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The combination of an ultrathin bronchoscope, navigational technology, and endobronchial ultrasound (EBUS) seems to combine the best of mutual abilities for evaluating peripheral pulmonary lesions, but ultrathin bronchoscopes that allow the use of EBUS have not been developed so far. To compare the diagnostic yield of transbronchial biopsy under EBUS, fluoroscopy, and virtual bronchoscopic navigation guidance using a novel ultrathin bronchoscope with that using a thin bronchoscope with a guide sheath for peripheral pulmonary lesions. In four centers, patients with suspected peripheral pulmonary lesions less than or equal to 30 mm in the longest diameter were included and randomized to undergo transbronchial biopsy with EBUS, fluoroscopy, and virtual bronchoscopic navigation guidance using a 3.0-mm ultrathin bronchoscope (UTB group) or a 4.0-mm thin bronchoscope with a guide sheath (TB-GS group). A total of 310 patients were enrolled and randomized, among whom 305 patients (150, UTB group; 155, TB-GS group) were analyzed. The ultrathin bronchoscope could reach more distal bronchi than the thin bronchoscope (median fifth- vs. fourth-generation bronchi; P < 0.001). Diagnostic histologic specimens were obtained in 74% (42% for benign and 81% for malignant lesions) of the UTB group and 59% (36% for benign and 70% for malignant lesions) of the TB-GS group (P = 0.044, Mantel-Haenszel test). Complications including pneumothorax, bleeding, chest pain, and pneumonia occurred in 3% and 5% in the respective groups. The diagnostic yield of the UTB method is higher than that of the TB-GS method. Clinical trial registered with www.umin.ac.jp/ctr/ (UMIN 000003177).

The primary mode of visualization during transcatheter procedures for structrural heart disease is fluoroscopy, which suffers from low contrast and lacks any depth perception, thus limiting the ability of an interventionalist to position a catheter accurately. This paper describes a new image guidance system by utilizing augmented reality to provide a 3D visual environment and quantitative feedback of the catheter's position within the heart of the patient. The real-time 3D position of the catheter is acquired via two fluoroscopic images taken at different angles, and a patient-specific 3D heart rendering is produced pre-operatively from a CT scan. The spine acts as a fiduciary land marker, allowing the position and orientation of the catheter within the heart to be fully registered. The automated registration method is based on Fourier transformation, and has a high success rate (100%), low registration error (0.42 mm), and clinically acceptable computational cost (1.22 second). The 3D renderings are displayed and updated on the augmented reality device (i.e., Microsoft HoloLens), which can provide pre-set views of various angles of the heart using voice-command. This new image-guidance system with augmented reality provides a better visualization to interventionalists and potentially assists them in understanding of complicated cases. Furthermore, this system coupled with the developed 3D printed models can serve as a training tool for the next generation of cardiac interventionalists.

Introduction Pre- and postoperative imaging constitutes a firm brick in planning and steering accurate stereotactic procedures. The availability of intraoperative control measures, e.g., CT, MRI, and microelectrode recording (MER), is often limited to a minority of centers. Our approach utilizes fluoroscopy for target planning and coordinates validation as control. Methods This technique was primarily conceived for the RM (Riechert Mundinger) stereotactic system, but it also applies to the ZD (Zamorano—Dujovny) system. In the present study, we shifted the zero of the Z-value (axis of the patient) to + 60 mm. This corresponds to the center of the Angio/X-ray localizing plates. By assigning a radiopaque marker to the center of each plate, aligning these centers produced orthogonal and non-distorted stereotactic space. In this space, the magnification variable matters to us the most. Using available viewer software, we printed a millimetric grid on translucent foils with the corresponding magnification factor, which can easily be superimposed on the fluoroscopic image. This allows the precise validation of the coordinates of points of interest, including typical stereotactic landmarks. This technique can be used in both views, AP and lateral. Results We have validated this technique under non-clinical (phantom) conditions and with intraoperative images obtained during routine stereotactic procedures. The latter were acquired using our classical stereotactic fixedly-mounted X-ray system. We found identical results, with an accuracy margin of error lower than 1 mm. Conclusion This simple geometrical adaptation proved to be an accurate, accessible, mobile, and manageable technique providing immediate access to stereotactic coordinates during surgery. The accuracy proved to be non-inferior to other more complex and time-consuming imaging modalities.

Accurate measurement of joint kinematics is a key requirement for understanding injury mechanisms, evaluate rehabilitation techniques, and improve the implant designs and techniques used in total knee arthroplasty (TKA). Fluoroscopy is an experimental technique to directly measure joint kinematics without being affected by soft-tissue artefacts. However, because of its limited field-of-view (FOV), stationary fluoroscopy can only measure small parts of more dynamic/progressive movements, such as walking. This manuscript presents a new generation of moving fluoroscope: The tracking dual-plane fluoroscope (tDPF) combines optical tracking with a bi-planar X-ray system on mechanically independent source and intensifier carriages on rails and model-predictive-control to measure the kinematics of the tibio-femoral joint in vivo during dynamic activities, such as level walking and stair ascent/descent, at all gait speeds. In this proof-of-concept study, the tDPF tracked the knees of 16 young and healthy subjects during complete, consecutive gait cycles of level walking, ramp ascent, ramp descent, stair ascent, and stair descent at self-selected gait speeds. For all gait speeds (average and standard deviation: 1.34 ± 0.14 m s − 1 during level walking), tracking performance for each activity was excellent and the knee centre stayed within both simulated image intensifiers’ FOVs for > 99 % of frames (no X-ray images were captured in this study). The tDPF is the first dual-plane fluoroscope to track the knee joint during entire cycles of stair and ramp ascent at self-selected gait speeds for young and healthy subjects. Notably, our device does not require any pre-recording of movement patterns—by using real-time position estimates of the tracked joint and tracking each trial independently, even the challenging measurements of tasks with high variability between trials become possible.

Flat-panel detectors or, synonymously, flat detectors (FDs) have been developed for use in radiography and fluoroscopy with the defined goal to replace standard X-ray film, film-screen combinations and image intensifiers by an advanced sensor system. FD technology in comparison to X-ray film and image intensifiers offers higher dynamic range, dose reduction, fast digital readout and the possibility for dynamic acquisitions of image series, yet keeping to a compact design. It appeared logical to employ FD designs also for computed tomography (CT) imaging. Respective efforts date back a few years only, but FD-CT has meanwhile become widely accepted for interventional and intra-operative imaging using C-arm systems. FD-CT provides a very efficient way of combining two-dimensional (2D) radiographic or fluoroscopic and 3D CT imaging. In addition, FD technology made its way into a number of dedicated CT scanner developments, such as scanners for the maxillo-facial region or for micro-CT applications. This review focuses on technical and performance issues of FD technology and its full range of applications for CT imaging. A comparison with standard clinical CT is of primary interest. It reveals that FD-CT provides higher spatial resolution, but encompasses a number of disadvantages, such as lower dose efficiency, smaller field of view and lower temporal resolution. FD-CT is not aimed at challenging standard clinical CT as regards to the typical diagnostic examinations; but it has already proven unique for a number of dedicated CT applications, offering distinct practical advantages, above all the availability of immediate CT imaging in the interventional suite or the operating room.

Purpose At present, most spinal surgeons undertake pedicle screw implantation using either anatomical landmarks or C-arm fluoroscopy. Reported rates of screw malposition using these techniques vary considerably, though the evidence generally favors the use of image-guidance systems. A miniature spine-mounted robot has recently been developed to further improve the accuracy of pedicle screw placement. In this systematic review, we critically appraise the perceived benefits of robot-assisted pedicle screw placement compared to conventional fluoroscopy-guided technique. Methods The Cochrane Central Register of Controlled Trials, PubMed, and EMBASE databases were searched between January 2006 and January 2013 to identify relevant publications that (1) featured placement of pedicle screws, (2) compared robot-assisted and fluoroscopy-guided surgery, (3) assessed outcome in terms of pedicle screw position, and (4) present sufficient data in each arm to enable meaningful comparison (>10 pedicle screws in each study group). Results A total of 246 articles were retrieved, of which 5 articles met inclusion criteria, collectively reporting placement of 1,308 pedicle screws (729 robot-assisted, 579 fluoroscopy-guided). The findings of these studies are mixed, with limited higher level of evidence data favoring fluoroscopy-guided procedures, and remaining comparative studies supporting robot-assisted pedicle screw placement. Conclusions There is insufficient evidence to unequivocally recommend one surgical technique over the other. Given the high cost of robotic systems, and the high risk of spinal surgery, further high quality studies are required to address unresolved clinical equipoise in this field.

The global needs for a reduction in radiation exposure (RE) are increasing. Endoscopic retrograde cholangiopancreatography (ERCP) is a significant fluoroscopic procedure in the gastrointestinal field. However, the actual RE in ERCP and its annual trend are still unclear. Therefore, we examined the yearly trend of RE in ERCP. This retrospective, single-center cohort study included consecutive cases of ERCP from September 2012 to June 2019. We measured the air kerma (AK, mGy), dose area product (DAP, Gycm2), and fluoroscopy time (FT, min). We also evaluated the annual trend of the RE before and after the fluoroscopy device update. In total, 2,174 patients receiving ERCP were enrolled. Among these, the mean age was 74.3 years, and 913 patients were women (42.0%). The median/third quartile values of AK (mGy), DAP (Gycm2), and FT (min) were 109/234 mGy, 13.3/25.8 Gycm2, and 18.2/27.7 minutes. The annual AK, DAP, and FT from 2012 to 2019 were 138, 207, 173, 177, 106, 71.0, 45.0, and 33.3 mGy; 23, 21.4, 19, 18.3, 11.9, 9.0, 6.8, and 6.4 Gycm2; and 12.5, 12.1, 9.7, 9.8, 8.2, 10.8, 9.4, and 10.3 minutes, respectively. The corresponding values before and after the update in July 2016 were 177 and 52 mGy (P < 0.0001), 19.2 and 7.6 Gycm2 (P < 0.0001), and 10.2, and 9.9 minutes (P = 0.05), respectively. The RE from ERCP tended to decrease every year, especially after fluoroscopy device updates.

Background Bile duct injury is a rare but serious complication of laparoscopic cholecystectomy and the primary cause is misinterpretation of biliary anatomy. This may occur more frequently with a single-incision approach due to difficulties in exposing and visualizing the triangle of Calot. Intraoperative cholangiography was proposed to overcome this problem, but due to multiple issues, it is not used routinely. Indocyanine green (ICG) near-infrared (NIR) fluorescent cholangiography is non invasive and provides real-time biliary images during surgery, which may improve the safety of single-incision cholecystectomy. This study aims to evaluate the efficacy and safety of this technique during single-site robotic cholecystectomy (SSRC). Methods Patients presenting with symptomatic biliary gallstones without suspicion of common bile duct stones underwent SSRC with ICG-NIR fluorescent cholangiography using the da Vinci Fluorescence Imaging Vision System. During patient preparation, 2.5 mg of ICG was injected intravenously. During surgery, the biliary anatomy was imaged in real time, which guided dissection of Calot’s triangle. Perioperative outcomes included biliary tree visualizations, operative time, conversion and complications rates, and length of hospital stay. Results There were 45 cases between July 2011 and January 2012. All procedures were completed successfully; there were no conversions and at least one structure was visualized in each patient. The rates of visualization were 93 % for the cystic duct, 88 % for the common hepatic duct, and 91 % for the common bile duct prior to Calot’s dissection; after Calot’s dissection, the rates were 97 % for all three ducts. Mean hospital stay was 1.1 days and there were no bile duct injuries or any other major complications. Conclusion Real-time high-resolution fluorescent imaging to identify the biliary tree anatomy during SSRC using the da Vinci Fluorescence Imaging Vision System was safe and effective.

Introduction Fluoroscopy uses collimators to limit the radiation field size. Collimators are often evaluated annually during equipment performance evaluations to maintain compliance with regulatory and/or accreditation bodies. A method to evaluate and quantify fluoroscopy collimator performance was developed. Methods A radiation field and displayed image measurement device consisting of radiopaque rulers and radiochromic film strips was placed on the x‐ray source assembly exit window to evaluate fluoroscopy collimator performance. This method was used to evaluate collimator performance on 79 fluoroscopic imaging systems including fixed C‐arms, mobile C‐arms, mini C‐arms, and radiographic fluoroscopic systems. Results The excess length (EL), excess width (EW), and sum EL + EW of the radiation field relative to the displayed image were measured and compared to the limits specified in 21CFR1020.32. Four systems exceeded these limits. Placing the radiation measurement device at the x‐ray source assembly exit window relative to the image receptor cover increased the film exposure rate by a factor up to 14.6. The time required to set up and complete the fluoroscopy collimator performance measurements using this method ranged from 5 to 10 min. Conclusions This method provides an easily implemented quantitative measure of fluoroscopy system collimator performance that satisfies regulatory and accreditation body requirements.

Background Digital dynamic radiography (DDR), integrated into Konica Minolta's portable mKDR system, provides dynamic imaging for pulmonary, orthopedic, and interventional applications. While DDR is not classified as fluoroscopy, its use of pulsed x‐rays for cine‐like image sequences raises concerns about radiation exposure and shielding, particularly given the absence of a primary beam stop, high output capabilities, and increasing clinical adoption. Purpose To characterize the primary and scatter radiation output of a DDR system and compare it against commonly used mobile C‐arm fluoroscopy units, and to evaluate shielding requirements and potential occupational exposure risks associated with DDR use. Methods Radiation dose output and scatter were assessed for a Konica Minolta mKDR system and three mobile C‐arms: GE OEC Elite, Siemens Cios Spin, and Ziehm Vision RFD 3D. Unshielded primary air kerma was measured at 100 cm SID using matched dose settings (low, medium, high). Scatter fraction and normalized scatter were measured at eight angles and three distances using a 20 cm PMMA phantom and an ion chamber. Additional direct comparisons of angular scatter doses between DDR and a GE C‐arm were made during 20‐s acquisitions at varying distances. The Klein–Nishina differential cross section was also calculated for photon energies representative of clinical settings. Leakage radiation and image receptor attenuation were quantified. Shielding requirements were estimated using NCRP 147 methodology under varying workload and occupancy conditions. Results DDR exhibited dose rates two to three times higher than C‐arms at medium and high dose settings, with longer pulse widths (16 ms) producing greater exposure than shorter ones (5 ms). Scatter fraction peaked at 165° and increased with lower beam energy due to energy‐dependent Compton interactions and reduced filtration. Compared to the GE C‐arm, DDR produced consistently higher scatter values at all angular positions. Measured scatter doses at 0.3 m and 1.0 m from the phantom exceeded those from the C‐arm, especially in the forward direction (0°). Image receptor attenuation measurements showed 98% beam reduction when the receptor was properly aligned. Leakage was minimal and well below FDA limits. Shielding assessments indicated that concrete thickness requirements for DDR could reach 145 mm under worst‐case conditions, driven primarily by the high primary beam output rather than scatter or leakage. Conclusions DDR systems provide portable dynamic imaging capabilities but deliver substantially higher radiation output than conventional mobile C‐arms. In addition, scatter dose rates from DDR were approximately 1.5–3 times higher than those from a conventional mobile C‐arm under comparable conditions. This elevated dose, driven by high tube currents and long pulse durations, raises important safety concerns for patients, personnel, and shielding infrastructure. While DDR offers potential clinical value in motion‐sensitive applications, its safe integration into practice requires careful protocol selection, attention to scatter exposure, and thoughtful shielding planning of exam rooms where the system will be used. As DDR systems become more prevalent and approach fluoroscopic performance, regulatory and design guidance may need to evolve to reflect their unique operational profile.