Needs Adjustment
By Keith Loria
Radiology Today
Vol. 25 No. 3 P. 16

C-arm technology is becoming more versatile.

One of the biggest issues in radiology is the everincreasing workload on radiographers and radiologists, coupled with a shortage of skilled workers. This has led to increased demand for automation and efficiency to help solve this challenge.

“AI has been heavily promoted as a way of helping to support the radiologists/ radiographers through automated positioning and diagnostic workflows,” says Conrad Dirckx, vice president of product management for Adaptix. “The trend of lower dose continues through the use of higher sensitivity detectors, AI everywhere, and an increasing awareness of the environmental impact of large imaging equipment.”

There’s also a trend toward moving imaging out of a large hospital context into smaller community centers, diagnostic clinics, and walk-in centers. Erin Libby, product marketing manager of digital radiography for Fujifilm Healthcare Americas Corporation, says the health care industry has witnessed an increase in surgical volumes and a notable uptick in ambulatory surgery centers (ASCs) across the United States over the last several years.

“Our customers who work in ASCs— in addition to hospitals and imaging centers—have expressed the importance of reducing total cost of ownership while having advanced imaging solutions that are designed to speed and simplify an array of image-guided procedures,” Libby says.

The demand for increased access at a lower cost has led to an uptick in compact, portable mini C-arm systems and other innovative technology.

Shifting Paradigm
Allison Henderson, director of marketing at Siemens Healthineers, adds there has been a significant shift towards the use of 3D imaging in broader applications— beyond its traditional use with spine surgery—in areas such as pulmonology, prostate artery embolization, and orthopedic trauma surgery.

“We’ve seen a shift from relying on 2D imaging from mobile C-arms to incorporating 3D imaging, as well,” she says.

In response, Siemens Healthineers unveiled the recently cleared CIARTIC Move at RSNA 2023, a new class of self-driving, mobile 3D C-arms that is intended to address the challenges of staff shortages and overloaded surgical teams in the operating room (OR). The CIARTIC Move was designed to allow independent movement, fully automated positioning, and effortless steering. A feature called Smart Control recalls up to 12 C-arm positions from the sterile field, allowing surgeons more control than they’ve had before and OR technologists more confidence to position correctly.

“This is the world’s first self-driving C-arm, and this will revolutionize intraoperative imaging workflows, which is going to improve the productivity and reduce the burden on the OR top to bottom,” says April Grandominico, vice president of surgical therapies with Siemens Healthineers North America. “It’s also going to bring precision, with automation through a remote control where you can preset the angulations you need during a surgery, regardless of the clinical application, and you can go back time and again with precision with less staff in the room to support you.”

Siemens Healthineers also offers the Cios Spin, a traditional mobile 2D and 3D C-arm for intraoperative quality assurance. The company recently partnered with Intuitive, bringing its Cios Spin and the Ion Endoluminal System together for robotic-assisted bronchoscopy. Some early studies have shown that Ion enables a diagnostic yield of approximately 80% with a relatively small average nodule size. 3D imaging is utilized in peripheral nodule biopsies to confirm that biopsy tools are appropriately placed in a suspicious nodule prior to tissue biopsy. One study demonstrated an improvement in diagnostic yield of nearly 10% when the Cios Spin was used with the Ion platform.

Recent Trends
Responding to recent trends, Fujifilm has developed a C-arm portfolio that meets the needs of hospitals of all sizes and ASCs. “Our C-arms are diverse and designed for several different use cases, including orthopedic, cardiovascular, and pain management, to name a few,” Libby says.

For example, in 2022, Fujifilm launched the FDR Cross, the world’s first two-in-one fluoroscopy and DR C-arm. This system performs fluoroscopic guidance and portable DR on a single platform, eliminating the need for two separate devices.

“Circling back to the needs of ASCs, cardiovascular procedures are on the rise and are one of the fastest growing clinical segments,” Libby says. “Seeing the demand for advanced cardiovascular imaging, Fujifilm has recently unveiled the Persona C-HR, our newest mobile fluoroscopy C-arm solution, offering active cooling, innovative detector technology, and a 4k 32-inch multitouch surgeon’s display.”

Rounding out Fujifilm’s C-arm portfolio is the Persona CS, an all-in-one C-arm that fits into small spaces and delivers high image quality, even for challenging procedures such as pain management. “All of Fujifilm’s flat panel C-arms offer up to twice the imaging area of conventional C-arm solutions with detector sizes of up to 43 cm,” Libby says. “Additional coverage allows for full-field visualization throughout operating procedures, matching the coverage possible on preand postoperative X-ray imaging.”

In addition to offering a larger field of view, flat panel technology is focused on lowering the dose to patients and operators. The downside to conventional C-arm design is the limited field of view, higher dose, and less optimal image quality than flat panel systems.

Versatile Options
Ellen Van Oostenbrugge, global marketing director at GE HealthCare, says the broad variety of imaging that’s needed for surgical procedures has led to more versatility, ease of use, and workflow improvements in C-arms. “Across the portfolio, we have introduced new imaging capabilities as well as some of the technologist-focused workflow efficiencies,” she says.

The company offers its OEC portfolio of C-arms, which ranges from mini C-arms for orthopedic imaging to mobile C-arms that do CT, with its OEC 3D. Introduced two years ago, the OEC 3D provides a large 3D imaging capability, with its 19 x 19 x 19 cm volume capturing 67% more volume than most other systems. Many sites use it for 3D imaging for spine orthopedic trauma, but the system allows for 2D imaging, as well.

“It’s the level of detail and the ability to be able to quickly adjust within the 3D volume that is welcomed [by surgeons],” Van Oostenbrugge says. “For technologists, it’s about how easy it is to use.”

Adaptix received 510k for its ultra-compact, stationary 3D imaging system last year, its first C-arm for the human market. This system allows low-dose 3D X-ray imaging of extremities using a new digital X-ray source that offers much greater diagnostic sensitivity than 2D for conditions such as scaphoid fracture.

“This combination of low dose and low cost can enable a change to imaging pathways in which the first diagnostic scan can be a digital tomosynthesis scan,” Dirckx says. “That greater diagnostic certainty is better for patients, physicians, and payers. It also benefits the planet as we move towards imaging equipment with a lower diagnostic footprint.”

At the heart of the system is a flat panel X-ray source containing a 2D array of low-dose X-ray sources turned on and off electronically within a single vacuum enclosure. “This is different from other tomosynthesis imaging systems, which use a traditional X-ray tube that is swept within an arc,” Dirckx says. “This design means we can image faster (not having to move something) and make a much cheaper, more compact system that requires much lower power (just plug it into a standard wall socket).”

Change on the Horizon
There are many variables that radiology departments need to consider when switching and changing out C-arms. Questions they need to consider are: Do they have the lowest dose and highest quality imaging possible, have they got the right mix of 2D and 3D imaging equipment, and does it make sense to move the equipment away from a large radiology department and closer to the patient?

Some Siemens Healthineers customers have been using the same C-arms for a decade. Grandominico notes that replacements are necessary not only for cost reasons but also because the space has seen such technological innovation that it allows clinicians to treat patients differently. “For the first time, you are now hearing clinicians talk about getting to ground-glass opacity in the lung,” she says. “They are getting to 2 mm lesions in the lung. This is enabling physicians to get to places that before we would send a patient home and do ‘watchful waiting,’ but now we’re mitigating that, which has changed the outcome for patients.”

Libby recommends health care providers and departments of all sizes and specialties should look to upgrade their conventional C-arms to flat panel design C-arms if they haven’t already. “Today’s flat panel design C-arms offer a larger and clearer field of view, sharper images, and are designed to be low dose,” Libby says. “When health care providers are looking to update their diagnostic imaging portfolio— including conventional C-arms—it is important that they partner with a vendor who is committed to not only providing advanced solutions but is dedicated to offering cost saving solutions.”

The Future of C-arms
Going forward, new 3D imaging capabilities for mobile C-arm systems will enhance procedure planning and improve real-time intraoperative guidance, while AI will undoubtedly be embedded in more ways. “In the same way that our cell phones and personal technology continue to advance, so will diagnostic imaging solutions such as C-arms,” Libby says.

“AI will support improvements to dose reduction and automated workflow and diagnosis, but, ultimately, great images coupled with skilled radiographers and radiologists will remain at the heart of great radiology,” Dirckx says.

Van Oostenbrugge says image quality will continue to be the focus of C-arms in the future, but versatility will also be an important consideration.

“We’re going to see more innovation in the mobile C-arm space as clinicians push us to bring more advanced imaging and features to a mobile C-arm in clinical settings,” Henderson says. “We are seeing the market shift outside the hospital more and more, but as we evolve and incorporate AI, they are asking for more—making the user experience better, improving clinical outcomes for patients, and changing the ways surgical procedures are conducted.”

— Keith Loria is a freelance writer based in Oakton, Virginia. He is a frequent contributor to Radiology Today.