The use of 3D image fusion for percutaneous transluminal angioplasty and stenting of iliac artery obstructions: validation of the technique and systematic review of literature.

Introduction: The effect of the insertion of guidewires and catheters on fusion accuracy of the three-dimensional (3D) image fusion technique during iliac percutaneous transluminal angioplasty (PTA) procedures has not yet been investigated.

Evidence Acquisition: Technical validation of the 3D fusion technique was evaluated in 11 patients with common and/or external iliac artery lesions. A preprocedural contrast-enhanced magnetic resonance angiogram (CE-MRA) was segmented and manually registered to a cone-beam computed tomography image created at the beginning of the procedure for each patient. The treating physician visually scored the fusion accuracy (i.e., accurate [<2 mm], mismatch [2-5 mm], or inaccurate [>5 mm]) of the entire vasculature of the overlay with respect to the digital subtraction angiography (DSA) directly after the first obtained DSA. Contours of the vasculature of the fusion images and DSAs were drawn after the procedure. The cranial-caudal, lateral-medial, and absolute displacement were calculated between the vessel centerlines. To determine the influence of the catheters, displacement of the catheterized iliac trajectories were compared with the noncatheterized trajectories. Electronic databases were systematically searched for available literature published between January 2010 till August 2017.

Evidence Synthesis: The mean registration error for all iliac trajectories (N.=20) was small (4.0±2.5 mm). No significant difference in fusion displacement was observed between catheterized (N.=11) and noncatheterized (N.=9) iliac arteries. The systematic literature search yielded 2 manuscripts with a total of 22 patients. The methodological quality of these studies was poor (≤11 MINORS Score), mainly due to a lack of a control group.

Conclusions: Accurate image fusion based on preprocedural CE-MRA is possible and could potentially be of help in iliac PTA procedures. The flexible guidewires and angiographic catheters, routinely used during endovascular procedures of iliac arteries, did not cause significant displacement that influenced the image fusion. Current literature on 3D image fusion in iliac PTA procedures is of limited methodological quality.