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Challenges in modern angiography

ESC Congress 2010

Invasive Imaging and Functional Assessment

During this session, new technical and clinical developments in and around the catheterization laboratories were presented and discussed. Although other coronary imaging modalities, both invasive (such as optical coherence tomography (OCT)) and non-invasive (such as multi-slice computed tomography (MSCT)) have been attracting a lot of attention during many congresses, including at the ESC 2010, the angiographic developments in the cathlab have been maybe a bit overlooked or even underestimated.

Prof. Hoeher showed us the technical developments and their advantages, such as image enhancement, rotational angiography (presenting three-dimensional reconstructions of the coronary artery tree, almost CT-like) and combining different imaging modalities such as CT, MRI and angiography to help treat patients better during electrophysiology procedures. However, these new technical developments can also have their pitfalls, which are not always obvious to see. Operators are often unaware if an image has been filtered, or otherwise enhanced, or if he is still looking at a RAW image. This could potentially lead to misinterpretation. For example, the quantitative effects of image compression were evaluated 10-20 years ago, but there is no data available for the recent new possibilities and the much higher image resolutions in many of the new cathlabs.

Newer cathlabs are equipped with image intensifiers (flat panels) that generate a minimum of 1024 * 1024 pixels. This increases the resolution considerably (previous labs were generating images at 512 * 512 pixels) and could potentially lead to a better appreciation of the observers in case of coronary stenoses, which in the past were difficult to evaluate. However, the increase in image possibilities, the higher resolutions and the increase also in the number of images (in case of rotational angiography) leads also to an increase in storage demands.

Dr. Niek van der Putten informed us that the hospitals are possibly lagging behind in the rapid technology developments of the medical device companies. Recently, we made the change in cardiology to transform from film to digital storage, however this practice is not always as standardized as we would like to see, or rather, what we need. Storage of image data on CDs or DVDs can be tricky, as they do not have a guaranteed shelf life. Thus, an angio made today may no longer be readable a few years from now. To avoid such issues, many hospitals have installed so-called picture archive systems (PACS). These PACS are excellent systems to store image data. However, they are expensive and therefore it is recommended that the images be compressed or that the number of runs stored be limited to those clinically necessary and that the hospital implement also a good regimen, according to local/national laws, about the retention period, as that is often not clear. This imaging environment needs careful planning and logistics and hospital management should/must be aware about the possible high costs involved. As in the consumer camera world, imaging in cardiology is increasing in quality and quantity.

A sometimes overlooked and perhaps somewhat ignored aspect in the cathlab is radiation safety. Dr. Bar revitalized the knowledge about the possible hazards radiation can impose for both patients and staff, but mentioned that there are numerous solutions which, if brought into practice, can minimize the possible fall-out of receiving too much radiation. Simple measures for the operator include reducing the distance between the x-ray tube and the image intensifier/flat panel detector, reducing possible excessive radiation. Other measures staff could take are good lead vests, glasses, gloves, injectors and proper management of recording the dosimetry for every individual working in the cathlabs is mandatory. Cases of skin problems for patients have been reported as well as necessary cataract surgery for the operators, so radiation hygiene should be a high priority of the management of the cathlabs.

Besides the earlier described technical developments in the angiographic laboratories, clinical developments are also ongoing. Whereas in the past, developments went in the direction of minimally invasive procedures, these days, the developments are sometimes the other way around, with procedures becoming more invasive. Today, percutaneous valve implantation is increasingly practised and requires the involvement of interventionalists, surgeons, anaesthetists and nursing staff trained for both interventional cardiology as well as surgery.

Dr. Williams presented the possibilities of hybrid cathlabs as well as the logistics necessary to run them. He also highlighted the possible clinical scenarios for which these hybrid labs could be useful. They are still in the stage of infancy but it is expected that their number will grow rapidly, and that procedures are not necessarily always performed via the least invasive approach. These hybrid labs combine the best of both worlds and we certainly will hear more about them in the near future.

This symposium, combining clinical and basic developments in interventional angiography, showed that there are rapid developments ongoing bringing new opportunities, but we need to be aware that they also come with a demand.




Challenges in modern angiography

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.