ fenestration and transjugular intrahepatic porto-systemic shunts.

In.nrw Hyther: Electromagnetically navigated in situ fenestration of aortic stent grafts