IntroductionEndovascular aneurysm repair requires the precise deployment of the graft. In order to achieve accurate positioning, the anatomical and morphological characteristics of the aorta and its branches is mandatory. Software that perform three dimensional reformatting of multislice tomographic images, allow for the study of the whole aorto-iliac axis and the perpendicular visualization of the origin of the renal arteries. The correct length of the proximal neck can be evaluated and adequate graft fixation and sealing may be foreseen. A technique is presented, using an software, for the orthogonal correction of the position of the renal arteries in relation to the proximal neck, which may guide the radioscopic orientation intraoperatively.MethodsWithin a multiplanar tomographic image reconstruction, virtual triangulation allows for the three dimensional orthogonal correction of the renal arteries' ostia position. The predetermined best angulations for visualization are annotated and used for the positioning of the surgical C-arm.Results/DiscussionSome authors discuss that the anatomic position of the renal vessels seen on the tomographic scan can change during the surgical procedure. It is known that the renal arterys' angular positioning does not alter, even after insertion of stiff guidewires, introducers, and the endograft itself. Therefore, it is possible, using concepts of spacial geometry and orthogonal correction, to predict the ideal bidimensional intraoperative positioning of the radioscopy device in order to reproduce the optimized renal artery ostial projection, ensuring the best accuracy during endograft deployment.ConclusionAs closer to the tomographic reproduction was the radioscopic correction, more careful is the visualization of the ostium of the renal artery, better is the exploitation of the lap for fixing and sealing and the endoprosthesis deployment is more accurate.

INTRODUCTIONDespite the patient and medical staff exposure to radiation in endovascular aneurysm repair, the benefits of this abdominal aortic aneurysm type of surgical management are justfied by minor recovery time and hospitalization, as well as an option for patients not elected to conventional open repair. In this minimally invasive surgical aproach, time of procedure and radiation doses can be substantial - and the increasing frequency of these procedures and it's complexity have impelled vascular surgeons to face additional and successive risk to occupational radiation exposure. Meticulous study of the computed tomography angiography during the endovascular aneurysm repair preparation allows reduction of unnecessary radiation exposure, as also reduces consecutive image acquisition and contrast use (that may be related to renal overload in susceptible patients). Some studies have proposed strategies to optimize endovascular intervention to reduce contrast use and X-ray exposure. Although they might prove to be effective, they rely on use of additional specific and advanced equipment, available only in major centers. As an alternative to this expensive and restrict technology, it is presented a simpler technique through image manipulation on software OsiriX, aiming to reduce both exposures.OBJECTIVETo analyze the efficacy of the adoption of a study protocol and a script-based guide in preparation for endovascular aneurysm repair through verifying it's impact over the surgical procedure - as referred to intravascular contrast infuse, effects over renal function, blood loss and operatory time.METHODSA longitudinal prospective study from March 2014 through March 2015, where 30 performed endovascular aneurysm repair were compared to a historic control group. The planning for endovascular aneurysm repair through the patient's tomographic image manipulation in the prospective group was performed with OsiriX MD software. A script-based guide upon gathering detailed computed tomography angiography images was elaborated by the author and distributed to the performing surgical team for appreciation, instruction and pre operatory judgment. Based upon the script, the C-arm gantry angle was specifically corrected in each case of endovascular aneurysm repair, for image optimization and aneurysm's neck visualization. Arteriography was performed under digital subtraction angiography after catheters were positioned according to predicted level description in the referred guide. Statistical analysis were performed with a significance level of 5% (P value<0.05).RESULTSThere was a statistically significant relationship between the two studied periods and the variables: contrast volume (284.5 vs. 31.8 mL), operative time (207.5 vs. 140.4 min.) and blood loss (798.1 vs. 204.4 mL), revealing that they are considerably larger in the historical control group than in the script guided current group. There was no difference related to the volume of contrast used in the two groups and the occurrence of renal impairment.CONCLUSIONIn the ...

IntroductionIn the past few years, the increase of endovascular surgeons' interest on tomography image edition through softwares is marked specially when it concerns to its use on preoperatory study for endovascular aneurysm repair. It is presumed that the bigger the number of informations extracted from the tomography exam and its three-dimensional reconstruction, the smaller is the need of patient's exposure to contrast, as well as the its exposure and the surgical team to radiation. Concepts of image manipulation on the OsiriX software with volume reconstruction of tridimensional tomographic scans of virtual fluoroscopy were used.MethodsThrough manipulation of multi-slice tomography images under three-dimensional reconstruction on software, it was able to modify values of the exam's dose-irradiated distribution. These volume reconstruction presets were saved as Virtual Fluoroscopy, reproducible upon any OsiriX platform. It was able to construct a biplanar image appearing to the patient's operatory fluoroscopy. When compared to the intraoperatory angiography, the images were alike.DiscussionDose-irradiated distribution data manipulation allowed to visualize as opaque bone surfaces and transparent low-dose radiation's areas (viscerae). Thus, under previously marked renal arteries, it was possible to predict it's anatomical positioning related to visualization under real fluoroscopy. Foretelling the better positioning of the C-arm through this technique enables to obtain images with the minimum influence of parallax effect. It is believed that it supports to assess the renal arteries topographic positioning on a bi-dimensional intraoperatory image. The need of frequent angiographies to localize the renal arteries is reduced, decreasing the exposure to contrast on vulnerable patients.

We have shown how the analysis of the angiotomography reconstruction through OsiriX program has assisted in endovascular perioperative programming. We presented its application in situations when an unexpected existence of metallic overlapping artifact (orthopedic osteosynthesis) compromised the adequate visualization of the arterial lesion during the procedure. Through manipulation upon OsiriX software, with assistance of preview under virtual fluoroscopy, it was possible to obtain the angles that would avoid this juxtaposition. These angles were reproduced in the C-arm, allowing visualization of the occluded segment, reducing the need for repeated image acquisitions and contrast overload, allowing the continuation of the procedure.

ResumoForam analisadas 25 pacientes atendidas no nosso centro entre 2010 e 2016, submetidas a cesárea e histerectomia, conforme o protocolo do serviço, sendo que todas tiveram o procedimento programado previamente. Houveram 9 casos de lesão vesical (36%) e 1 caso de lesão ureteral (4%). Houveram 4 casos de HPP grave (16%), sendo que 11 pacientes necessitaram de transfusão de concentrado de hemácias. Oito RN tiveram taquipneia transitória (32%) e 3 RN tiveram Sd. Desconforto Respiratório (12%), sendo que 2 fizeram uso de oxigenoterapia (8%). Tardiamente, 1 puérpera desenvolveu fístula vesico-vaginal (4%), 4 desenvolveram ITU no pós operatório tardio por manipulação ureteral (16%) e 1 caso de claudicação por complicação da embolização (4%). O diagnóstico pré-operatório da placenta percreta pode reduzir morbimortalidade materna e infantil. Apesar de ser uma condição sem um consenso estabelecido, foi visto que a abordagem programada e multidisciplinar, ajuda a alcançar o melhor resultado materno e perinatal.