CREATION OF AN OPTIMAL ANGIO SUITE

1. CREATION OF AN OPTIMAL ANGIO SUITE A. CHATZIOANNOU

2. DEPARTMENT LAYOUT • Total 65 m2 not including the X ray control • Large lead lined doors to allow admission of bed with ancillary equipment • Ceiling 3,5 -4 m with additional space above to allow mechanical access

3. Fluoroscopy unit MAIN FEATURES Dirty utility space adjoining the examination space Scrub sink with hot and cold water Surveillance X ray control (10 m2) Storage space, apron rack and shelves for all equipment Surgical ceiling mounted lights Patient preparation space/room

4. Fluoroscopy history Popular Science: July 1939

5. Fluoroscopy unitMotion features • C or U arm which can rotate in axial and sagittal planes • Angles of rotation must be displayed on the monitor • Ability to vary source detector distance • Combination of fluoroscopy arm and table movement should make imaging of the whole body possible • Manual override and locking should be possible

6. Fluoroscopy unitTable features • Support at least 140 kg of weight • Tilting capability both in craniocaudal and lateral direction • Ability to move away from C-arm in case of emergency • Additional ( foot and hand) controls to use by the radiographer

7. Fluoroscopy unitImaging features • Image intensifier with large field of view (FOV) • Digital subtraction and acquisition (DSA) • Pulsed fluoroscopy for dose reduction • Variety of frame rates • Various collimators • Filters to reduce skin dose • Road mapping and land marking • Last image hold and frame grab

8. Fluoroscopy unitImage quality • The image quality mainly depends on the flat panel(image intensifier) and the processing system • Image quality of fixed systems >> quality of mobile systems (difference in focal spot and tissue penetration)

9. Fluoroscopy unitImage quality – Image Intensifier The image intensifier determines the Field of View (FOV). FOV is of great importance especially in aortic interventions. It depends on the size of the image intensifier. The image intensifier should have: - large FOV (36 -41 cm) - three modes of magnification -spatial resolution at least 2.5 line pairs/mm in the 36-cm FOV, 3.3 line pairs/mm in the 23- cm FOV, and 4.6 line pairs/mm in the 15-cm FOV - contrast ratio at least 20:1 - automatic brightness control

10. Fluoroscopy unitImage quality – Processing system Digital Subtraction and Acquisition • 1024x1024 image matrix (ability to display compressed images • on a 512x512 matrix) • Display at least five frames per second in the 1024x1024 • mode. • Road-mapping (helpful during percutaneous transluminalangioplasty, with or without stent placement,and during passage of guidewires through tortuous vessels) • Measurement of vessel diameter

11. Fluoroscopy unitHeat capacity • Overheating is rare in modern equipment due to the presence of excellent cooling systems (oil and water based)

12. Fluoroscopy unitRadiation exposure • It varies greatly between different procedures • It is dependent on multiple factors. Onefactor is the fluoroscopy unit itself. • Radiation exposure is higher using portable C-arms than fixed systems

13. Don’t forget

14. Important issues of a modern angiosuite • Sterility issues • Ability to convert • Anaesthesia • Ergonomics • Personnel

15. Important issues in a modern angiosuiteSterility issues • Angiographic and interventional procedures should be performed in strictly aseptic conditions • Primary and secondary operators should wear sterile gowns and gloves as well as surgical caps and masks. • Sterile, impervious barriers should be available to cover any part of the equipment that may contaminate the field • Appropriate receptacles for contaminated items should be readily available • OR sterility > Angiosuite sterility

16. Important issues in a modern angiosuiteAbility to convert • Majority of endovascular procedureswithout major intra-operative complications • In case of conversion to open surgery, the lack of adequate lightning, suction, surgicaland anaesthetic equipment and room for surgicalinstruments, and the extra personnel can make evensmall procedures challenging

17. Important issues in a modern angiosuiteAnesthesia • Although endovascular procedures are minimally invasive,adequate monitoring of the cardiopulmonarysystem is essential in certain procedures (eg carotid stenting) • The presence of an anesthesiologist,a specialized nurse and all anesthetic equipment seemto be of major importance

18. Important issues in a modern angiosuiteErgonomics • Poor ergonomics is one of the major drawbacksof mobile systems • Ideally, a monitorshould be placed just below eye level (10-15 degrees angle) • Monitors on bothsides of the table • Ceiling-fixed monitors perform a great range of positions,without claiming space on the floor. Adjustment of the position of thesemonitors is easier

19. Important issues in a modern angiosuitePersonnel • Specially trained personnel • Physicians should spend enough time doing procedures to fulfill the obligations of the angio suite and should perform a sufficient number of procedures to maintain proficiency and competence. • All personnel should have knowledge aboutcatheter techniques and the variousmaterials thatare used such as sheaths, guide wires, catheters andstent-grafts • All personnel should have knowledge aboutradiation safety measures