The Gateway to Innovative Clinical Pathways
Andrea Lutz | 20-12-2017
The Angio-CT enables efficient workflows in interventional therapy.
Nuremberg’s 310Klinik has installed Germany’s first Angio-CT dual-room solution, making space for good ideas. Fabian Hubacek, CEO of the 310Klinik and Clinical Director Michael Moche, MD, PhD present the advantages of the technology and how this can lead to new clinical pathways.
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Photos: Steffen Kirschner
A few hundred meters before you reach the entrance to the 310Klinik in Nuremberg’s Nordostpark, you will pass a sign for HighTech Center Nürnberg. Established here in 2002, the 310Klinik exists in the company of innovation-hungry technical service providers, software developers, and materials researchers who have devoted themselves to tackling the big issues of the future. For some time now, the hospital’s reputation has extended far beyond the boundaries of the Nuremberg Metropolitan Region. The people behind 310Klinik consistently focus on high-tech medicine, but they also chose the hospital’s name to reflect the fact that patient well-being is their top priority: 310 Kelvin corresponds to approximately 37 degrees Celsius, the figure associated with a healthy body temperature.
From the outset, interventional radiologist Michael Moche, MD, was impressed by the unique combination of patient proximity and advanced technology. He therefore left the structures of a renowned university hospital and accepted a position at 310Klinik in Nuremberg. Today, Moche is in charge of the hospital’s interventional radiology department. “I like dealing with sophisticated technology,” he says. Accordingly, he is working side by side with engineers in the context of several EU-funded projects to develop solutions for interventional procedures. However, he also stresses that “we mustn’t be tempted to focus only on images – we must always treat the patient as a whole.”
From a bare industrial building to a hybrid interventional room in record time
CEO Fabian Hubacek is convinced that image-guided interventions are a crucial part in the spectrum of minimally invasive treatments and therapy: “We are sure that many open surgical procedures will be replaced by this technology”. But there are not yet many hospitals in Germany with a dedicated ward staffed by interventional radiologists. Patients treated using interventional techniques are often accommodated on the surgical ward – a perceptual problem that Moche hopes to overcome using his hospital as a model: “Interventional radiology must become a clinical partner for colleagues from other disciplines. In order to do so, we need to specialize even further. We need even more new, committed recruits. Above all, however, we need the opportunity to operate interventional radiology wards and to be integrated into patient preparation and aftercare.” In Nuremberg, Moche can put his ideas about interventional radiology into practice in a dedicated ward that he designed and gave shape according to his wishes.
Moche set up the new department in record time: It took him three months of planning plus three months of construction to go from a bare industrial building to the first intervention in an IR environment whose indoor air classification even permits open surgery and where he was able to realize his vision for a dual-room solution. Hubacek: “The efficiency of the collaboration with Siemens Healthineers was impressive. Short communication paths, maximum technical support, and ongoing consultancy are the keys to success. This allowed the project to be implemented in a short time, whereas it usually takes much longer to complete.” Today, with the exception of neuroradiology, the 310Klinik can cover the entire spectrum of interventional radiology – from acute care to interventional oncology and from peripheral revascularization to embolization for benign diseases in every organ of the body. However, Moche is especially proud of an organizational aspect: “We are an interventional radiology department with its own beds – an independent clinical location that can count on 310Klinik’s entire infrastructure covering surgery, internal medicine, orthopedics, intensive care, and intermediate care.”
Two rooms for greater efficiency and safety
Angiography and computed tomography (CT) are the workhorses of interventional radiology. “We have an especially innovative system with our Angio-CT suite which leverages the strengths of both,” says Moche. He is evidently proud that this is the first system in Germany to be set up as a dual-room solution. Moche believes that dual-room solutions provide key advantages: “Even in procedures where both systems are needed, CT is only applied for a relatively short time during the procedure in many cases. In such cases, CT can be used separately in the second room, e.g., for regular diagnostic scans.” Accordingly, it quickly became clear that the dualroom option would be the solution of choice for 310Klinik. Hubacek justifies the decision: “In 70 percent of cases, this system will be used independently so the two-room solution can help to increase the utilization rate and enhance return on investment.”
Moche describes the clear advantage for his workflow: “Although we use the CT scanner for emergencies or to perform complex interventions in combination from the outset, we can slide it into the adjoining room on rails when it’s not in use. This gives us more room to move and allows us to work more efficiently, because the CT is then meanwhile available for diagnostics or smaller interventions in the other room.” By means of this flexibility, Moche plans to perform regular diagnostics or shorter minimally invasive procedures, for example biopsies, on about eight to ten patients per day in the CT room. On average, these will be joined by five to eight regular angio or two complex interventions with combined percutaneous and endovascular access – for instance, treating an endoleak – where both modalities are needed.
Treating endoleaks more safely
Endoleak is the most common complication after endovascular stent graft repair of aortic aneurysms (EVAR). “Safe and efficient treatment of type II endoleaks will play a major role in the future,” says Moche. Even today, endoleaks are predominantly treated using interventional techniques. Typically, a type II endoleak is punctured using CT guidance, followed by the introduction of a guidewire, and then the patient is moved from the CT unit to the angio suite, which is time-consuming. Moche wants to eliminate the risks known to be associated with this: “When the patient is moved, there is always a risk of dislocating the guidewire. With our new Angio-CT system, we can perform the complete workflow very safely without transferring the patient from CT to the angio suite.”
Maintaining a high quality of life for pancreatic cancer patients
In addition, Moche believes that a new interventional procedure could also benefit from the combined dual-room solution: “Patients with pancreatic cancer often have a poor prognosis – the tumor is rarely resectable and systemic chemotherapy is often ineffective. For these patients, interventional therapies will play an increasingly important role.” One increasingly common procedure is known as Irreversible Electroporation (IRE). It uses ultrashort pulses of high-voltage current to damage tumor cells in a relatively selective manner. “Because no heat is generated in the process, vascular structures are preserved – so the procedure is well suited to treat this aggressive cancer, which is often richly surrounded by vital vessels.” Until now, treatment was often performed via open surgery using sonographic guidance. Moche wants to make the procedure minimally invasive, safer, and more efficient for the clinician to plan. He therefore favors combined treatment, in which he uses fluoroscopy for angiographic visualization of vessels and CT guidance to precisely navigate the probes around the tumor without injuring the vessels: “Intra-arterial injections leverage the strength of both modalities. The superior soft tissue resolution and the better 3D capability are clear advantages over the treatment planning and image guidance under ultrasound.”
Training will change dramatically
Moche is aware that technical progress has revolutionized his discipline in particular over the last few years: “Imaging has made incredible leaps forward. Today, we work with multimodal image guidance, and use PET and CT in combination to visualize functional changes in tumors. In addition, we can merge image data and provide the clinician with additional image information via augmented reality. In the near future, we will further increase the integration of robotic systems, delivering even greater precision and more radiation protection for clinicians.” However, to be able to optimally use all of these capabilities, changes will be needed to train radiologists. “I’m convinced that we’ll need to carry out even more training on simulators in the future in order to make the learning curve steeper. We’ll also need to use simulation software to validate our methods and to plan interventions even more effectively.”
Moche is in no doubt that “anyone who aims at exploring new clinical pathways in interventional radiology may consider combined CT and angiography.” However, he adds that those who want to benefit from a system like the Angio-CT suite must also be prepared to explore the capabilities of such a system, and to make consistent use of its advantages. In his opinion, these advantages by no means only apply to complex interventions: “With Angio-CT, we are improving safety in many cases with additional image information, by optimizing the workflow, reducing the time of the intervention, and by completely eliminating the potential risks involved in transferring the patient between the modalities.”
The new nexaris Angio-CT1
- The common coordinate system unifies CT and angiography. With Instant Fusion1, CT volumes – with intra-arterial injection – are instantly overlaid on live fluoro images, allowing fast and easy access to the relevant visuals.
- Quick Switching2 with smart collision protection:
- By simply sliding the table between the two modalities, it will be easier than ever to perform CT-guided ablation and angio-guided embolization in one session and on one table.
- Fully connected, the interventionalists will be able to access angiography, CT and ultrasound sources side-by-side on a single, large display in the exam room and via a single Cockpit2 in the control room. Common Patient Registration1 allows automated patient data transfer with only one registration at the start.
- The unique 2-room design of the nexaris Angio-CT allows independent usage of each modality:
- Different disciplines can work in parallel and potentially raise the utilization rate and return of investment.
- Mounted on rails up to 12 meters in length, the CT gantry slides easily into a dedicated ‘garage’, while the C-arm swings into the foot-side park position3, making space for key personnel by moving the major components out of the way.
- With instant access to optimal imaging technology on one table, a broad range of clinical pathways can be re-shaped, such as bone metastasis, blunt poly trauma, and acute stroke. Advanced functional imaging may make intraprocedural endpoint-determination more precise.
About the Author
Andrea Lutz is a journalist and business trainer specialized on medical topics, technology or healthcare IT. She lives in Nuremberg, Germany.
1The product/feature is pending 510(k) clearance, and is not yet commercially available in the U.S.
2The product/feature is still under development and not commercially available yet. Its future availability cannot be guaranteed.
3The product/feature is not commercially available in all countries. Its future availability cannot be guaranteed.
The statements by Siemens’ 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.