Editorial Comment

Optimal Equipment for HybridProcedures: How Things HaveChanged!

Julius H. Grollman, Jr., MD

Memrad Medical GroupDepartments of RadiologyLittle Company of Mary HospitalTorrance, CAUCLA School of MedicineLos Angeles, CA

As a first-year UCLA radiology resident in 1960,cardiovascular imaging was a major part of my train-ing. My first experience was in congenital heart dis-ease, learning from the senior cardiac radiologists,pediatric cardiologists, and cardiac surgeons. The pe-diatric cardiologist performed right heart catheteriza-tions via antecubital venous cut-down in a roomequipped with a primitive image intensifier. This novelfluoroscopic imaging device was viewed through mir-ror optics (maximum two observers at a time) andmounted on a tilt table used originally for gastrointes-tinal imaging. He then left an NIH catheter in the rightheart and the patient was transferred on a gurney,catheter secured in place, to the angiographic room forselective angiocardiography with biplane Schonanderroll film 140 (36 cm) changers supervised by the radi-ologist. If a left heart angiographic study were needed,the surgeon would perform open brachial arteriotomy,so the cardiologist could pass a similar catheter to theascending thoracic aorta or left ventricle. Thus, theinteraction began between cardiologist, radiologist,and surgeon that has continued since in drasticallyevolving fashion. I personally found the field intrigu-ing, starting me on the pathway that led to the excitingfield of cardiovascular disease.

Technological progress was rapid even then. Fouryears later, as a senior resident, I was learning recentlyintroduced percutaneous minimally invasive transarterialperipheral and cardiac angiography. We too performedhybrid procedures, studying the left heart and peripheralcirculation commonly at the same sitting by percutane-ous transaxillary catheterization [1]. Left ventriculogra-phy, selective coronary, and peripheral arteriography

were relatively easily performed in the upgraded hybridangiographic laboratory. This state-of-the-art room wasequipped with an image intensifier with newly availabletelevision monitoring for fluoroscopy and cine photoflu-orography for angiocardiography and coronary arteriog-raphy. The patient was positioned in a Cordis rotator(Cordis, Miami, Florida) [2]. A Schonander cut filmchanger (Elema-Schonander, Stockholm, Sweden) wasplaced under their newly designed Koordinat motorizedtable capable of primitive bolus chase peripheral lowerextremity angiography [3,4]. Thus, integrated minimallyinvasive peripheral/peripheral and coronary/peripheraldiagnostic angiography was developed in the early1960s. Of course, the surgeons were the only cardiovas-cular interventionalists at that time.

Subsequent technological developments are wellknown to the active cardiac angiographer. Cardiac cath-eterization and angiographic laboratories have evolved tothe present sophisticated technological level with dual-and triple-mode 90 (23 cm) high-resolution image inten-sifiers and cinefluorographic and filmless digital cineimaging. Peripheral angiographic laboratories haveshown even more remarkable evolution with large format14 and 160 (36 and 40 cm) image intensifiers and digitalsubtraction imaging techniques, including sophisticatedpostprocessing technology such as road mapping, peakpixeling, and remasking.

Although integrated minimally invasive endovascu-lar treatment of atherosclerotic vascular disease asdescribed by New et al. [5] can be performed in thesame laboratory at the same setting, contrast mediumvolumes and renal function must be carefully moni-tored. The angiographic/catheterization laboratoryused for coronary/peripheral hybrid interventionalprocedures must include cineangiography with filmand/or digital imaging and digital subtraction angiog-raphy with postprocessing capabilities to allow thesafe performance of these potentially risky procedures.On the other hand, it is still preferable to perform thediagnostic procedures in separate laboratories de-signed optimally for peripheral or cardiac imaging.Swing laboratories are now being used to handle bothdiagnostic cardiac and peripheral angiographic imag-ing. Although they have become an economic neces-sity especially in smaller hospitals, my experience inthis area has consistently demonstrated significantcompromises. Nine-inch image intensifiers are not

Catheterization and Cardiovascular Interventions 52:162–163 (2001)

© 2001 Wiley-Liss, Inc.

suitable for diagnostic abdominal and lower extremityangiography. Likewise, 14 and 160 image intensifiersdo not permit adequate diagnostic coronary anatomicdetail except in small patients with normal-sizedhearts who are not in congestive heart failure. In largeradults, the technical factors on the magnificationmodes will usually be suboptimal. In between, 120 (30cm) image intensifiers are commonly used in these“combo” laboratories, but again they are compromisesthat are suboptimal for both cardiac and peripherallower extremity angiographic imaging. We must re-member that the best patient care with reasonable costconstraints must be our primary concern for our pa-tients. Hybrid procedures are certainly appropriate andeven life-saving in many situations, but should beperformed in the optimal setting for patient safety.

REFERENCES

1. Hanafee W. Axillary artery approach to carotid, vertebral, abdom-inal aorta, and coronary angiography. Radiology 1963;81:559–567.

2. Weidner W, MacAlpin R, Hanafee W, Kattus A. Percutaneoustransaxillary selective coronary angiography. Radiology 1965;85:652–657.

3. Riley JM, Cannon JA, Hanafee W. Total larger vessel angiogra-phy in the selection of patients for direct arterial surgery. Surgery1966;56:6–27.

4. Riley JM, Hanafee W, Weidner W. Left axillary approach to theabdominal aorta. Radiology 1965;84:96–99.

5. New G, Roubin GS, Iyer SS, Vitek JJ, Moussa I, Al-Mubarak N,Leon MB, Subramanian V, Moses JW. Integrated minimally in-vasive approaches for the treatment of atherosclerotic vasculardisease: “hybrid procedures.” Cathet Cardiovasc Intervent 2001;52:154–161.

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