Currently, interventional and surgical disciplines are facing an obvious paradox. Despite the excellent diagnostic imaging capabilities of MRI, which does not expose patients and physicians to ionizing radiation it is not widely used. Ultrasound and the emerging field of Biophotonic imaging are usually not MRI compatible and not designed to be used in conjunction with MRI. As a consequence, surgeons continue to use traditional operating techniques, which are based on visual inspection of the pathological anatomy structure either by traditional open or endoscopic surgery. Radiologists still have to expose themselves and their patients to long fluoroscopy times to perform complex cardiac or even paediatric interventional procedures. In fact, the frequent inadequacy of fluoroscopy as a navigation guide and to visualize the pathological target results in long procedure times, the use of nephrotoxic and allergenic iodine contrast agents and an unacceptable x-ray exposure. In Germany 1.5% of the cumulative risk of cancer has been attributed to diagnostic X-ray (Lancet 2004; 363:345-351).

The IIIOS project will provide technology and training for the integration of ultrasound and biophotonics based imaging with magnetic resonance imaging (MRI), Computed Tomography (CT) and Positron Emission Tomography (PET) to define the specs of an Integrated Interventional Imaging Operating System (III OS) aimed at minimal invasive treatment of common life-threatening disorders, e.g., cancer, cardiovascular disease and structural heart defects. Effective therapy of these conditions will require a range of safe surgical and interventional devices used with the necessary visualization and tracking under real-time image guidance.

IIIOS will provide a group of researchers with internationally leading technical training facilities which cannot usually be provided to doctoral students, and, specific new technology study courses available to both medical and technology based researchers. The Network will foster cross interdisciplinary research and training between the clinical disciplines (Interventional Radiology/Cardiology, Cardiovascular Surgery, Anesthesia) on the one hand, and instrument design, safety and R&D with academic scientists and industry on the other. The research program of this Initial Training Network will provide a stimulating training environment for all participating early stage researchers and experienced researchers by utilizing unique imaging environments across Europe.

 

Research Projects

Over four years of the project the IIIOS network will train 13 early stage researchers and 6 experienced researchers. Details of the research projects at each partner site can be found below:

 

• University of Dundee

• University of St. Andrews
• Oslo University Hospital
• Norwegian University of Science and Technology
• University of Homburg SAAR
• Delft University of Technology
• MR Comp GmbH
• University of Luebeck
• Fakultini Nemocnice u sv. Anny v Brne

 

University of Dundee

Development of workflows for minimally invasive vascular radiology interventions in a multimodality image-guided environment - Fabiola Fernandez Gutierrez (ESR1)

Image guidance is becoming a key concept in minimally invasive surgery. The combination of different imaging techniques such as Magnetic Resonance Imaging (MRI), computed tomography (CT) and positron emission tomography (PET) with biophotonics, ultrasound or optical coherence tomography (OCT), could improve patients diagnosis and treatments. Integration in a unique Imaging Operating Room (IOR) presents a multitude of new challenges: safety, economics aspects, layout design, ergonomics workflow, etc.

Computer simulation has been broadly used in industry for workflow and ergonomics design. During the last decade, it has been shown as a successful method to optimize efficiency in hospitals, emergency departments and surgical environments. 

Fabiola is currently working on the development of workflows for minimally invasive vascular radiology interventions in a multimodality image-guided environment. Her work includes the improvement of current procedures as well as the design of new ones.

To approach her objectives, Fabiola will be analysing data from real radiology interventional suites associated with the IIIOS Project Network. This data will be used to build realistic models of the different operating rooms that will help to detect bottlenecks during the interventions.

For testing the development of new procedures under image-guidance, Fabiola is using the facilities at the Institute for Medical Science and Technology (IMSaT) in Dundee (Scotland, UK). IMSaT has a 2-room integrated MR/Interventional suite which is designed to allow easy transport between the operating room and the 1.5T MR scanner.

In addition, Fabiola is working on improving the ergonomics of real environments for endovascular procedures, as well as setting the basis for the design and layout of an Imaging Operating Room with the aim of the integration of different imaging techniques.

 

Marker and Tracking Development for Cardiovascular Interventions under Real-Time MR Image Guidance – Martin Rube (ESR2)

Image-guided cardiovascular interventions are currently mostly performed using X-Ray fluoroscopy. It is a well established imaging modality for relatively safe and successful procedures. However X-Ray exposes the patient and the staff to ionising radiation. Another major shortcoming is the poor contrast of soft tissue such as the heart and vessels. MRI could provide additional valuable capabilities and does not expose the patient or physician to any ionising radiation. Due to superb soft tissue contrast, multiple contrast mechanisms, imaging techniques with arbitrary plane orientation in near real-time, MRI could provide the physician with valuable information throughout the whole procedure.

Reliable device tracking and visualisation is a key element for interventions and localisation is one of the fundamental problems in catheter driven interventions under MR guidance. It is essential to monitor the inserted devices accurately and critical to visualize the device and its surrounding anatomy in detail.

Martin is currently working on methods for passive and semi-active device tracking for vascular devices such as guidewires, catheters and cannulae. He is designing resonant circuits and exploring the potential for nanoparticles to be incorporated into device material as passive markers.

The tasks of the research work include the following:

• Review and analysis of MRI tracking and navigation methods
• Investigating the interventional workflow and the potential interventional magnetic resonance imaging techniques
• Conducting experiments at the MR facilities at the Institute for Medical Science and Technology (IMSaT) in Dundee (Scotland, UK)
• Investigating the incorporation of markers into medical devices as guidewires, catheters and cannulae
• Studying the control and programming of MR Scanners
• Establishing a real time scanner interface at the Institute for Medical Science and Technology (IMSaT) in Dundee (Scotland, UK)

 

Development of a pre-clinical model for testing of devices and mentoring of IIIOS ESRs - Rachel Toomey (ER1)

In her post as an experienced researcher, Rachel is assisting in the co-ordination of the IIIOS network in addition to her research.  She has been involved in liaising between the Early Stage Researchers, in event planning and in dissemination of project materials.  Rachel’s primary research work is in preparing a model for preclinical tests.

The IIIOS project will involve the development of new techniques, devices and workflows.  All of these will require thorough testing before they may be applied in the clinical setting.  Human cadavers provide realistic human anatomy, an advantage over phantom or animal models.  However, fresh and frozen cadavers suffer from short useful periods and may create infection risks for experimentalists, while cadavers embalmed with conventional formalin-based methods are inflexible and lose their lifelike colouring.  The Thiel embalming method, although it has been in existence for decades, is relatively little-known.  In contrast to conventional formalin embalming, it preserves lifelike colour and flexibility and uses a much smaller amount of carcinogenic agents.  It also carries little or no infection risk to the experimentalist as the embalming agents contain biocidal agents, and allows bodies to be preserved for at least three years.  These features combine to make Thiel-embalmed cadavers a promising model for testing new devices and procedures.

However, despite their advantage, Thiel-embalmed cadavers do not exhibit the physiological /functional characteristics for living patients.  For example, they do not exhibit any blood flow, nor do they demonstrate any respiratory motion.  Rachel is working, in conjunction with other researchers at the University of Dundee and the Dundee Pulsatile Flow System project, to simulate these functions in cadavers.  The work also involves assessing the vascular systems of the cadavers using techniques such as digital subtraction angiography.

 

University of St. Andrews

Development of bio-photonic tools for Raman spectroscopy combined with optical coherence tomography (OCT) for potential integration with other modalities of assistance in MR interventional operating systems - Rajesh Kumar (ESR3)

The project at USTAN involves the development of a free space optics based Raman spectroscopy experimental setup and fabrication of a MRI compatible fiber optic Raman probe. Work on the development of Raman probe will involve a preliminary study on the output behaviour of optical fibre in presence of external high magnetic field.. To find out detection capability of the probe, some preliminary data will be gathered using sample compounds. A further focus will be on enhancement of the characteristics of the probe including the signal to noise ratio.. Through collaborations with IIIOS partners USTAN will also explore further applications for the Raman probe

Oslo University Hospital

Investigation and evaluation of the catheter tracking approaches in magnetic resonance images during interventions - Abubakr Eldirdiri (ESR4)

Magnetic resonance imaging (MRI) has become a very attractive imaging modality in interventional procedures especially for the guidance of catheter-based interventions. This is due to several attributes that distinguish MRI from other modalities including; the rich soft tissue contrast, the absence of the ionizing radiations, and the capability of MRI to provide anatomical and functional information. In addition, due to the advancements in MRI scanners and imaging techniques it is now possible to obtain MR Images in real time with satisfactory spatial resolution.

This project is concerned with the investigation and evaluation of the catheter tracking approaches in magnetic resonance images during interventions. An additional task is to develop a scheme in which the output of the catheter tracking process is used to control the scanner to guide the image acquisition during the intervention and develop an effective user interface for the interventionist to facilitate the navigation of the catheter. Moreover, the constantly evolving magnetic resonance imaging techniques will be investigated to ensure the acquisition and delivery of images in real time during the interventional procedures.

The tasks of the research work include the following:

• Review of catheter tracking methods
• Conducting experiments at the MR facilities at Intervention Centre on detection and visualization of catheters  (publication).
• Investigating the incorporation of image processing to assist the catheter detection and visualization (publication).
• Investigating the magnetic resonance imaging techniques that can be used intra-operatively during interventions
• Studying the Control and programming of MR Scanners
• Investigating the Implementation of catheter tracking on series of MR images and the use of processing to enhance the tracking and path recognition (publication)
• Development of interface that incorporate the tracking algorithm to guide the image acquisition intra-operatively  (publication)

 

Delivery of better navigation systems for Image Guided Cardiovascular and  Laparoscopic Procedures using preoperative MRI and Intra-operative MRI and Ultrasound - Rahul P Kumar (ESR5)

The human body contains various types of curvilinear structures – blood vessels, bronchial trees, bile ducts, etc. – whose visualization is crucial for the planning of and navigation during interventional therapy and biopsy, as well as for diagnostic purpose. Segmentation of the vascular tree will facilitate volumetric display and will enable quantitative measurements of vascular morphology. The blood vessel visualization is mainly helpful in liver surgeries and cardiac catheterizations. While a liver tumour surgery, it must be ensured that the major arteries or veins in the liver are not cut or damaged to sustain their vital functions. Knowledge of anatomical variations in the vascular system and good navigation to operate the region of interest is of great importance in this context. Cardiac catheterization is a medical procedure used to diagnose and treat certain heart conditions. This procedure allows the doctor to treat heart valve diseases and weakened arteries by placing artificial valves and stents. For this purpose, live visualization and navigation through the blood vessels, such as aorta, will significantly help the doctors.

This project aims to find better methods of computation and  visualization of 3D anatomy blood vessels structures in the liver and the aortic section. The research will also investigate and deliver better navigation systems for Image Guided Cardiovascular and  Laparoscopic Procedures using preoperative MRI and Intra-operative MRI and Ultrasound.

 

Norwegian University of Science and Technology

Integrated navigated laparoscopic ultrasound for intraoperative guidance of laparoscopic liver surgeries - Sinara Vijayan (ESR6)

Minimally invasive therapy requires technology that ensures safe and accurate guidance of the procedures. By using images and navigation technology, it is possible to perform minimally invasive procedures with improved overview and patient outcomes in various clinical disciplines and applications.

In laparoscopy, endoscopes have been used for guidance during surgery. Using the endoscope, however, only provides a surface view of the organs. Laparoscopic ultrasound is a good alternative to use for real time surgical guidance as this not only gives a clear indication of where a tumor is located but also helps to detect blood vessels important for avoiding bleeding and also small tumors which may not have been detected during preoperative imaging. The problem with laparoscopic ultrasound is orientation and signal to noise ratio, which makes the interpretation and understanding of the ultrasound images quite difficult. Navigated laparoscopy is a solution to this problem, making a connection between images and tracked instruments. There are no commercial products that aid navigated laparoscopy, as it is quiet a complex problem requiring further research. In addition to this, the major challenge to achieve satisfying image guided surgery is to accurately register preoperative images to the patient and update images due to the changes during surgery.

The idea of this research project is to integrate navigated laparoscopic ultrasound for intraoperative guidance of laparoscopic liver surgeries. This will be accomplished by improving visualizations of the liver intraoperatively and solving the orientation problem by using navigation technology to display the ultrasound in combination with preoperative images. The specific research problems to be addressed in the project are the deformations and shifts that occur as a result of the surgery and pneumoperitoneum, calibration issues with electromagnetic tracking of flexible laparoscopic ultrasound probes, and multimodal visualizations optimized for intraoperative planning and guidance.

 

University of Homburg SAAR

Passive and active visualization of endovascular instruments in the MRI environment and optimization of MR sequences for better depiction of interventional instruments and materials on MR images - Malgorzata Wolska-Krawczyk (ESR 7)

Clinic of Diagnostic and Interventional Radiology in Homburg (Germany) is part of the medical faculty at University Clinic Homburg, Saarland. The clinic offers all diagnostic imaging modalities including computed tomography, magnetic resonance imaging, mammography and ultrasound. One clinical and research focus encompassed minimally invasive procedures such as vascular interventions, drainages or tumor therapies. Within the IIIOS research project we aim at a possible reduction of radiation exposure, which can be relatively high in case of X-ray guided procedures. Consequently, we try to establish MR guided interventions, which are still evaluated in clinical studies all over the world. The complexity of the interventions, the necessary instruments and the demands of the MR environment require the development of new medical innovations. Our aim is to introduce those new techniques into the clinical scenario and thereby make modern technology available for patients as soon as possible.

Since February 2010 Malgorzata accomplished a clinical training in Computed Tomography and in addition began gaining physical background concerning Magnetic Resonance Imaging. During this time she hosted several ESRs at the University Clinic in Homburg showing the current concepts of X-ray guided interventional radiology procedures. The great hindrance in performing MR guided interventions is the lack of appropriate devices. Therefore, she focuses currently on passive and active visualization of endovascular instruments in the MRI environment and on optimization of MR sequences for better depiction of the interventional instruments and materials on MR images. In the following months she plans to cooperate and exchange experiences with Dundee and Oslo University in respect of instrument tracking under real time MR guidance. The final goal is to perform MR guided intervention first in vitro and eventually in vivo.

 

Delft University of Technology

Investigation and development of an interfacing and control method for multi-segment steering in minimally invasive surgery - Chunman Fan (ESR8)

The ideal steerable medical device should have full maneuverability to approach a target during surgery. However current steerable hand-held MIS devices still have limitations in the Degree of Freedom(DoFs) and man-machine interfacing. For instance, it is difficult to reach an obstructed target effectively with a single-segment steerable device in clinical practice. 

A pioneer multi-segment steerable prototype has been developed, with the “cable-ring” mechanism, it has five steerable segments and offers 20 DoFs. However, to our knowledge,  an effective man-machine interface for multi-segment medical steering device is still unknown. The aim of this project is to investigate and develop an interfacing and control method for multi-segment steering in minimally invasive surgery.

The outcome of this project will contribute to the development of flexible steering medical instruments, e.g. catheters and guide-wires.

 

Development of MRI compatible and steerable instruments for minimally invasive intervention - Helene Clogenson (ESR9)

Recently, metallic steerable instruments such as the steerable endoscope, inspired on the anatomy of squid tentacles have been developed at TUDelf. The instrument  consists only of standard parts such as cables, coil springs, rings, and tubes.

Such steerable mechanism are of interest in other fields such as interventional radiology and cardiology. Steerable instruments offer improved manoeuvrability and may thereby reduce operating time and the risk of complications.

The goal of this project is to develop MRI compatible and steerable instrument for minimally invasive intervention.

 

MR Comp GmbH

Development of methods to determine MR safety of implants and instruments - Yacine Noureddine (ESR11)

The project at MR:comp focusses on the development of  a new  method to assess the RF heating of implants in the MR environment and the application of this method to the implants.. The method will be based on both measurement and simulation. The purpose of this method is to get realistic results for SAR and temperature in a simulated human model.  
Measurements of both electrical and magnetic field will also be conducted in a homogeneous phantom with and without implant. Measurements and simulation results will then be compared and to validated the developed model.

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University of Luebeck

Anaesthesiological care in the MR environment - Sebastian Brandt (ESR10)

The importance and frequency of imaging procedures and interventions has increased significantly within the last years. It is also well-known that a number of the patients undergoing these procedures require a form of anaesthesiologic service. This can be provided by general or regional anaesthesia (e. g. for infants, critically ill patients, incompliant patients or if painful procedures are to be performed). However, in other situations it may be adequate to have an anaesthesiological team on stand-by („monitored anaesthesia care“), because the patients haemodynamic or respiratory situation is unstable.

In contrast to the increasing demands for anaesthesiological support it is known, that conditions are more severe if the anaesthesia is performed in these „hostile“ environments outside the traditional operation room (OR). The challenge for the anaesthesiologist in these fields is to cope with lack of access and visibility of the patient, restrictions by radiation or magnetic fields, working far away from possible support from colleagues.

The IIIOS-workgroup at the University of Lubeck tries to address these challenges in order to make anaesthesia-related procedures during imaging and / or interventions safer for both the patient and the staff working in this environment.

Main Projects:

Noise Protection for MRI-procedures

Noise protection for paediatric patients undergoing MR-imaging is currently not clearly regulated. The responsibilities are unclear (radiologists, paediatricians, anaesthetists?) and the protection devices are very often not made for small patients and differ in damping efficacy.

MRI-safe Body Temperature Monitoring.

Maintaining normothermia during general anaesthesia is a matter of course in perioperative medicine. The negative effects of hypothermia e. g. on wound-healing, infections, coagulation etc. are well described in multiple scientific papers. However, during general anaesthesia for MR-imaging, the situation is different. During MRI both hyper- and hypothermia are described. The magnetic field may increase the body temperature of patients during imaging – in contrast we also noticed cases of hypothermia (e. g. in newborns).
Standard MR-safe patient monitors are rarely able to measure core body temperature. However fibre-optic skin-temperature probes and probes for technical applications are available.
We are planning to elucidate the phenomenon of body temperature deviations in different patient populations in a systematic matter. Furthermore we intend to test different probes / monitors to make core-temperature measurements during MR-imaging easily possible.

Remote Care and Control for Anaesthesiological Monitoring for Imaging Procedures.

In contrast to the situation in the OR it is not unlikely that the anaesthetist caring for a patient undergoing imaging or interventional procedures stays outside the suite for safety reasons (e. g. radiation, high magnetic fields etc.). We think that the anaesthesiological equipment (respirators, patient monitors, syringe-pumps) should assure the same high level of safety as in the OR. Until now this is not the case. Together with academic and industrial partners we work constantly to improve the equipment. Challenges for the future are

• Wireless transmission of signals and alarms to remote displays outside the suite (Remote Care)
• Ability to operate all devices from outside (Remote Control)   
• Redundancy in alarm transmission
• Wireless video and communication systems

Artefacts 

Anaesthesiological equipment, medical gases (e. g. oxygen), anaesthestics (e. g. propofol infusion, inhalational anaesthetics) may cause artefacts on MR-imaging. A systematic analysis of these anaesthesia-related artefacts will be a future project of the Lubeck team.

 

Fakultni Nemocnice u sv. Anny v Brne

Novel methods of semi-invasive and non-invasive early diagnosis and treatment of diseases in cardiac arrhythmia - Krzysztof Czechowicz (ESR12)

The scientific objective that ICRC Team is trying to solve is how to overcome the influence of the Magnetohydrodynamics Effect (MHD) on the Electrocardiogram (ECG) measured in the magnetic field. Due to the interaction between the field and blood flow the ECG measurement cannot be used for diagnostics. The ECG signal in the magnetic field consists of information gathered from the heart, a regular ECG, and information about the blood flow in the aortic arch. The goal of ICRC Brno team is to separate that information. This should enable the possibility for early diagnostics of patients. Also the similar problem can occur when trying to measure hearts Electrophysiology. Turbulent blood flow in the heart can generate electric potential that will disrupt the data making interventions on the heart impossible without any signal processing. ESR12's role will be to explore this problem. To deal with these problems ESR12 will generate computer models of the heart and the aortic arch, that will include the interactions with the magnetic field and then develop a method for signal separation.