Cutting-Edge Technology

Improved Imaging and Radiation Reduction With the ARTIS icono System at North Shore University Hospital

Rajiv Jauhar, MD, FACC, FSCAI

Chief of Cardiology, Northwell Health, Manhasset, New York

Rajiv Jauhar, MD, FACC, FSCAI

Chief of Cardiology, Northwell Health, Manhasset, New York

Can you tell us about your cath lab and facility?

North Shore University Hospital is part of Northwell Health, a 24-hospital health system. We are the quaternary hospital for our health system, which means we do transplants, utilize ventricular assist devices and extracorporeal membrane oxygenation (ECMO), treat cardiogenic shock, and perform structural heart disease treatment and complex angioplasties. We do about 2,700 angioplasties annually and about 12,000 diagnostic catheterizations. North Shore University Hospital has five labs.

What factors did you consider when you purchased your latest angiography system?

When we started looking for a new system, we considered all the major imaging corporations. We did our due diligence, flying to different cities (pre-COVID, obviously), and brought a team including all types of interventional cardiologists: a peripheral operator, a complex chronic total occlusion (CTO) operator, our structural/transcatheter aortic valve replacement (TAVR) operator, and I also joined the team. The lab is used for several different types of procedures and we wanted feedback from the full spectrum of end users. Everyone has different needs. Peripheral has different needs in terms of digital subtraction angiography and CO2 imaging. Structural has different needs in terms of spin and other things. I wanted to make sure we looked at every option from every angle.

When we saw the Siemens ARTIS icono angiography system, we were impressed with the quality of the imaging based on the radiation dosage. It is amazing to consider our older, previous system from a different company and what we see now with our new Siemens lab. Can you imagine what the reduction in radiation amounts to over 12,000 cases? Also impressive was the control I had at tableside. Instead of asking someone to help me, I can do everything I want for the procedure tableside and it is very easy. A system may have 47 different ways to do things, but if I can’t understand how to get to the 47th way, then it has no value for me. I need an easy way to navigate between different options. The ARTIS icono angiography system is very user friendly. I can basically do everything on the system tableside, including something as trite as turning lights on and off, to affecting dosages and manipulating the screen to see what I want. I should note that I have no affiliation with Siemens or any other company. Our team felt that Siemens was the most innovative in their latest technologies. We wanted the latest and the greatest, and saw better growth opportunity and adaptability for the future with the Siemens technology.

Is the ARTIS icono angiography system in all five of the North Shore University Hospital labs?

It will be in four of our five labs (one lab has another system that is only a few years old). We are installing one at a time, so we don’t have to shut down the whole department. One system has now been installed, the next one will start imminently, and we are hoping over the next two years to finish installation in the remaining labs.

What workflow or procedural flow changes have you experienced with the ARTIS icono angiography system?

The integration into the system is seamless, so we are doing significantly more intravascular ultrasound (IVUS) and optical coherence tomography (OCT) in our cath labs. These systems are now available by the tableside instead of having to bring in machines, set them up, and turn them on, which was always cumbersome. The IVUS and OCT imaging is fully integrated into our screen, making life much easier. Another tableside option, which is really cool, is the ACUSON Freestyle Series. It is a wireless ultrasound that is right there on the tableside for access, which makes using ultrasound much easier. We have now been using the new lab for a little over two months. I think that people are happier, because anecdotally people are already seeing radiation doses are about 7 times lower.* One thing we have changed is that the more complex procedures that we assume will take more time are now done with the ARTIS icono angiography system, because it means less radiation. Our chronic total occlusions, complex peripheral interventions, and complex structural cases such as atrial septal defect closures that we would normally put anywhere, are now placed in that room. It is a smaller detector, so it is not the classic, large detector that we have for vascular peripheral cases, but the larger detector is planned for our next Siemens room, where we will be doing all our peripherals.

Have you documented the radiation reduction you are experiencing?

We are currently working with Siemens on a radiation reduction study to show the dramatic reduction in radiation dosages across different types of procedures, looking at our historical dosages versus dosages with the ARTIS icono angiography system. We are already seeing anecdotally that the reduction is about 7 times lower.* This is important because there is an increased incidence of cancer, left-sided brain tumors, in interventional cardiologists, as well as increased cataracts. Other companies also have lower dosages, no question, but my impression is that the Siemens has the lowest.

Which Siemens service and support capabilities do you find most valuable?

Whenever you get new technology, you have to tweak it to your liking, and Siemens has been very good in working with us. It’s like when you buy a TV and bring it home: someone likes more contrast, someone likes more color, someone likes more brightness. The one thing that I told Siemens up-front was that I needed access and I needed support. I can say that they have been very liberal with their support, which has been great. I’ve had the senior leadership call me to make sure everything was okay. The fact that they reached out to me was very encouraging.

Can you share an example of North Shore’s commitment to staying on the forefront of cutting-edge technology?

Northwell Health is a 24-hospital health system, and we have one quaternary hospital, four tertiary hospitals, and several community hospitals. We have several hospitals with cath labs and peripheral labs. The ability to view imaging at different sites is very important. I want to be able to view the imaging at Peconic, Plainview, and Lenox Hill on my workstation. Siemens is working with us on a cloud-based approach. Once we get all the labs set up, we will be able to view all the imaging from all the different sites in a seamless fashion. It is very exciting.

Any final thoughts?

I have no affiliation with any company. I don’t make any money off any company. I am truly agnostic. In looking at the different products, I considered the level of technology, service, adaptability, and future products. I thought that in those four arenas, Siemens’ ARTIS icono angiography system was the best option. The other thing I want to add is that people who have seen the lab are now ordering it for our other sister hospitals. That speaks volumes. 

This article is sponsored by Siemens Healthineers.

*The statements by Siemens Healthineers’ customers described herein are based on results that were achieved in the customer’s unique setting. Since there is no “typical” hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption), there can be no guarantee that other customers will achieve the same results.

The opinions expressed in this article are solely those of the featured physicians and may not reflect the views of Siemens Healthineers.

 

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CASE REPORT

Loukas S. Boutis, MD, and Rajiv Jauhar, MD, FACC, FSCAI, Chief of Cardiology, Northwell Health, Manhasset, New York

A 69-year-old obese female with history of transient ischemia attack, hyperlipidemia, hypertension, and diabetes mellitus type 2 presented with worsening anginal symptoms and dyspnea on exertion while on appropiate antianginal therapy and medical therapy, with a subsequent abnormal stress test. Her labs and echocardiogram were clinically unremarkable.

She was taken to the cardiac catheterization laboratory. Due to the small size of the patient’s radial arteries, 4 French (Fr) groin access was obtained via ultrasound with 4 Fr diagnostic catheters (Judkins Left [JL] 4, Judkins Right [R] 4) utilized to perform the diagnostic procedure (Figure 1, Video 1).
 

 

 

The JR4 was used to get left ventricular end diastolic pressure. The sheath was upsized to a 6 Fr size for the intervention and after giving heparin and 500 mcg nicardipine, a JL4 guide and Sion blue wire (Asahi Intecc) were used to cross the lesion. A 2.0 x 20 mm Apex balloon (Boston Scientific) was used to predilate the proximal to mid left anterior descending (LAD) coronary artery (up to 14-18 atmospheres [atm] for 7 seconds x3). 2.50 x 38 mm Synergy XD and 3.00 x 20 mm Synergy XD stents were placed (14 atm x1 and 14 atm x1), respectively in the mid and proximal vessel, followed by 2.50 x 20 mm (20 atm for 5 seconds x3) and 3.50 x 20 mm NC Apex (16 atm for 9 seconds x1) balloons. This was followed by an intravascular ultrasound (IVUS) run (Figures 2-3), resulting in further balloon dilatation with 2.75 x 15 mm (up to 16-25 atm for 7-11 seconds x4) and 3.75 x 15 mm Euphora NC (up to 18-25 atm for 7-8 seconds) (Medtronic) balloons in order to further dilate the under-expanded sections. We used CLEARstent Live (Siemens Healthineers) to help position the NC balloons. Final angiography showed a good result (Figure 4). The patient underwent closure with an Angio-Seal (Terumo) and she was placed on aspirin and ticagrelor, given the extent of stenting.

Dose area product (DAP) used in the new lab (Siemens ARTIS icono System) was 7454.21 cGycm2 versus 11740.30 cGycm2, or about 37% less compared to an older lab from a different company for a similar-sized patient and a similar intervention.*

 

 

Dr. Jauhar can be contacted at rjauhar@northwell.edu