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• W4367011193 abstract "C-arm cone-beam computed tomography (CT) with a flat-panel detector represents the next generation of imaging technology available in the interventional radiology suite and is predicted to be the platform for many of the three-dimensional (3D) roadmapping and navigational tools that will emerge in parallel with its integration. The combination of current and unappreciated capabilities may be the foundation on which improvements in both safety and effectiveness of complex vascular and nonvascular interventional procedures become possible. These improvements include multiplanar soft tissue imaging, enhanced pretreatment target lesion roadmapping and guidance, and the ability for immediate multiplanar posttreatment assessment. These key features alone may translate to a reduction in the use of iodinated contrast media, a decrease in the radiation dose to the patient and operator, and an increase in the therapeutic index (increase in safety-vs-benefit ratio). In routine practice, imaging information obtained with C-arm cone-beam CT provides a subjective level of confidence factor to the operator that has not yet been thoroughly quantified. C-arm cone-beam computed tomography (CT) with a flat-panel detector represents the next generation of imaging technology available in the interventional radiology suite and is predicted to be the platform for many of the three-dimensional (3D) roadmapping and navigational tools that will emerge in parallel with its integration. The combination of current and unappreciated capabilities may be the foundation on which improvements in both safety and effectiveness of complex vascular and nonvascular interventional procedures become possible. These improvements include multiplanar soft tissue imaging, enhanced pretreatment target lesion roadmapping and guidance, and the ability for immediate multiplanar posttreatment assessment. These key features alone may translate to a reduction in the use of iodinated contrast media, a decrease in the radiation dose to the patient and operator, and an increase in the therapeutic index (increase in safety-vs-benefit ratio). In routine practice, imaging information obtained with C-arm cone-beam CT provides a subjective level of confidence factor to the operator that has not yet been thoroughly quantified. C-ARM cone-beam computed tomography (CT) is an advanced imaging capability that uses state-of-the-art C-arm flat-panel fluoroscopy systems to acquire and display three-dimensional (3D) images. C-arm cone-beam CT provides high- and low-contrast soft tissue (“CT-like”) images in multiple viewing planes, which constitutes a substantial improvement over conventional single-planar digital subtraction angiography (DSA) and fluoroscopy. Although C-arm cone-beam CT has been in development for the past 2 decades, it has only been applied in the interventional radiology clinic in recent years. The clinical emergence of C-arm cone-beam CT has lagged only a little behind that of flat-panel detector fluoroscopy systems, which, as early research has demonstrated, offer higher spatial resolution than conventional image intensifier detector systems (1Baba R. Konno Y. Ueda K. Ikeda S. Comparison of flat-panel detector and image-intensifier detector for cone-beam CT.Comput Med Imaging Graph. 2002; 26: 153-158Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar). In general, the assessment of whether C-arm cone-beam CT adds value to existing technologies in the interventional radiology suite requires that several questions be answered. Among them, will C-arm cone-beam CT enable the treating physician to plan more effective interventions, and will this result in a reduction in treatment-related complications? On the basis of early experience, it is clear that operators performing complicated interventions requiring information about both vascular and soft tissue anatomy have more confidence in the imaging information provided with C-arm cone-beam CT when it is used as an adjunct to DSA or fluoroscopy. The extent to which operator confidence is improved, however, is difficult to quantify. Three C-arm cone-beam CT systems are commercially available in the United States: DynaCT (Siemens Medical Solutions, Forchheim, Germany), XperCT (Phillips Medical Systems, Eindhoven, the Netherlands), and Innova CT (GE Healthcare, Waukesha, Wisconsin). Each of these systems has its own imaging protocol, necessitated by each system's different rotation time, number of projections acquired, image quality, and time required for reconstruction. The two factors that will most affect the successful integration of C-arm cone-beam CT into the interventional radiology practice are time (for set up, image acquisition, and image reconstruction) and image quality. The use of retrospective case material for this review did not require institutional review board approval at any of the contributing institutions. Reports of the use of C-arm cone-beam CT are beginning to emerge in the medical literature, with early case reports of its advantages coming from its use for neurologic interventions. For example, Heran and coworkers (2Heran N.S. Song J.K. Namba K. Smith W. Niimi Y. Berenstein A. The utility of DynaCT in neuroendovascular procedures.AJNR Am J Neuroradiol. 2006; 27: 330-332PubMed Google Scholar) used C-arm cone-beam CT to detect intracranial hemorrhages during three neurologic interventions, and Benndorf and coworkers (3Benndorf G. Strother C.M. Claus B. et al.Angiographic CT in cerebrovascular stenting.AJNR Am J Neuroradiol. 2005; 26: 1813-1818PubMed Google Scholar, 4Benndorf G. Claus B. Strother C.M. Chang L. Klucznik R.P. Increased cell opening and prolapse of struts of a neuroform stent in curved vasculature: value of angiographic computed tomography: technical case report.Neurosurgery. 2006; 58 (ONS–E380, discussion ONS–E380)Google Scholar) used C-arm cone-beam CT to improve the visualization of intracranial and extracranial stents in four patients. In the study by Benndorf et al (4) in which three patients underwent intracranial (n = 2) and extracranial (n = 1) stent placement, the authors demonstrated that C-arm cone-beam CT depicted both the stent struts and their relationship to the arterial walls and aneurysm lumen. The visualization of these structures with C-arm cone-beam CT was superior to that achieved with conventional DSA and digital radiography. Reports of the early clinical use of C-arm cone-beam CT for other interventions emerged shortly thereafter. Binkert and coworkers (5Binkert C.A. Alencar H. Singh J. Baum R.A. Translumbar type II endoleak repair using angiographic CT.J Vasc Interv Radiol. 2006; 17: 1349-1353Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar) used C-arm cone-beam CT to manage type 2 endoleaks in abdominal aortic aneurysm stent grafts by using a translumbar approach. Hodek-Wuerz and coworkers (6Hodek-Wuerz R. Martin J.B. Wilhelm K. et al.Percutaneous vertebroplasty: preliminary experiences with rotational acquisitions and 3D reconstructions for therapy control.Cardiovasc Intervent Radiol. 2006; 29: 862-865Crossref PubMed Scopus (17) Google Scholar) used C-arm cone-beam CT to assess the distribution of cement after vertebroplasty. Georgiades and coworkers (7Georgiades C.S. Hong K. Geschwind J.F. et al.Adjunctive use of C-arm CT may eliminate technical failure in adrenal vein sampling.J Vasc Interv Radiol. 2007; 18: 1102-1105Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar) reported their experience using adjunctive C-arm cone-beam CT during adrenal venous sampling to reduce technical failure in nine consecutive cases. Catheters initially placed for sampling were malpositioned in two cases (22%) on the basis of C-arm cone-beam CT findings and successfully repositioned into the proper location. This resulted in concordance between cortisol results and C-arm cone-beam CT findings. Hirota and coworkers (8Hirota S. Nakao N. Yamamoto S. et al.Cone-beam CT with flat-panel-detector digital angiography system: early experience in abdominal interventional procedures.Cardiovasc Intervent Radiol. 2006; 29: 1034-1038Crossref PubMed Scopus (128) Google Scholar) reported their experience with C-arm cone-beam CT during visceral interventions in 10 cases, including five chemoembolizations, three hepatic port implantations, and two partial splenic embolizations. They concluded that C-arm cone-beam CT provided information that was useful, especially in the chemoembolizations, for confirming the perfusion area of the target region's supplying artery during superselective catheterization; for the partial splenic embolizations, it was helpful in assessing the volume of embolization. Meyer and coworkers (9Meyer B.C. Frericks B.B. Albrecht T. Wolf K.J. Wacker F.K. Contrast-enhanced abdominal angiographic CT for intra-abdominal tumor embolization: a new tool for vessel and soft tissue visualization.Cardiovasc Intervent Radiol. 2007; 30: 743-749Crossref PubMed Scopus (68) Google Scholar) recently described five patients who underwent transarterial chemoembolizations, in whom C-arm cone-beam CT provided such detailed information about patients' vascular anatomy and therapeutic endpoints both during and immediately after the intervention that it ultimately influenced the course of treatment. Wallace and coworkers (10Wallace M. Murthy R. Kamat P. et al.Impact of C-arm CT on hepatic arterial interventions for hepatic malignancies.J Vasc Interv Radiol. 2007; 18: 1500-1507Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar) have also presented their experience with Carm cone-beam CT for hepatic arterial interventions, which included infusions, radioembolizations, embolizations, and chemoembolizations. During the study period, C-arm cone-beam CT was used in 86 of 240 interventions (36%) in 135 patients. The mean number of acquisitions per study was 1.9 (range, 1–4). In 35 of the 86 interventions (41%), C-arm cone-beam CT gave additional information without affecting procedure management; it had an effect on patient treatment in 16 cases (19%). Chemoembolization benefited the most from the additional information provided with C-arm cone-beam CT. The authors concluded that C-arm cone-beam CT provided imaging information beyond that provided with DSA during approximately 60% of hepatic arterial interventions and that the additional information had an effect on the technical management in 19% of the procedures. On the basis of imaging studies using experimental C-arm cone-beam CT units in the abdomen, the contrast resolution of low-contrast structures on C-arm cone-beam CT scans has been reported to be 5–10 Hounsfield units (11Linsenmaier U. Rock C. Euler E. et al.Three-dimensional CT with a modified C-arm image intensifier: feasibility.Radiology. 2002; 224: 286-292Crossref PubMed Scopus (109) Google Scholar, 12Vandehaar P. Noordhoek N. Timmer J. Direct comparison of commercially available C-arm CT to multi-slice CT image quality.in: Radiological Society of North America scientific assembly and annual meeting program. Radiological Society of North America, Oak Brook, Ill2006: 377Google Scholar). Approximately 50 Hounsfield units is a more practical expectation, best demonstrated when an interface exists between the fatty and soft tissue structures or when fluid allows various abdominal organs and structures to be differentiated from each other. When required, iodinated contrast medium can be used to improve the ability of C-arm cone-beam CT to image low-contrast soft tissue structures confined within an organ or surrounded by other tissue of similar densities. Potential vascular applications of C-arm cone-beam CT include its use for preprocedure anatomic diagnosis and treatment planning, intraprocedure device or implant positioning assessment, and postprocedure assessment of procedure endpoints. Most of these applications require the use of iodinated contrast medium to opacify the vascular system and make its corresponding soft tissue structures opaque. However, the acquisition of implant devices (eg, stents, stent-grafts, and stent filters) to evaluate vessel wall apposition and the completeness of device opening after deployment does not necessarily require additional contrast medium. It is important to start contrast medium injection before rotational acquisition to properly fill the vascular structure and, if needed, allow for soft tissue enhancement of the organ and/or region of interest. The administration of iodinated contrast media requires imaging delays that vary depending on the type of vascular intervention, the proximity of the catheter to the target location, and the degree of image detail required. For example, the acquisition of basic vascular information about an area close to the catheter may require a delay of approximately 2 seconds; examples of this include selective injections into the arteries of the liver, kidney, and spleen. The delay can vary between 2 and 3 seconds in large vessels with high flow rates (aorto–vena cava) or during selective injection of smaller vessels with no need to analyze parenchymal enhancement (Table 1, Table 2). This delay can be increased 5–6 seconds during selective injections if visualization of both vascular and soft tissue (parenchyma or lesion) structures is required.Table 1C-arm CT Acquisition Protocols for Hepatic Arterial Interventions at the University of Texas M. D. Anderson Cancer CenterArea of InterestCatheter Tip LocationRate of Injection (mL/sec)Contrast Medium Dilution (%)Imaging Delay (sec)Vascular informationCHA, PHA2302–3Enhanced parenchymal informationCHA, PHA2504–6Selective RHA, LHA0.5–1 (to avoid reflux)502–3Note.—CHA = common hepatic artery, PHA = proper hepatic artery, RHA = right hepatic artery, LHA = left hepatic artery. Open table in a new tab Table 2C-arm CT Acquisition Protocols for Peripheral Arterial Interventions at Centre Hospitalier De L'Université De MontrealArea of InterestContrast Medium Dilution (%)Imaging Delay (sec)Flow Rate (mL/sec)Total Volume (mL)Contrast Equivalent⁎Since the contrast is diluted, the contrast equivalent is the amount of undiluted contrast used.Infrarenal abdominal aorta302–3880–8824–26Infraabdominal aorta during endovascular aneurysm repair305–68104–11231–34Iliac arteries30366620Femoropopliteal arteries2033337Note.—Protocols are for an 8-second rotational acquisition time. Since the contrast is diluted, the contrast equivalent is the amount of undiluted contrast used. Open table in a new tab Note.—CHA = common hepatic artery, PHA = proper hepatic artery, RHA = right hepatic artery, LHA = left hepatic artery. Note.—Protocols are for an 8-second rotational acquisition time. Because C-arm cone-beam CT provides 3D vascular and soft tissue detail, it is instrumental to improve the visualization of the vascular distribution of the selected arterial territories and their corresponding areas of tissue perfusion within an organ or region of interest. Because C-arm cone-beam CT provides this enhanced 3D imaging capability, it provides more subtle vascular and soft tissue information compared with conventional DSA. The additional imaging information enables the operator to adequately identify sites for embolization and potentially avoid complications relating to non-target therapy. These imaging advantages are particularly useful during embolizations of the spine, pelvis, solid organs (liver, kidney, spleen), and vascular anomalies in addition to interventions in other peripheral vascular territories. One of the most important advantages to using the detailed anatomic images from C-arm cone-beam CT over the conventional, frontal projection images from DSA is that they enable the user to “page through” C-arm cone-beam CT image sections and reformat them for viewing in various slab thicknesses and projections; this allows vascular structures to be viewed in relation to complex overlapping anatomy. If these improvements are proved to reduce the number of selective catheterizations and the number of DSA acquisitions from various obliquities required to delineate crucial anatomic structures, both patient and operator exposure to contrast medium and radiation—even during complex interventions—could be minimized. In addition, C-arm cone-beam CT is helpful for planning the treatment of target lesions that are difficult to visualize at DSA but that can be visualized with either conventional CT or magnetic resonance (MR) imaging. Although the resolution of low-contrast structures at C-arm cone-beam CT is not as good as that of conventional multidetector CT, C-arm cone-beam CT images acquired with use of iodinated contrast media can capture more soft tissue detail than can conventional DSA (Fig 1) —enough to enable the identification of parenchymal lesions or structures of interest. Operators can then confidently identify and correlate the findings from C-arm cone-beam CT images with those from conventional CT or MR imaging in the appropriate plane of viewing. The ability to page through different planes of C-arm cone-beam CT scans depicting arterial structures can also be useful in the characterization of arterial stenoses, occlusions, and aneurysms. During early clinical experience, C-arm cone-beam CT appears better than DSA for the pre- and post-therapeutic evaluation of stenoses in large and medium-sized arteries, especially when en face arterial lesions limit the extent to which the residual arterial lumen can be adequately imaged. The high level of detail on C-arm cone-beam CT scans also allows the dimensions and shape of patients' lesions to be more precisely measured before stent implantation; after implantation, it allows the adequacy of coverage and lumen restoration to be assessed. C-arm cone-beam CT can also provide information used in aneurysm interventions, which is especially crucial when a clear understanding of the aneurysm, the neck, and the adjacent branching structures that may be at risk for occlusion with the insertion of a covered prosthesis is required or if those structures require embolization before device deployment. C-arm cone-beam CT appears to be better than DSA in the evaluation of the adequacy of wall apposition in the case of both stents and stent-grafts. After stent-graft deployment, C-arm cone-beam CT can also be used to confirm aneurysm sac exclusion and immediately identify some types of endoleaks. As with arterial interventions for occlusive disease, C-arm cone-beam CT may be helpful for similar venous recanalization types of interventions. Early clinical experience has demonstrated C-arm cone-beam CT to be a useful adjunct to DSA in hepatic vascular interventions, including arterial infusions, embolizations, chemoembolizations, and radioembolizations. One specific advantage to using C-arm cone-beam CT with conventional DSA is that C-arm cone-beam CT gives users the information they need to create an anatomic survey for treatment planning that delineates a patient's vascular anatomy and accounts for vascular structures, the associated parenchyma, and the target lesion This ability enables more selective catheterizations to be performed, which may improve the safety and efficacy of interventions by depositing therapeutic agents more selectively; that is, the amount of therapeutic agent delivered to the target area is increased and the amount of non-tumor–bearing liver exposed to the agent decreased. In addition to delineating crucial anatomic structures, an anatomic survey also allows for the confident identification of nontarget extrahepatic arteries and variant anatomic structures supplying the small bowel (supraduodenal and retroduodenal arteries), stomach (right gastric artery, Fig 2), diaphragm (anomalous phrenic artery), and skin (falciform artery) during hepatic arterial chemotherapy infusion, radioembolization, or chemoembolization (13Liu D.M. Salem R. Bui J.T. et al.Angiographic considerations in patients undergoing liver-directed therapy.J Vasc Interv Radiol. 2005; 16: 911-935Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar). C-arm cone-beam CT may depict vessels not identified at DSA or, more likely, help clarify extrahepatic or variant anatomic vascular structures that are indeterminate at DSA evaluation without or despite selective catheterization and DSA imaging in multiple obliquities. In addition to providing a better vascular roadmap for selective catheterizations, C-arm cone-beam CT can also allow the operator to determine, before therapy, whether the entire target lesion is included within the treatment area. If only a portion of the lesion is supplied by the branch vessel in question, that portion of the tumor can be estimated (Fig 3) and the chemoembolic regimen can be proportioned accordingly. Because C-arm cone-beam CT provides soft tissue information, the operator can still selectively treat lesions that are difficult to visualize at DSA but that can be visualized with other conventional imaging modalities (CT or MR imaging) and would potentially not have been feasible to treat with DSA alone (Fig 4).Figure 4Images from conventional CT (a), DSA (b), and C-arm CT (c) in a patient undergoing hepatic artery chemoembolization. (a) Axial multisection contrast-enhanced conventional CT scan demonstrates a mass in the posterior aspect of the right lobe of the liver (arrow). There is only a mild degree of peripheral tumor enhancement. (b) Image from DSA obtained before chemoembolization shows that the lesion could not be visualized because it was not adequately hypervascular. C-arm CT was used to identify the lesion and the supplying branch hepatic artery to enable superselective catheterization. (c) C-arm CT scan obtained before chemoembolization with a microcatheter superselective in a branch of the right posterior hepatic artery demonstrates the angiographically occult lesion (white arrows) within the arterial territory of the catheterized vessel with enhancing parenchyma surrounding the relative less enhancing tumor. (d) Unenhanced C-arm CT scan obtained after chemoembolization demonstrates adequate ethiodized oil accumulation within the target lesion (white arrows).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Information acquired with C-arm cone-beam CT can also allow the accurate correlation of vascular anatomy or distribution with the corresponding volume of parenchyma. This is especially useful in patients with extensive bilobar hepatic metastases and those with hormonally active tumors that are to be treated palliatively by using embolization. Volume assessments based on C-arm cone-beam CT information are likely to be more accurate than those based on conventional DSA information; operators also value the ability of C-arm cone-beam CT to allow the viewing of soft tissue and thin-slab–reformatted images. The current technique used at the University of Texas M. D. Anderson Cancer Center (source: M.J.W.) varies depending on the imaging information desired. Variable factors include imaging delay after contrast medium initiation (seconds), rate of injection (milliliter/second), and dilution of contrast medium (percentage by volume). The imaging delay varies by target area and catheter tip location (Table 1). For basic arterial imaging of the hepatic arterial system, a delay of approximately 2–3 seconds is usually sufficient assuming the contrast medium has been injected into the proper or common hepatic artery. The usual rate of injection is 2 mL/sec, and the injection is typically administered via a microcatheter. A longer imaging delay of up to 6 seconds is used when hepatic parenchymal or lesion enhancement is also needed. For subselective arterial examinations, a lower rate of injection (0.5–1 mL/sec) is used to avoid reflux into an adjacent branch artery paired with a shorter imaging delay (2–3 seconds). Diluted iodinated contrast medium (30%–50% by volume) is used for contrast medium–enhanced C-arm cone-beam CT. Higher percentages are used for hepatic arterial applications when parenchymal or tumor enhancement is desired; lower percentages are usually adequate for visualization of arterial anatomy. Although the soft tissue contrast resolution of contrast-enhanced C-arm cone-beam CT is not equivalent to that of conventional multidetector CT, Carm cone-beam CT is helpful in its ability to identify parenchymal lesions that DSA cannot adequately depict. With use of C-arm cone-beam CT, operators can confidently identify structures and correlate findings to those on conventional CT (Fig 4) or MR images in the appropriate viewing plane. C-arm cone-beam CT also provides better information than DSA and, occasionally, conventional CT about the number and distribution of tumors. When C-arm cone-beam CT does provide more information than conventional CT, it may be because of the hyperacute nature of the arterial contrast medium bolus and its ability to depict even very small lesions. When C-arm cone-beam CT is used in chemoembolization procedures that employ ethiodized oil as part of the therapeutic regimen, it can also help assess whether a therapeutic endpoint has been achieved after the intervention. This is because ethiodized oil acts as both a carrier of the chemotherapeutic agent and a contrast agent, accumulating preferentially within hypervascular tumors (Fig 3c). This preferential accumulation can be imaged with Carm cone-beam CT and does not require additional iodinated contrast media enhancement. The completeness of therapy can then be assessed by evaluating the distribution of ethiodized oil within the target lesion. If the oil has not accumulated in a portion of the lesion, the operator can search for hepatic or extrahepatic collateral tumor supply. For portal vein embolizations, having a good understanding of the portal venous anatomy is crucial— especially when partial or segmental embolization is required (eg, when performing an extended right hepatic embolization that includes the embolization of segment IV of the liver). C-arm cone-beam CT accurately depicts segment IV branches (Fig 5) in various planes and can potentially help the operator avoid nontarget embolization to branches supplying segments II and III. For extended left hepatectomy, Carm cone-beam CT is useful for visualizing the right-side hepatic segments clearly enough to determine which are to be preserved and which are to be embolized. C-arm cone-beam CT is also useful for assessing portal venous supply to various liver segments when portal venous variants (which are not uncommon) are present; this reduces the possibility that nontarget segments will be embolized during portal vein embolization. The current technique used at M. D. Anderson Cancer Center (source: M.J.W.) for visualizing portal venous anatomy during portal vein embolization is to use 30% dilute iodinated contrast medium injected at a rate of 3 mL/sec with an imaging delay of 4 seconds for a main portal vein injection. For left portal vein injections, an imaging delay of 2 seconds is usually sufficient to accomplish adequate portal opacification. One of the most challenging aspects of TIPS placement is completing the puncture from the hepatic to the portal vein. This step, during which needle passes are made, contrast medium is injected, and radiation from fluoros-copy and/or DSA accumulates, is often the rate-limiting portion of the procedure. Biliary, capsular, and arterial punctures may occur during this phase of the procedure and lead to complications. For example, if contrast medium is injected into the parenchyma during needle pull-back, it can obscure visualization, and both patients and staff in the procedure room can be exposed to large amounts of radiation if access proves difficult. Classically, guidance for the puncture is obtained by using wedged venography with CO2 or contrast medium. Two or three DSA runs are performed in different obliquities to delineate the portal vein and its branches with respect to the accessed hepatic vein. The puncture is then carried out blindly under live fluoroscopy on the basis of these runs. As mentioned earlier, Carm cone-beam CT has the potential to provide information to build a 3D roadmap for a portal vein puncture. To accomplish this, a compliant balloon occlusion catheter is positioned in the accessed hepatic vein and a wedge CO2 injection performed to opacify the portal vein. If the portal vein is not filled, C-arm cone-beam CT is not attempted. The current technique used at Mallinckrodt Institute of Radiology (source: C.C.) includes the use of two 60-mL syringes containing CO2 connected with a three-way stopcock to the balloon occlusion catheter by means of high-pressure injector tubing. The injector tubing allows the operator to manually inject the CO2 from a safe distance behind a leaded shield. C-arm cone-beam CT scans are then obtained with the manual injections done in rapid succession throughout the entire C-arm rotation. Wedged CO2 C-arm cone-beam CT portography is performed by using an 8-second program without an imaging delay, with the patient's arms alongside the body. The 3D roadmap of the portal vein is then laid over the working fluoroscopy screen (Fig 6) and portal vein puncture performed. Although several maneuvers in this procedure still require refinement, C-arm cone-beam CT has the potential to improve the targeting of the portal vein during TIPS placement. Misregistration of the 3D model and fluoroscopic overlay is one of the main shortcomings of this technique. It can be caused by respiratory and organ motion, inferior displacement, and rotation of the liver w" @default.
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• W4367011193 title "Three-dimensional C-arm Cone-beam CT: Applications in the Interventional Suite" @default.
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