Five years ago, interventional radiologist Dr. Oren Herman would have sent a patient with peripheral vascular disease to the hospital for an overnight stay to undergo lower extremity angiography.

Today, he and his colleagues at ProHealth Care Associates can complete this and a range of other procedures in his office in one day using a mobile C-arm.

“These procedures are just as safe in the outpatient setting and patient satisfaction is even greater when they don’t have to go to a hospital to be treated,” Herman told HealthCare Business News. “I can only imagine what types of procedures and how many more patients we can help on a daily basis as the image quality and equipment continues to improve.”

At ProHealth, they’re using an OEC Elite CFD from GE Healthcare, the first mobile C-arm with both a 31 centimeter and 21 centimeter CMOS (complementary metal oxide semiconductor) flat-panel detector.

The emergence of advanced dosage options, flat-panel technology, increased fields of view and robotic systems have transformed fixed and mobile C-arm solutions, enabling performance of a number of angiographic procedures that were previously not possible.

From left and right heart catheterizations to radioembolization, the list continues to grow with experts calling it the beginning of an evolution that is set to sweep through operating rooms over the next few years.

Mobile angio units embrace flat panels as fixed units get versatile
Along with GE Healthcare, the global fixed and mobile C-arm market is dominated by companies like Siemens Healthineers, Philips, Hologic, Shimadzu, Canon (Toshiba), Ziehm Imaging and OrthoScan. According to market analysis published last year by Research & Markets, the segment is projected to reach a total value of $2.3 billion by 2025.

Of the over 400 hybrid operating systems that Siemens has installed throughout the U.S., about 280 are robotic systems, which provide enhanced ease in C-arm motion and positioning. According to Sudhir Kulkarni, segment director of hybrid OR at Siemens Healthineers, these benefits have made them the most widely used interventional angiography systems in the operating room nationwide.

“The base of the robot sits in the corner, and the robot arm just moves in and out,” Kulkarni told HCB News. “There’s nothing on the ceiling, so it’s completely free to maintain a sterile airflow and mount the lights and booms. The robot just comes in and out very easily. It leaves all the room that you need for anesthesia, which is a challenge with other systems because the C-arm will come in its way.”

Some OEMs have developed, or are in the process of developing, fixed robotic angiography systems that provide elements of mobile C-arm technology and a variety of other benefits. Gustavo Perez-Fernandez, president of GE Healthcare’s Imaging Guided Solutions, says such capabilities enable greater flexibility and enhanced workflow.

“You provide that kind of freedom to the interventional surgeons, enabling interdisciplinary teams to transform from an operational lab into an operating room seamlessly,” he told HCB News, referencing GE’s IGS 7 platform, which he calls a first-of-its-kind, “semi-fixed system.”

Experts agree that although mobile and fixed angiography solutions are evolving, they each retain unique value propositions.

Although fixed systems began shifting from image intensifiers to flat-panel detectors more than seven years ago, mobile C-arms have only begun making that transition in the last two or three years. With benefits for image resolution and 3-D imaging, flat panels have become part of the majority of mobile C-arm technologies on the market.

“You can be more accurate in positioning any device in the patient’s body because you can look at it three dimensionally,” says Kulkarni. “This means it would result in lower complication rates, better clinical outcomes and reduced length of stay and, therefore, lower costs.”

Unlike fixed systems, which all utilize flat-panel technology, Kulkarni says mobile solutions with image intensifiers are still available to providers that require quality imaging on a constrained budget.

“For the kind of work that mobile C-arms are being used for, image intensifiers were able to do the job reasonably well,” he says. “The images weren’t the crisp and beautiful images that the flat-panel detectors give, but they worked.”

The desire for better images has led to other demands, including 4K resolution and the addition of graphic processing units like those commonly found in cell phones and computer workstations.

In addition to these trends, the emphasis on dose optimization and limiting exposure to patients and providers alike has ushered in new, safer-performing solutions.

The Fluroscan Insight FD mini C-arm, a mobile solution designed by Hologic that can lower dose by up to 50 percent while still maintaining exceptional image quality, is an example of this.

“You want the largest, clearest image possible to ensure an accurate diagnosis at a low dose to ensure patient and user safety,” Mike Toomey, senior director of marketing for Hologic, told HCB News.

Of surgical tables and imaging tables
When it comes to the technology used for imaging patients, the whole is always greater than the sum of the parts, and that includes not only C-arms but tables, too. The predicament of choosing a table involves a series of considerations from the positioning of patients to the type of procedures performed.

“Are they going to need a specific positioning other than, for example, a beach chair or a flower position?” says Kulkarni. “Do they also need to image in those kinds of positions? If they do, they’re better off using a surgical table. Otherwise, just a flat imaging table is good. However, if they plan to utilize the room for both open surgical procedures as well, a surgical table with changeable imaging top is preferred.”

Such considerations can impact not only patient outcomes but the workflow, time and ease experienced by physicians, which play into the successful completion of procedures and can impact the hospital’s bottom line.

Matthew Blaustein, president of Bluestone Diagnostics, a company that specializes in the rental and sale of refurbished C-arm equipment, says that choosing the right table depends largely on the kind of procedures the system will be used for. “Most pain management doctors require a table with a minimum amount of functionality, whereas a customer seeking vascular functionality might desire a more complex table,” he says.

When ProHealth Care Associates replaced its fixed table system with one that was movable, Herman and his colleagues discovered firsthand how that functionality could improve their work.

“Before we could only move the C-arm, which put a big strain on the operator’s back and shoulder,” says Herman. “Now, the table moves with ease, putting much less stress on physicians and making the procedure itself quicker and smoother.

Solutions to mitigate downtime
Like any capital equipment in the hospital, service maintenance is a crucial element of the hybrid OR investment and providers should take system monitoring, available hands-on support and the ordering of parts into account when inking a new deal.

"For hybrid operating rooms, we offer a tailored service program that provides hospitals with workflow consulting and training beyond the time of purchase,” says Kulkarni. “Customers are assigned a unique telephone number and concierge representative who proactively handles all customer care functions.”

For Siemens customers, having access to the Signature Service concierge support line means having service engineers on hand who are ready to triage any issue.

But what if your facility does not have a comprehensive service package or the C-arm becomes temporarily non-operational due to an upgrade installation? In these situations, rentals can be the key to ensuring patient throughput isn’t compromised.

One of the main advantages of renting is that all service costs throughout the rental period are included, according to Blaustein. His customers have begun seeking C-arms with a larger field of view, a trend he credits to the increase in surgery for total joints (i.e., anterior hips) being added to the procedure list at outpatient surgery centers.

Modular Devices, which has a fleet of 25 complete cardiovascular imaging systems, has made a business out of renting entire cath labs, modular and mobile, to providers that find themselves in a pinch.

“There is a lot that goes into properly installing the X-ray system, C-arm and table in our interim labs,” Mark Koers, executive vice president of sales and marketing at Modular Devices, told HCB News. “All of the systems in our labs, both mobile and modular, are FDA- and OEM-approved installations, fully supported and serviced throughout the U.S.”

Space considerations make the modular units particularly well-suited for customers embarking on a long term project or planning to conduct more complex procedures, according to Koers, since they are at least twice as large.

A singularity on the horizon
Although refurbished C-arms with flat panel detectors are still rare and therefore expensive, Blaustein expects about 40 or 50 percent of the systems in the used market to have them within five years, and the price to come down accordingly.

As technology evolves and time goes on, some experts predict these systems are heading toward a convergence where mobile and fixed C-arms could merge and perhaps incorporate other imaging modalities. Such a system could conceivably yield many benefits, including reduced procedure times and enhanced workflow for patients getting a range of necessary care of imaging in a single treatment.

“You could have an angiographer for interventional cardiology and an ultrasound shoulder to shoulder, taking care of the patient, each one using its own devices, but at the same time, the information could interchange between interventional suite and ultrasound and ultrasound and interventional suite,” says GE’s Perez-Fernandez.

These capabilities could also enable confirmation in the success of operations, such as the resection of a tumor, with options such as functional MR available and ready for use.

“You might want to mid-procedure, while the patient is open, move him or her into an MR to check if the entire tumor has been removed,” says Kulkarni. “If not, you can come back and remove the entire tumor before you finish the operation.”

He notes that a future without the need for imaging with radiation may one day be possible, provided MR technology and MR compatible devices continue to evolve.

Like all areas of health care, AI and machine learning are also poised to have a bigger impact on the fixed and mobile angiography units of tomorrow.

“What we see with AI is the ability to reduce the gaps between the exceptional practitioner and the average practitioner by providing access and guidance to those average ones in terms of how the best ones perform,” says Perez-Fernandez.