March 2014

Technology Update: Mobile C-Arm — The Market May Look Very Different Since Your Last Mobile C-Arm Purchase
By Dan Harvey
Radiology Today
Vol. 15 No. 3 P. 18

Flat-panel detectors are increasingly replacing image intensifiers on mobile C-arm systems, part of a migration of technology that once was available only in fixed room systems. This shift means that potential C-arm buyers are looking at a very different market than when they bought their C-arms a decade ago.

All of the leading C-arm–producing companies are offering significant advancements, says Greg Jett, a C-arm consultant and the founder of Creative Surgical Solutions. Before starting his consulting company, Jett worked for C-arm producers Ziehm Imaging and GE Healthcare.

Jett advises current buyers to make a well-studied assessment of what vendors are offering before investing in equipment that they’ll use for the next 10 to 15 years. “Take a good look because C-arm technology has really changed,” he advises.

“Trends toward advanced cooling and flat-panel technology accommodate the more demanding cases,” Jett adds. “Today, better control is placed in the user’s hand, whether the user is a technologist, a surgeon, or a nurse that needs to access the equipment,” Jett says. “The currently more intuitive platforms complement workflow. Easier use translates into fewer steps, and that speeds up workflow and, in turn, saves facilities money and promotes safer patient practices. Also, equipment that doesn’t overheat and then go down can only drastically improve safety and efficiency.”

While economic efficiency is an important consideration, Jett notes that the price of new technology is rising, but mobile systems offer new technology at a fraction of the cost of top-of-the-line fixed systems. “Still, compared to fixed room costs, [mobile C-arms] are significantly less,” he says. “I’ve observed that in Europe, customers willingly invest in the higher-end C-arms, which have more advanced cooling capabilities and better software interface systems.”

Dave Ferguson, director of global product marketing for GE Healthcare’s surgery business, offers his observations on C-arm technology. “I see two major trends. The first is on the clinical side,” he says. “We see continued growth in minimally invasive surgery. In orthopedics, that means spine surgery, hip surgery, and minimally invasive procedures that have been around for years but have spread across the globe. The second trend involves providing a solution that is not just an imaging device but one that really connects to improving workflow, which means improving ergonomics, easier usage, and facilitating efficient feeding of data into the PACS archive and EMR. It’s also about combining modalities into one device for multiple clinical uses out of one box, if you will. That saves floor space in the operating room [OR]. We also believe that providing expert education and dedicated field support can enable clinicians to maximize the benefits of their equipment.”

Lisa Reid, Siemens Healthcare’s surgery segment director, describes the picture from her company’s perspective. “Some of what we see is a shift to more mobile solutions within urology as opposed to fixed systems, thus providing more versatility. And with improvements in image quality, the added ability to image vascular and cardiac procedures. Also in orthopedics, 3D C-arm CT-like imaging enables intraoperative revisions and evaluation which helps avoid the need for resurgeries.”

“Peripheral vascular disease, which is underdiagnosed and undertreated, places a considerable burden on patients and health care systems,” adds Patricia van Kemenade, PhD, Philips’ marketing director for mobile surgery. “Advances in this area are spurred by the developments on devices for small vessels in the extremities. Good visualization of these small devices is key.”

Also, new endovascular approaches to treat hypertension and enlarged prostates are expected to substantially increase the pool of vascular patients, van Kemenade continues. “The health care sector is increasingly under cost pressure. Returns on investment are important. Innovative care models improve productivity, increase quality, and lower costs. Innovations such as EVAR [endovascular aortic repair] and minimally invasive surgery enable shorter procedures with reduced trauma and recovery time, allowing procedures to move from inpatient to outpatient facilities. We must ensure that our systems increase productivity by enhancing OR workflow, offering the best possible image quality and a minimum of downtime.”

Here’s a look at what the major players in mobile C-arm are offering in their systems.

Ziehm Imaging
Ziehm has been in business for nearly 40 years and was the first company to introduce flat-panel detectors into C-arm imaging. Today, the company offers touch-screen and bedside user control, and the equipment is reliable, quick, and easy to use, according to Jett.

In particular, Ziehm offers its Vision RFD, a concept that provides the full flexibility of a mobile C-arm combined with fixed room imaging capabilities, according to the company. Features of the system include the following:

• distortion-free image quality from flat-panel detector technology;

• expanded anatomical visualization (compared with an image intensifier);

• an active cooling system designed to provide extended performance in demanding endovascular procedures;

• high-power pulsed fluoroscopy monoblock generator;

• inexpensive installations that can translate into substantial cost savings;

• fixed-room performance in a mobile solution;

• intuitive, efficient workflow; and

• an open architecture and upgradeable software designed to extend the product’s life cycle.

Siemens’ ARCADIS product family offers systems at a variety of price points that support a broad range of clinical settings to suit customers’ specific needs. “Customers range from the stand-alone imaging centers to the major medical centers,” Reid says. “All systems can accommodate a variety of clinical settings, but the higher-end systems feature software that performs more complex analysis.”

The latest ARCADIS platform provides a strong focus on image quality and dose reduction. “Today, the main hardware differentiators are the size of the image intensifier, generator, and cooling system,” says Parag Patel, Siemens’ C-arm product manager. “The technology allows for longer procedures and accommodates larger patients while virtually eliminating overheating and procedure delays. Plus the improvement in image quality makes it possible to accomplish longer, more complex exams. All the systems have integrated software to automatically control contrast and brightness for consistent image quality during the procedure and also dose control to help support patient and staff safety without compromising image quality.”

The ARCADIS Varic primarily is used for orthopedic and trauma-type surgeries but is a multipurpose system that also handles vascular surgery and urology. This new-generation platform includes the dose savings software optimization tool. “The image quality is better, and the system provides extended fluoro times over 50 minutes at low dose,” Patel says.

The ARCADIS Avantic accommodates all types of exams and is well suited to advanced workflows, such as cardiovascular, Patel adds. “It has a larger image intensifier for more anatomical coverage and better power for imaging the longer cardiovascular cases. Also, we don’t see the C-arm overheating, thanks to the advanced cooling mechanism,” he explains.

The ARCADIS Orbic 3D, the high-end C-arm with isocentric design and 190-degree orbital movement, was developed for spine and neuro work. It can be equipped with NaviLink 3D1, the direct 3D navigation interface. “You can get a 3D, CT-like image reconstruction of 2D images, which helps avoid need for resurgeries, and with a substantial dose reduction from a CT scan,” Patel says. According to the company, ARCADIS’ benefits include the following:

• reduces the rate of revision surgeries with intraoperative 3D imaging and evaluation;

• saves money by reducing the need for postoperative CT control;

• supports standard fluoroscopy and both 2D and 3D imaging with one system; and

• maintains mobility and decreases dose, especially compared with a CT system.

GE Healthcare
Today, three in four US surgeons use OEC C-arms in surgery, Ferguson says. “With the need for more productivity, standardizing on a fleet of OEC C-arms can mean reduced training, improved workflow, and a renewed confidence within the surgical team—confidence gained by using the same familiar C-arm interface for most every procedure,” he says.

Ferguson adds that GE has introduced several programs and enhancements around issues of particular customer interest: workflow, ergonomics, cost, and reducing clinician dose.

Ferguson says GE’s Brilliant program has trained more than 2,500 clinicians in practical dose reduction techniques. “Adding a new TechView monitor to current products, as well as integrating GE ultrasound into C-arm, can help the staff increase their productivity,” he explains. “Building lighter-weight, easy-to-maneuver new products like the OEC Brivo addresses the ergonomic needs of clinicians. And offering certified refurbished OEC 9800 and 9900 C-arms, with genuine OEC parts and software while fully backed by the OEC support team, means high quality can exist in a value-priced C-arm.”

There are more than 34,000 OEC mobile C-arms, including 10,000 OEC 9900 Elite systems, in use throughout the world today, Ferguson says. He adds that OEC has proprietary precision imaging technology using Dynamic Range Management for high-quality images in almost every situation. OEC has incorporated these features aimed at improving image quality:

• no-mask motion-tolerant subtraction that allows digital subtraction angiography while moving the C-arm or the patient;

• preset imaging profiles that automatically adjust to highlight the anatomy of interest;

• a smartview pivot joint that improves positioning by making the C-arm easy to place precisely; and

• a motorized option that allows the surgeon to control the C-arm movements and obtain images from a tableside control.

The OEC line has certified staff of 200 service engineers and 60 clinical imaging specialists working across the United States, according to Ferguson.

“We recognize the industry’s interest in using flat-panel detectors as a replacement for the image intensifier on a mobile C-arm,” he adds. “In general, flat-panel technology is regarded as providing a higher-quality image and, therefore, customers believe they can instantly get better mobile C-arm images if they use a flat-panel detector. Our research shows, however, that for a flat-panel detector to perform as well as our OEC 9900 Elite [with a image intensifier], power must be greatly boosted and cooling [capability] must be increased.”

Ferguson explains that today’s flat-panel detectors, available on some models of mobile C-arms, can produce quality images in smaller anatomy and during short procedures. However, he says they require a higher dose than an OEC 9900 when used for dense anatomy or during complex surgical procedures.

Philips continues its innovation of flat-detector technology with its second-generation Veradius Neo, following the introduction of the Veradius flat-panel detector system. The company’s fixed system shares the detector technology, offering superior image quality while lowering dose. “This helps surgeons feel secure even in the complex cases,” van Kemenade says.

As with the other major players, Philips designs its products to be easy to understand and operate. “High performance needs to be easily achieved,” van Kemenade says. “We have consulted with surgeons throughout the world to create the ideal geometry. We’ve improved the [user interface] and introduced color-coded locks and movements to enhance the communication in the OR.”

Veradius Neo features a new C-arc geometry, which is optimization geometry with maneuverability specially designed to accommodate even obese patients.

As van Kemenade notes, mobile C-arms are repositioned many times during most procedures to deliver visualization for image-guided interventions. “To simplify communication between surgical team members and make it easy to quickly move to a requested position, the Veradius Neo now has a color-coded geometry,” she says.

Once in the desired position, the system’s flat-detector technology provides high-quality images without the distortion that’s inherent in images produced by previous generation image intensifier technology. “Surgeons can use these undistorted images to help place screws and other devices with precision. Minimally invasive procedures such as endovascular repairs are performed by surgeons using small stents and other devices that can be difficult to visualize,” she explains. “To provide adequate visualization during a procedure, a mobile C-arm must be able to produce high-contrast images of dynamic anatomy. The flat detector on the Veradius Neo has a greater dynamic range than older image intensifier technology, meeting these high requirements by providing high-contrast digital subtraction angiography that runs and road maps guidance. Veradius Neo’s advanced X-ray generation technology allows distortion-free visualization of dynamic anatomy in challenging procedures like transaortic aneurysm repair.”

X-ray dose remains a concern for all C-arm manufacturers, particularly in general procedures and long minimally invasive procedures. Veradius Neo incorporates a full range of dose management features that allow low X-ray dose without compromising image quality.

The Philips beam filters enhance X-ray quality, while the monoblock design results in sharp pulses to support excellent dose efficiency, van Kemenade says. “The easily removable grid on the flat detector makes it possible to visualize small anatomy and extremities with exceptional image quality. Veradius Neo also offers flexible and intuitive dose management settings so that image quality can be optimized for each type of procedure, contributing to the aim to keep X-ray dose as low as reasonably achievable.”

The system’s geometry allows faster and easier positioning of the imaging device even with obese patients. In vascular cases, for example, it provides full body coverage while keeping the system on one side of the patient, van Kemenade says. “In orthopedic cases, the C-arm is able to easily reach the lumbar spinal area even when the patient is obese, but with the newly designed C-arc, the Veradius Neo doesn’t compromise on ergonomics and can go lower than alternative systems in, for example, cervical cases,” she explains.

The Veradius Neo can be used for a multitude of clinical procedures, from orthopedics and spine procedures to cardiac and vascular interventions. “One system does it all,” van Kemenade says.

Market Picture
Jett sees a stable C-arm market that should only grow. “With new health care reforms, I expect a sharp increase in C-arm sales for two main reasons: They cost less, and they are more advanced and reliable.”

“Minimally invasive medicine is the future of progressive health care,” notes Joost Mikkers, a product manager for Philips. “Improved image quality of interventional X-ray systems is enabling interventional oncologists and radiologists to treat an increasing number of lesion types using techniques such as ablation or embolization therapy. ... This is an example showing promising minimal invasive alternatives to more invasive therapies such as open surgery bringing clear benefits to patients and their health care providers.”

— Dan Harvey is a freelance writer based in Wilmington, Delaware.